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Dying for the Rich

Our income gap is really a life and death health issue.

Crawford Kilian 6 May

Tyee contributing editor Crawford Kilian blogs about this issue at Bridging the Income Gap.

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Insecurity breeds stress, disease.

Statistics Canada confirmed last week the rich are getting richer, the poor are getting poorer, and the middle class has been treading water for a quarter-century.

The Globe and Mail published a Second Coming headline about those findings. Pundits chimed in. Yet, despite all the chatter, we still seem unable to confront this fact: The wider the income gap in a country, the worse its life expectancy.

For close to a century, public-health researchers have been tracking this strange correlation. In countries with narrow gaps between richest and poorest, everyone lives longer. In countries with wide gaps, people die sooner. Every social class is healthier than the one below it, and sicker than the one above it.

National wealth and medical spending don't seem to matter. According to the World Health Organization, Cuba spent $230 per capita on health care in 2004. The U.S. spent $6,096 per capita. But Cuba has a lower infant-mortality than the U.S., and Cuban life expectancy, at 78.3 years, is just ahead of the Americans' 78.2.

So the U.S. ranks first in health spending and 38th in life expectancy. Canada spends just half of what the Americans do ($3,038 per capita), but we rank 11th in life expectancy at 80.3.

What's going on here?

Public-health researchers are still debating the correlation between inequality and health, and whether inequality is actually a cause of disease and early death. But most studies seem to confirm the correlation, and most researchers confidently assert that inequality really is bad for your health.

In the decade of World War I, for example, British life expectancy actually went up despite the carnage in the trenches. During that decade, the rich paid more in taxes than they ever had before, and workers got better pay and working conditions than they had ever enjoyed before.

The famous "Whitehall survey" has tracked the health of 17,000 British civil servants since the 1960s. In a country with a national health service, the clerks at the bottom of the pay scale have three times the mortality rate of the top mandarins, and die four times as often from heart disease.

Richard G. Wilkinson, a British epidemiologist who's studied the correlation between income and health, cites this and many other cases in his book Unhealthy Societies: The Afflictions of Inequality. He notes that in 1965, Japan had a slightly lower life expectancy than Britain. Japanese now have a life expectancy of 82 years.

What happened? Well, the income range between Japanese workers and top executives stayed fairly narrow. In Britain, Maggie Thatcher encouraged the enrichment of the richest, and the gap widened. Improvement in British life expectancy (currently 78.7 years) has lagged since then.

Wilkinson has also recorded some alarming U.S. data, where the gap has been widening for decades. In 1990, for example, Louisiana had the widest income gap of any American state. Half the population was living on 17 per cent of the state's total income. At the same time, Louisiana had the highest death rates and homicide rates in the U.S.

The Canadian gap: Not so bad?

A British Medical Journal article in 2000 compared income inequality and mortality in Canada and the U.S., and found, surprisingly, that while the income gap correlated with U.S. death rates, it didn't correlate so closely in Canada.

The authors speculated that we effectively narrow the gap thanks to our health care system and equal provision of services like education.

Canadian researchers have looked closely at our gap. Dennis Raphael, editor of the important book Social Determinants of Health, points out in the first chapter that income differences between Canadians are responsible for more premature years of life lost than any other cause except cancer. We may be better off than the Americans, but not by much.

What, then, is the mechanism for this loss of life? Most researchers attribute it to two related causes: psychosocial stress and the loss of social capital.

Psychosocial stress doesn't mean feeling sad because Bill Gates is rich and you're not. Wilkinson, in his 2005 book The Impact of Inequality, argues that as social animals we need to maintain a certain level of secure status and control over our lives. We feel stress when our status is threatened and we lose control. Cortisol, a stress hormone, plays a role in many diseases.

In egalitarian societies where the rich aren't that much richer than the poorest, everyone feels more secure. But where the gap is wide, the poor feel threatened, and the rich both despise and fear them.

Eroding social capital

Social capital -- the level of trust between people -- also erodes as the gap widens. In Bowling for Columbine, Michael Moore praised supposedly easygoing Canadians for leaving our front doors unlocked, and not feeling the need for a gun in the house. But Canadians who once walked to school now tote their own kids to school in SUVs.

Wilkinson argues that stress underlies violent crime, alcoholism, and drug use. When people can't control much about their own lives, they can at least punch someone else, or smoke, or get drunk.

Wilkinson probably goes too far in blaming stress for almost every social problem we have, but he and Raphael and a host of others have raised some very serious issues about the way we distribute wealth.

Most Canadians accept the income gap as a fact of life. Responsible individuals, they believe, live with the consequences of their own actions. The rich are rich because they deserve to be, and the poor can be rich too, if only they'll get a job and work hard.

Even the poor tend to agree, and blame themselves for their own sorrows. This isn't surprising after a couple of centuries of North American optimism. Horatio Alger was a poor boy who got rich writing novels about poor boys who get rich.

But even Alger, in stories like Pluck and Luck, admitted that luck is as important as pluck. If you couldn't rescue a banker's daughter, you weren't going to get far.

To argue that the gap is a health issue, therefore, makes a lot of us very defensive -- you might even say stressed. It sounds like income redistribution, taking money away from the deserving rich and giving it to the feckless poor.

Some narrow-gap countries do tax the rich, but it doesn't go to the poor in one-time cheques. In fact, countries like Iceland and Japan don't seem to have many really poor people. That's because taxes support a solid infrastructure of housing, education and health care.

The rich robbing the poor

The problem is not the poor robbing the rich through taxes, but the rich robbing the poor through tax cuts that wreck the infrastructure. And the rich have to the chutzpah to tell us that this robbery is the way to prosperity for all.

Governments excuse themselves from delivering social services because they don't have the tax revenues any more. So private education and health care begin to look good to the affluent, while public education and health care, like public housing and transit, become down-market services for losers.

Because so many people still believe in Horatio Alger, the income-gap debate has stayed away from the health issue. Even the NDP and the Canadian Centre for Policy Alternatives define the problem as one of fairness -- as if poverty were simply a needless inconvenience to the poor.

If the Raphaels and Wilkinsons are right, however, the growing income gap in Canada -- as in the U.S., Britain, Russia, and China -- is literally a matter of life and death. The poor are dying early to subsidize the rich, who are too stupid to realize they're dying early too.

Dennis Raphael quotes the 19th-century Prussian physician Rudolf Virchow, who 150 years ago argued that "Medicine is a social science, and politics is nothing else but medicine on a large scale."

Virchow was wrong about some things, but he was dead right about that.

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