How do inequality and health relate? Increasing evidence from scientists the world over indicates that many health outcomes — everything from life expectancy to infant mortality and obesity — can be linked to the level of economic inequality within a given population. Greater economic inequality appears to lead to worse health outcomes.
By greater inequality, epidemiologists — the scientists who study the health of populations — don’t just mean poverty. Poor health and poverty do go hand-in-hand. But high levels of inequality, the epidemiological research shows, negatively affect the health of even the affluent, mainly because, researchers contend, inequality reduces social cohesion, a dynamic that leads to more stress, fear, and insecurity for everyone.
Covid-19 and Health Inequalities
Cross-National Comparisons
Inequality and Health in the United States
Covid-19 and Health Inequalities
With the leading Covid-19 vaccine makers refusing requests to share their technologies, people in poorer countries have had less access to this critical tool in the fight against the global pandemic. As of December 2022, the number of vaccine doses administered per 100 people was still more than six times higher in high-income than lower-income countries, according to data from the WHO and the World Bank. The Moderna CEO’s 2021 compensation came to $18.2 million in 2021, while the Pfizer chief exec made $24.3 million.
According to APM Research Lab, white and Asian Americans, who have the highest average incomes, have substantially lower Covid-19 mortality rates than those of other racial and ethnic groups. Between the start of the pandemic and October 2, 2022, indigenous people suffered 582 deaths per 100,000 people – more than twice the death rate for whites and Asians.
People of color are more likely to suffer severe illness from Covid-19, regardless of their age. According to CDC data, hospitalization rates have been highest among indigenous and Black Americans. About 2,100 indigenous and 1,700 Black Americans were hospitalized for Covid-related symptoms per 100,000 people in their respective ethnic and race groups between the beginning of the pandemic and October 22, 2022.
The racial disparities in Covid-related health indicators have contributed to a steeper decline in the U.S. life expectancy for people of color, according to data from the National Center for Health Statistics and the CDC. Between 2019 and 2021, American Indians and Alaska natives experienced the biggest drop, with life expectancy at birth plunging by more than 6 years to 65.2. The Latino and Black communities both experienced a drop of four years, while Asian and white Americans have seen a decrease of about two years since the start of the pandemic.
Transgender people are always in a precarious position, but the Covid-19 pandemic has made them particularly vulnerable. According to research from the Williams Institute at UCLA, transgender Americans are at a higher risk for Covid-19 for several reasons. They are more likely to be low-income, with 47.7 percent of transgender people living below 200 percent of the official U.S. poverty line, compared to 28.9 percent of the general U.S. population. They are also significantly more likely to suffer from asthma and HIV, conditions that put people at higher risk of mortality if they contract Covid-19. And they experience high barriers to receiving health care.
Cross-National Comparisons
Economists and health experts have known for years that people who live in poorer societies live shorter lives. But research also points to an additional factor in explaining life expectancy: a society’s level of inequality. People live longer, according to World Bank data, in nations with lower levels of inequality. The Gini coefficient, a standard global benchmark, is used here to measure inequality. The higher the Gini, the greater the inequality. In the United States, average life expectancy is four years shorter than in some of the most equitable countries.
A study published in the Journal of the American College of Cardiology in 2019 found that the higher the level of income inequality, the higher the rate of cardiovascular-related deaths and hospitalizations. Based on surveys from 2009 to 2015, participating countries with the lowest levels of income inequality (Central Europe and Scandinavian countries), had the lowest heart failure rate, at 10.9 per 100 person-years. Countries with intermediate income inequality levels (North America, Australia, and India) had a rate of 11.7 per 100 person-years, while those with the highest level of inequality had the highest rates of heart failure, at 13.7 per 100 person-years.
In 2017, nations with the smallest income gaps between households at the 90th and 10th percentiles as calculated by the OECD had significantly fewer infant deaths, according to WHO data, than other nations. A household at the 90th percentile has more income than 90 percent of households. The United States is at the extreme end among other industrialized countries, with the largest gap between the rich and the rest of the population and by far the worst infant mortality rate, at 5.7 per 1,000 live births, compared to just 1.6 per 1,000 in Iceland.
