Part 2...
How is it that a bigger gap society has worse health than a more egalitarian society. Consider two extremes: an egalitarian society where everyone is more or less equal, and a very hierarchical one where there are a few fabulously wealthy rich and the rest of us, sort of like the USA. What is life like in an egalitarian society? What are the prevailing relationships and feelings. Wouldn't they be those of friendship, support, trust, caring, helping, sharing, and community? Don't those words sound healthy? What about the other extreme, a very hierarchical society? What is it like inside such a population? Well, those on top with the wealth have power and can dominate, compel and coerce those beneath them to get things done. The rest of us resign ourselves to our job and role, but feel humiliated and shamed. Shame is the important emotion at work. None of these feelings such as shame or relationships of power and domination sound healthy, do they? But in countries such as the USA, these are the prevailing mechanisms at work, even though we think we are all middle class there is an ever increasing gap between the rich and poor here. In a society with a bigger gap, those above put down those below, and this is related to the amount of violence in society and helps explain why we have so much homicide. Costa Rica is an example of a nearby country that is pretty egalitarian, and even though it is much poorer than the US, it is healthier than we are. Canada is another example, our neighbor to the north, which is much much healthier than the USA. The final example is Cuba, a country that we have been strangling for 44 years with trade sanctions and embargoes. Cuba is as healthy as we are, despite, or maybe because of our policies.
Consider the healthiest country in the world, Japan. Fifty-five years ago when we were one of the healthiest countries in the world, right after World War II, Japan was less healthy compared to other countries than we are today. Yet the USA gave it the medicine it needed to become the healthiest country in the world by 1978. The medicine was prescribed by the greatest population health doctor who ever lived, General Douglas MacArthur. The medicine administered during our occupation of that country from 1945 to 1950 had 3 ingredients and I will review them here. The first was demilitarization. Japan was forbidden to have an army. The second ingredient was democratization, as MacArthur wrote the country's constitution, providing for a representative democracy, free universal education, the right of labor unions to organize and engage in collective bargaining, and the right of everyone to a decent life. The third D was decentralization, as MacArthur broke up the 11 family zaibatsu that ran the huge corporations that controlled the country. He legislated a maximum wage for the country of the equivalent of $4333 in US dollars. He also carried out the most successful land reform program in history. What this did is bring down the economic hierarchy, and level the playing field. The resulting rise in health is the most rapid ever seen on the planet.
Japan presents some interesting issues about population health. Japanese men smoke the most of all rich countries. Yet they are the healthiest population on the planet. It seems you can smoke in Japan and get away with it. It's not that smoking is good for you, but that compared to other things, it isn't that bad. Smoking is much worse for you in the US than it is for the Japanese in Japan, where the gap between the rich and poor is much less. So I tell people that if they want to smoke they should be born in Japan. Similarly, it isn't Japan's health care system that is responsible for its remarkable health. Anyone who has looked at their system will tell you it isn't much to write home about. I talked before about designer labels, and if you probe, you will find that everyone in Japan shops at designer stores and buys the Gucci icons. That is the key element, everyone wears them. In the USA, everyone wants them, and that is the difference. Japan is a caring and sharing society that looks after everyone and that matters most for your health.
Let me give my opinion now on why Hispanics have better health in the USA than non-Hispanic whites. It has to do with the support they give one another and their strong family lives that counter the adverse effects of the gap and their poverty. Much has been written about this so-called Hispanic Paradox. I came to understand the reasons by reflecting on Hispanic patients I see in the ER. I never see a single Hispanic patient. There is always a group of people huddled together. I have to go and figure out who the patient is, for everyone comes to offer support. By contrast, I'm much more likely to see a white person lying there writhing in pain alone. So we can conclude that it is the nature of psychosocial relationships, the support people have and give in a society, that is more responsible for their health as communities, than any other factor.
So what has happened in America to bring about our health decline? We have changed the rules in America that decide who gets what share of the pie. How we decide where to spend tax dollars, how we decide who to tax and how much, how we decide to fund basic research and development. How we decide to give subsidies to various elements of our society. Instead of trying to make the rules level the playing field, we have decided to let the rich have as much as they can grab, and we'll be happy to share the crumbs. I say we'll be happy, because if you ask many if not most Americans whether they feel the rich should get as much as they do, you'll get an answer something like: "of course the rich deserve it because they work hard, and are better than we are" or something like "yes I'm in favor of having a big gap between the rich and the poor, because someday I'm going to strike it rich and I want to have it all then."
We have been seduced into believing in the American Dream, the rags to riches myth, the Horatio Algier stories, where if we just work hard enough we can attain anything we want. The American Dream, ladies and gentlemen, is a nightmare. Among all countries studied, we have the lowest percentage of people making it, in the sense of going from rags to riches, whether in one generation or two. That is what the economists who have studied this show.
