Being Poor and Sick in the US

Health system reform for the "Two Americas"

By Mike Magee, MD

I entered Medical School in 1969, nearly 40 years ago. During my lifetime in medicine in the United States of America, we have gained a much better understanding of the scientific causes of disease, how best to address this burden, and as a result have increased lifespan significantly. But is that the entire story?

A recent study by Dr. Majid Ezzati and colleagues at Harvard of health statistics, county by county across America, from 1961 to 1999 suggests not.¹ Here's what they found:

Overall U.S. life expectancy increased from 67 to 74 years of age for men and from 74 to 80 years for women.
Between 1961 and 1983, the death rate fell in both men and women, relatively evenly across America, mainly the result of reductions in deaths from heart disease and stroke.
In the early 1980s this trend reversed itself in some of the counties across the nation.
In the poorer counties, death rates began to increase -- especially for women --a shift that the researchers call “the reversal of fortunes.” Why? The culprit appears to have been a reduction of deaths from cardiovascular disease and some increase in disease burden from lung cancer, chronic lung disease, and diabetes, in both men and women, as well as a rise in HIV/AIDS and homicide in men.
Of the 3,141 counties measured between 1983 and 1999, 30 percent of the counties showed a reversal of positive trends for women, and 2 percent of counties showed a negative trend for men. Those counties that declined showed a positive correlation with lower socio-economic conditions.
Stagnation or increase in mortality was notable among the poorest segment of the population, affecting 4 percent of the poor male population and 19 percent of the poor female population.
Putting it all together - the gap in health between poor and rich in America initially narrowed and then widened.

This newest report documents what global and national public health experts have been stating about American health care for more than a decade.

In 1999, the U.S. health care system received a shot across the bow from the World Health Organization. The W.H.O. had been fast at work on a comparative study of national health systems. The study ranked the United States a dismal 37th, primarily because we scored comparatively low in distribution of resources and in distribution of financial burden.²

The report seemed to reveal the issue of feast or famine in U.S. health. The feast? According to a 2002 Institute of Medicine report, Americans today, compared to Americans in 1900, "are healthier, live longer, and enjoy lives that are less likely to be marked by injuries, ill health or premature death."³ The famine? As stated by health policy experts Stephen Isaacs and Steven Schroeder in the New England Journal of Medicine in 2004, "Any celebration of these victories must be tempered by the realization that these gains are not shared fairly by all members of our society." They went on to say that, "Race and class are both independently associated with health status, although it is often difficult to disentangle the individual effects of the two factors."⁴

A few simple numbers illustrate this point. Whites have a median net worth in the United States that is 10 times greater than blacks.⁵ While 11 percent of whites live below the poverty line, 27 percent of blacks struggle with poverty.⁶ The life expectancy of blacks is seven years less than that of whites. And blacks suffer higher rates of cardiovascular disease, diabetes, hypertension, infant mortalities, homicides, and a variety of cancers.⁷

Are these differences due primarily to race or class? It's clear that prejudice and discrimination, the hallmarks of racism, impact the health of minorities in America. But low socioeconomic status, which is often a byproduct of racial discrimination, may be the dominant contributor to poor health. Factors previously associated with low socioeconomic status and poor health include poor nutrition, increased smoking, decreased exercise, increased stress and fear, unsafe neighborhoods with high crime levels, substandard housing, inaccessible and expensive services, environmental hazards, and poor schools.⁴

Why is this important now? The Harvard study above dramatically and geographically links health to poverty. With the 2008 election just around the corner, and with health care reform front and center, we need to remember John Edwards’ emphasis on "two Americas" and understand that we will not be able to successfully address health care in America without simultaneously addressing poverty.

For Health Commentary, I'm Mike Magee.

References

1. Ezzati M, Friedman AB, Kulkarni SC, Murray CJL. The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States. PLoS Med 5(4): e66 doi:10.1371/journal.pmed.0050066. 2008

2. World Health Organization Assesses the World's Health Systems [news release on World Health Organization Web site]. Accessed November 30, 2004.

3. Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public's Health in the 21st Century. Institute of Medicine. 2002. Accessed November 30, 2004.

4. Isaacs SL, Schroeder SA. Class - the ignored determinant of the nation's health. NEJM 2004;351;1137-42.

5. Williams DR. Race and health: trends and policy implications. In: Auerbach JA, Krimgold BD, eds. Income, socioeconomic status, and health: exploring the relationships. Washington, D.C.: National Policy Association, 2001:70. Cited in Isaacs SL, Schroeder SA.

6. U.S. Census Bureau. Poverty in the United States. 1997. Accessed November 30, 2004. Cited in Isaacs SL, Schroeder SA.

7. Thomas SB, Quinn SC. Eliminating health disparities. In: Braithwaite RL, Taylor SE, eds. Health issues in the black community. San Francisco: Jossey-Bass, 2001:543-63. Cited in Isaacs SL, Schroeder SA.