Extreme inequality appears to affect how people perceive their well-being. In nations where the top 1 percent hold a greater share of national income, people tend to have a lower sense of personal well-being, according to University of Oxford Saïd Business School research. Researchers are also finding links between inequality and mental health. Countries with larger rich-poor gaps have a higher risk of schizophrenia incidences. In general, a 0.2 point increase in a country’s Gini coefficient results in eight additional incidences of schizophrenia per 100,000 people. Researchers believe that higher inequality undercuts social cohesion and capital and increases chronic stress.
Inequality and Health in the United States
The same association between high economic inequality and poor health can be observed within the United States.
“Deaths of despair” — premature deaths from suicide, alcohol abuse, and drug overdoses — are at historic highs, with lower-income Americans particularly hard hit. The opioid crisis has driven the starkest gap. In 2021, people without Bachelor’s degrees were eight times more likely to die of a drug overdose than those with degrees, Brookings Institution research shows. Education level is a useful proxy for economic inequality, since the median income for college graduates in 2022 stood at $52,000, compared to just $34,320 for high school grads.
After rising steadily for many decades, U.S. life expectancy dropped dramatically by 2.5 years during the pandemic to 76.4 in 2021. Given past trends, the impact of this drop probably fell most heavily on lower-income Americans. A landmark 2016 study published by the Journal of the American Medical Association found that low-income Americans, particularly men, live shorter lives than those at the top of the income scale. In 2014, men in the top 1 percent of the income distribution could expect to live 15 years longer than those in the bottom 1 percent. For women, the difference was about 10 years.
Within the United States, people live longer in the more equal states, as calculated by the Journal of the American Medical Association. In Hawaii, which has relatively equitable income distribution according to Census Bureau Gini coefficients, people can expect to live nearly seven years longer than in highly unequal Mississippi.
Not only do more equal states have higher average life expectancies, they also have lower mortality rates, even after adjusting for population age difference. In Louisiana, one of the most unequal states, the number of deaths per 100,000 people in 2019 was 973. By contrast, in much more equitable Hawaii, just 606 people per 100,000 died that year, based on data from the Institute for Health Metrics and Evaluation.
In the 1970s, death rates from all cancer types were similar in rich and poor U.S. counties. As inequality has increased across the nation, this has changed. Today, as American Cancer Society data shows, rich counties have significantly lower levels of cancer deaths than poor counties. Lung cancer deaths in low-income counties have actually increased, from 41.2 per 100,000 per year to 47.7, while dropping slightly in the higher-income counties.
The American Psychological Association published a report which shows that U.S. households with annual incomes below $50,000 report higher levels of stress than other families. Average stress levels gradually declined after the 2007-2008 financial crisis, but the stress gap between rich and poor households has been increasing. Blue collar and low-income jobs are often more stressful and physically demanding than white collar jobs. This contributes to a variety of other health problems, such as high blood pressure, back problems, and diabetes. Societal forces, such as discrimination based on race, gender, and sexual orientation, add to the stress level of certain population groups.
On average, according to CDC research, women in the United States have lower rates of obesity as their income rises. Those with household incomes above 350 percent of the federal poverty line have obesity rates of 29.7 percent, compared to 45.2 percent for incomes less than 130 percent of the federal poverty line. In addition to higher stress levels, factors such as food deserts and lack of recreational facilities in poor communities contribute to higher obesity rates among low-income women. Among men, obesity rates are similar across income groups, while male college graduates have a significantly lower rate than those with less education.
U.S. smoking rates vary widely by income group, from 12.1 percent in households earning more than $100,000 per year to 32.2 percent in households earning less than $20,000 per year, as shown in CDC research. In addition to higher stress levels, low-income communities face heavier targeting by tobacco corporations, both through advertising and high concentrations of stores that sell cigarettes.
The lower American workers rank on the national economic ladder, the more likely their jobs will be physically demanding. Such jobs can lead to more stress, both physical and mental — and higher medical bills. Center for Economic and Policy Research data shows that workers in physically demanding jobs such as janitorial, maintenance, and housekeeping positions, also typically retire earlier, before they can claim full Social Security benefits.
The bottom third of U.S. earners tend to retire earlier than other Americans, as calculated by the Brookings Institution, in part because their jobs are often more physically demanding. Because American workers cannot claim full retirement benefits before age 66, this trend exacerbates economic inequality among seniors.