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January/ February 2013 Is Inequality Shortening Your Life Span?

White, black, or brown, we’d all live longer in a more equal, less status-driven society.

By Phillip Longman

But to conclude in this instance that your lack of upward mobility is because of your poor health is to beg the question of why you have developed these afflictions in the first place. Maybe you would drink in any event. Maybe you’d describe life as stressful regardless. But would you drink as much, and feel so bad about it in the morning, if you also felt (like that famous, highly effective, long-lived alcoholic Winston Churchill) that you were in command and getting important stuff done?

To continue this thought experiment, what if you did not feel slighted and powerless at work; if your boss didn’t make eight times your income but only double; if he didn’t seem to look down on you and “your kind”; if losing your job didn’t mean losing what little control you have over your life; if you didn’t feel variously envious, intimidated, and infuriated by coworkers, neighbors, and people you see on TV who seem to have it all; if you could point to some way of keeping score in this life by which you were a winner and life had meaning?

The specific biological mechanisms that lead from feelings of relative powerlessness and low status to specific diseases are not well understood at the molecular level. Some researchers have pointed to the role of cortisol, a steroid hormone released by the adrenal gland in response to stress that has the effect of suppressing the immune system. Among people who are overweight, those with high levels of cortisol are more likely to contract diabetes than those with low levels. More than 200 laboratory studies have also shown that the highest cortisol levels are found in people required to perform tasks outside their control that involve, as the epidemiologist Richard Wilkinson puts it, “threats to self esteem and social status in which others can negatively judge your performance.” A hard-charging executive may use the word “stress” to describe his reaction to the burdens of command, but it is his cowering subordinates who are most likely to feel the kind of stress that literally changes body chemistry.

The negative effects may be compounded if those subordinates must also endure the stress and humiliation of either perceived or real racial or class discrimination. And the effects may be further multiplied if they have also internalized feelings of inferiority based on these or other negative stereotypes or social constructions.

In an intriguing study at Emory University, researchers found, for example, that black men who reported being victims of racial discrimination experienced an increased risk of heart disease. But a much greater risk of heart disease was found among African American men who agreed with negative statements about blacks. Indeed, the highest rates of heart disease were found among African American men who said they were not personally victims of racial discrimination but still viewed their own race as inferior. Put another way, being or believing yourself to be the victim of racial discrimination is not good for your health, but what’s really bad is to absorb a social belief system that says you are at the bottom.

Cross-country comparisons also establish a clear link between poor health and social stratification. Among developed countries, for example, there is no correlation whatsoever between per capita GDP and life expectancy. But there is a strong correlation between countries that have low levels of inequality and those in which long lives are most common.

Sweden and Japan, for example, are very different countries, but both have extremely low levels of income inequality and the lowest rates of premature death in the developed world. Sweden achieves its egalitarianism through a large welfare state that massively redistributes income and opportunity; Japan has a comparatively small welfare state, but, according to custom, bosses refrain from paying themselves too many multiples of what workers earn. For the purposes of maximizing public health, Wilkinson observes, it does not seem to matter how a nation achieves relatively equality, only that social and economic stratification is somehow kept to a minimum.

A similar pattern emerges when we compare how long white people live in different parts of the United States. To better see what happens, consider one last thought experiment.

Suppose, before you were born, you were told that you had to be a white man, but you could choose whether you would live out your days in Mississippi or Minnesota. If you could not know anything else about these states except their life tables, what would the rational choice be?

The life tables would tell you that if you wound up a white man in Mississippi, your chances of not dying before age sixty-five would be little better than 74 percent, and that if you did live to that age, you could expect to be dead within 15.35 years. But if you were a white man in Minnesota, your chances of living to age sixty-five would be better than 83 percent, and your remaining life expectancy at that point would be 17.49 years.

The choice would seem clear, but what explains how stark it is? One big difference between Mississippi and Minnesota is the number of black people in each state. But unless you think that blacks in Mississippi are responsible for the deaths of huge numbers of white males—and they aren’t—that can’t be the reason why white men in Mississippi live shorter lives than white men in Minnesota. Nor are differences in median household income between whites in Mississippi and Minnesota large enough to explain such a large disparity in health: few whites in either state are poor enough that their health is threatened by lack of food or shelter.

The key factor may be how these states differ in their degree of social and economic stratification. Mississippi is among the states with the highest inequality of income. Moreover, throughout most of the last two decades Mississippi has led the nation in the growth of income inequality, whether as measured by the difference between those at the very top and those at the very bottom or by the gap in income between the middle class and the very rich.

Minnesota, by contrast, has much lower disparities of income, and is much more egalitarian in many other dimensions as well, including educational attainment, access to health care, and even, dare we say, cultural style. Garrison Keillor’s joke about all the kids in Lake Wobegon being “above average” contains an important truth: Minnesota is not a place where invidious distinction is typical, or kindly looked upon. And perhaps because of that, it is also not a place where stress and insecurity about social standing and loss of face is very common.

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.

Comments

  • Larry Roth on January 21, 2013 6:25 PM:

    Thought provoking essay - and pretty much the conclusion reached by Wilkinson and Pickett in their book "The Spirit Level" looking at the same studies and the same data. I'm rather surprised there was no mention of them and their work.