In 2013, the U.S. Institute of Medicine (IOM) released a book called U.S. Health in International Perspective: Shorter Lives, Poorer Health. The IOM report points out that reading, science, and mathematics outcomes for U.S. fifteen-year-olds are poor compared to other countries. Just as with health care, we spend a great deal on education and have little to show for it. The IOM report presents appalling information about violence and firearm deaths in the United States. But although we have very high rates of violent deaths for young people compared to other rich nations, that risk is a sideshow, too. The violent deaths of children are terrible events, but if we count up, for example, all the school shootings, they average out to about ten deaths a year. However tragic for the individual families, youth violence is an insignificant cause of our relatively limited life spans.
A political system that fosters inequality limits the attainment of health.
The report also includes a long section on the factors for our high death rates. Among the main causes cited are poverty, income inequality, low social status, stress, epigenetics (factors on the genome telling your genes to switch on or off, speak loudly or whisper, that are influenced by a host of environmental factors broadly considered and are transmitted across generations), and early-life disadvantage. Although recent attention has been paid to the rising economic inequality in the United States, the links of that trend to our health have not been presented to the public. Those associations remain buried in academic research.
The life-course perspective in particular is out of the public eye. Looking more deeply into research on the effects of early life, it is possible to estimate that roughly half of our health as adults is programmed from the time of conception to around two years of age. The importance of these “first thousand days” is the subject of increased interest and study, and explains a lot about the difficulties of focusing on short-term interventions to improve health. Countries with healthier populations structure this formative period by making it easier for parents to parent. In practical terms, this means that in modern societies where most people work outside the home, providing paid parental leave is the single most effective social intervention that can be undertaken for improving health. It can be thought of in the same light as public sanitation systems that make water safe to drink. We all benefit, rich and poor alike, from clean water, from sewage treatment, from immunizations, and other public health measures.
Everyone in a society gains when children grow up to be healthy adults. The rest of the world seems to understand this simple fact, and only three countries in the world don’t have a policy, at least on the books, for paid maternal leave—Liberia, Papua New Guinea, and the United States. What does that say about our understanding, or concern, about the health of our youth?
Infant death rates, those occurring in the first year of life, are a particularly sensitive measure of health in a population. According to a U.S. Centers for Disease Control and Prevention report released in 2013, our infant mortality rate is about 6.1 deaths for every thousand live births. Sweden has an infant mortality rate less than half of ours, 2.1 deaths per thousand births. If we had Sweden’s rate of infant deaths, the United States would have around forty-seven fewer infants dying every day in the United States. That is what is achievable: every day forty-seven babies wouldn’t die if we had Sweden’s rate of infant deaths.
Differences in mortality rates are not just a statistical concern— they reflect suffering and pain for very real individuals and families. The higher mortality in the United States is an example of what Paul Farmer, the noted physician and anthropologist, calls structural violence. The forty-seven infant deaths occur every day because of the way society in the United States is structured, resulting in our health status being that of a middle-income country, not a rich country.
There is growing evidence that the factor most responsible for the relatively poor health in the United States is the vast and rising inequality in wealth and income that we not only tolerate, but resist changing. Inequality is the central element, the upstream cause of the social disadvantage described in the IOM report. A political system that fosters inequality limits the attainment of health.
The claim that economic inequality is a major reason for our poor health requires that several standard criteria for claiming causality are satisfied: the results are confirmed by many different studies by different investigators over different time periods; there is a dose-response relationship, meaning more inequality leads to worse health; no other contending explanation is posited; and the relationship is biologically plausible, with likely mechanisms through which inequality works. The field of study called stress biology of social comparisons is one such way inequality acts.
Those studies confirm that all the criteria for linking inequality to poorer health are met, concluding that the extent of inequality in society reflects the range of caring and sharing, with more unequal populations sharing less. Those who are poorer struggle to be accepted in society and the rich also suffer its effects.
A recent Harvard study estimated that about one death in three in this country results from our very high-income inequality. Inequality kills through structural violence. There is no smoking gun with this form of violence, which simply produces a lethally large social and economic gap between rich and poor.
