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The idea that our economic divides affect how long we live remains difficult for many Americans to swallow. But swallow we must because inequality is killing us.
By Dr. Stephen Bezruchka
How do we come to believe something is true?
I asked this question once to an eighth grade class. No one answered, only a deafening silence.
Finally a boy raised his hand.
“If our parents tell us when we are very young, if our teachers and friends reinforce that, and if we’ve experienced it,” the boy noted, “then we know it to be true.”
I’ve been thinking about that boy’s answer because Forbes has just published a column on the topic of my presentation to his eighth grade class, the adverse impact of inequality on health.
Tim Worstall, a fellow at the Adam Smith Institute in London, argues in this Forbes column that inequality has no such adverse impact. Inequality, argues Worstall, “doesn’t decrease lifespans.”
So who should Americans believe, Worstall and the evidence he cites or the enormous body of research on health and inequality that has been appearing over the past quarter-century?
Let’s begin by noting that inequality is, of course, not some disease that an individual can catch. Inequality is rather a property of a society.
Our parents, teachers, and friends – the people that eighth grader saw as the sources of truth – typically experience health as a matter of avoiding disease. They don’t “experience” any connection between health and any property of society.
That’s not surprising. Inequality – like a highly toxic, colorless, odorless gas – leaves no smoking gun. But inequality kills just as surely as that toxic gas, if hundreds of studies over recent decades are to be believed. Inequality, these studies suggest, lurks behind the heart attacks, diabetes, strokes, violence, and cancers that afflict us.
Can this link between increased income inequality and worse health outcomes be substantiated? Let’s keep in mind that a little over 50 years ago the notion that cigarette smoking could be bad for our health just didn’t seem credible to the general public. After all, doctors themselves were advising us on the best brands to smoke.[pullquote]Inequality – like a highly toxic, colorless, odorless gas – leaves no smoking gun.[/pullquote]
But then the 1964 surgeon general’s report on Smoking and Health laid out the evidence and presented criteria for inferring causality. To demonstrate a causal link, the report noted, we needed many different investigators looking at different groups over different times – “consistency of the association,” as the study put it.
We also needed to consider the strength of the association and the specificity. Is more inequality associated with worse health? Are there other explanations? And then the temporal relationship: Does health worsen and inequality increases or does inequality increase and then health worsen? Finally, the coherence of the association: Is the suspected link biologically plausible?
Does the association between inequality and worse health satisfy these criteria? Resoundingly, yes.
The latest research word on this association comes from two British epidemiologists, Kate Pickett and Richard Wilkinson, who’ve just reviewed the causal nature of the inequality/health relationship in the prestigious journal Social Science & Medicine.
Why do some Americans not accept this relationship between inequality and worse health outcomes? Maybe for the same reason it took so long to recognize that cigarette smoking endangers our health.[pullquote]All major new truths in science pass through three stages.[/pullquote]
Back years ago, most American adults smoked. With smoking so enmeshed in the fabric of everyday life, we had trouble identifying smoking as the problem. Today we have a similar situation, with inequality running at record levels in the United States. In effect, we do not sense the poisonous gas.
Our new understanding that structural factors in society can fundamentally impact our health constitutes a scientific revolution in thinking. New science, we need to remember, always encounters resistance. Galileo was excommunicated for saying the earth revolved around the sun.
All major new truths in science essentially pass through three stages. First, the truth is ridiculed, then violently opposed. Finally, the new truth is accepted as self-evident.
Americans die younger than people in the other rich nations. This truth applies even to those of us who are privileged and do all the right things to be healthy, as the most important advisory body on health matters in this country now recognizes. The title of the 2013 Institute of Medicine report on these matters says it all: U.S. Health in International Perspective: Shorter Lives, Poorer Health.
So how can we create a greater awareness about the adverse health impacts of inequality?
The Institute of Medicine report lays out what to do. The first step: informing the public that we stand dead first in mortality. The second: looking at what healthier countries are doing that might be of use to us here.[pullquote]We all die younger than people in the other rich countries because of our high inequality.[/pullquote]
How to inform the public? Repeat this refrain: “We all die younger than people in the other rich countries because of our high inequality.”
That might get some attention and lead to honest discussion.
Relating our health to our economic inequality remains the challenge of our time. Eventually, even this relationship will become self-evident.
Dr. Stephen Bezruchka has worked in clinical medicine for 35 years. He currently teaches at the University of Washington School of Public Health.