Poverty and Health

When I was a young boy in the early 1950s watching my father care for patients and their families in his office attached to our house, it was clear that his roles as counselor, coach and confidant on a broad range of issues was at least as important as his functions as clinician and scientist. At the time, few would argue that a family’s income, social class, neighborhood, job, and education directly impacted present and future health, and that absence of health significantly lowered the overall horizons of the family.

Over my career, somehow these insights gradually faded into the background and all but disappeared in the high flying 90s and the past five or six years of the new millennium. Recently sage statesmen like Steve Schroeder, former head of the Robert Wood Johnson Foundation, have ventured back into this space. In 2006, he and co-author Stephen Isaacs had this to say: “Race and class are both independently associated with health status, although it is often difficult to disentangle the individual effects of the two factors.”¹

Now, as a new presidential election approaches, and a change in leadership is assured, the connection between poverty, education and health is coming into sharper focus. This time it is with an eye toward the natural economic impacts that are predictable should current trends in increased rates of poverty, declining personal income, and widening income inequality continue to escalate.Epidemiologist Steven Woolf recently had this to say: “Given the influence of social determinants on health, efforts to improve education and income – seemingly unrelated to medicine – have the potential to accomplish more to reduce the severity and costs of major diseases than traditional medical advances.”²

Here are the facts:

• Poverty is on the rise in the United States. It rose overall from 11.3 percent to 12.6 percent from 2000 to 2005.^3,4 Severe poverty, that is 50 percent or more below the poverty level or less than $10,000 a year to support a family of four, increased from 4.4 percent of our population to 5.4 percent. Children accounted for one in three poor people and rates in blacks and Hispanics were 24 percent and 21 percent compared to whites at 8 percent.^3,4,5
• Except for the top 10 percent, U.S. household income is declining. While total population income grew 9 percent in 2005, income for those below the 90 percent percentile declined by .6 percent.⁶
• Income inequality -- that is, the distance between our richest and poorest citizens -- is rising. The portion of our nation’s total income coming from our wealthiest ten percent rose from less than a third (31 percent) in 1980 to nearly half (44 percent) of our combined earning in 2006. Those in the top one percent, earning more than $250,000, now account for 17 percent of national income compared to just eight percent in 1980.⁶ And the gap between employer and employee income has exploded. In 1965, the average U.S. corporate CEO’s salary was 24 times that of the average employee. In 2005, it increased to 262 times the average worker’s salary.⁷

But what does this have to do with health? The simple answer? Everything! Consider that the greater your poverty, the more limited your health insurance, the lower your adherence to treatment plans, the more likely you are to forego medicines or screening exams, and the more likely to smoke, be inactive, have poor diet and be overweight.² And these effects compound in children, building a burden of disease for the nation that extends for decades down the line. Poverty also means less education. Rates of chronic disease after correction for other variables in those without a high school degree compared to college graduates are world’s apart. In the former, diabetes affects 12%, compared to just 6% in college grads. And for coronary artery disease the rate is 10% for poorly educated compared again to 6% in college educated citizens.⁸

As we look ahead, we would do well to look back. What would my father do? Build more hospitals and chase the disease curve? Not likely! I expect he’d try to figure out how to give his patients a hand up, how to get them a better job or at least a higher hourly wage, how to get their children better educated, how to network them into community resources to address their fear, safety and depression, how to get them to save and plan and dream and accomplish. As Dr. Woolf says, “Improved income and education could reshape disease trajectories and medical spending, but their benefits could also extend beyond the health sector to more broadly improve the lives of individuals, communities and the economy.”²

As dad would say, “that’s just good common sense.”

References

1. Isaacs SL and Schroeder SA. “Class – the ignored determinant of the nation’s health.” New Engl J of Med. 2004; (3511):1137-1142.

2. Woolf SH. Future Health Consequences of the Current Decline in US Household Income. J Amer Med Assoc. Oct 24/31, 2007; 298(16):1931-1933.

3. DeNavas-Walt C et al. Income Poverty and Health Insurance Coverage in the United States. 2005. Washington, DC: US Government Printing Office. 2006:60-231. US Census Bureau Current Population Reports, consumer Income.

4. Woolf SH, Johnson RE, Geiger HJ. "The rising prevalence of severe poverty in America: a growing threat to public health." Am J Preventive Med. 2006; 31(4): 332-341.

5. DeNavas-Walt C, Proctor BD, Smith J. Income, Poverty and Health Insurance Coverage in the United States 2006, Washington DC: US Government Printing Office: 2007:60-233. US Census Bureau Population Reports, Consumer Income.

6. Piketty T, Saez E. Income inequality in the United States, 1913-1998. Quarterly J Economics. 2003;118:1-39.

7. Economic Policy Institute. "CEO-to-Worker pay imbalance grows.” Economic Snapshots. 21 June 2006. 

8. Pleis JR, Lethbridge-Cejku M. Summary health statistics for U.S. adults: National health Interview Survey. 2005. National Center for Health Statistics. Vital Health Stat 10. 2006:10(232):1-153.