And the price we pay for believing in the American Dream is, I say, the ultimate price. Namely, you and I die younger than we need to, so much younger that it is equivalent to winning the war on heart disease. Our president, speaks of the estate tax as the death tax, and it really should be called the Death Averting Tax, since it helps narrow the gap a little and avert deaths. As he signs more tax cuts on the rich into law, he should be honest and tell you that this is a small price to pay for living in this richest and most powerful country in world history, namely you live less healthy and die much younger than you need to. But the rich are appreciative, all the way to the bank. What even they don't know is that even they die younger than they need to by living in this country.
So if we are going to ask the right question at this point, it may be something along the lines of "what happened, how did we let things get to this point?" Our story begins at the end of the Second World War. It was a difficult period for the world, and for Americans. We lost many lives in that conflict, and many people suffered without dying by serving in the war effort. So it was felt that such people needed to be taken care of. The oldest amongst you may remember GI-loans, housing loans, education bills that allowed vets to go to school. Our tax structure was very different then. Compared to today, the rich paid over 90 % on their top chunk of income instead of around 35% today. The tax rate on the bottom income category has remained about 25% through all this time period. So the rich have taken proportionately more home, than the rest of us have. And the gap grows.
After the Second World War, our businesses and industry did very well, with technological advances, and work in rebuilding Europe. They enjoyed high profit margins on revenue. They were happy. But towards the end of the 1960s and in the 1970s, their profits declined because of competition from Japan and other East Asian economies that began in earnest then. In 1940, corporations paid 40% of the federal tax bill. But with declining profits, they managed to demand lower tax rates, just as the rich did, so by 1960 they paid 26% of the federal tax bill. But with further declining profits, they wanted even more government handouts, and so by 1990 they were paying 13% of the federal tax bill. They also enjoyed huge government subsidies, in other words the taxes we paid went into their coffers in many ways that are probably familiar to you here. Of course the rich and powerful have only wanted one thing through history, and that is everything. So by 2002, last year, corporations paid only 7% of the federal tax bill. As Greg Palast says, we have the best democracy money can buy, and so these rich corporations buy themselves tax breaks and huge government subsidies by funding so-called democracy.
Another way to look at this is how much we pay our CEO's - the heads of our corporations. In 1980, we paid them 40 times what an entry level worker made. By 1999, they were being paid 478 times what an entry level worker made, and in 2001, for the Fortune 100 companies, the CEO's made a thousand times what an entry level worker made. If we ask what is the maximum wage in the US, it is around $150,000 an hour, and this person got a $10,000 an hour pay raise over the year before, while his company performed poorly and the stock price dropped 67%. As we say in America, nice work if you can get it, and you can get it if you try. Now in Canada, our much healthier neighbor to the north, the CEO/worker pay gap is twenty to one, while in Japan, the world's healthiest country, it is eleven to one. In the recent economic downturn in Japan, what did CEOs and managers do? Lay off workers and take pay raises? No, they took pay cuts rather than laying off workers. This isn't what our CEOs do. They lay off 40,000 workers and give themselves a bonus for increasing efficiency. This is not good for our health!
If corporations used to pay 40% of the tax bill and now only pay 7%, where is the rest coming from? Look in the mirror. Since the 1950s, the working class have paid proportionately more taxes than the rich. And today's tax relief for the rich, boy the rich are really hurting and need tax relief, is just the latest example. As an example, I'm sure that all of you in this room paid more income tax than our biggest employer in Washington State did in 1995. You all paid more tax than Boeing did in 1995. That is, unless you received or than a $33 million tax credit that year. In other words, we paid Boeing, you and I paid Boeing, $33 million as their tax bill that year.
It is one thing to talk about income, the take home pay-check, which you are all familiar with. But what really matters is assets, wealth. Remember, you are sitting on your assets. The gap in wealth is even more obscene than the gap in income. The richest ten percent have almost 80% of the assets in this country. The richest one percent have almost half. So there isn't much left for you and I. In fact, from 1983 to 1995, the bottom 40% of families in America actually lost assets. The cushion under you became harder to sit on during that time period.
At the same time, we have done everything we can to make life worse for the working class. As I mentioned, we cut funding for low cost housing, throwing millions on the street. We have cut funding for public schools with the result that our students score worse on international achievement test comparisons. We have done everything to decimate the family, at the same time as we preach family values. We have the highest percentage of single-person households among all rich countries and the great number of children being raised in single-parent families. It would be nice if the parent was there to raise the child, but instead we force the parent to work at several low-paid, insecure jobs, and leave the child rearing to the wolves. Studies have shown in Sweden that being raised in a single-parent family is bad for the child's health. Not only do such children become sicker, spend more days in hospitals, and have more behavioral problems, they also have higher mortality. In other words, in a country like Sweden, which has social supports unimagined in the United States, kids being raised in single-parent homes die more. Why? Well, as I said, in Sweden, it isn't that these homes lack enough stuff. But the mother isn't there to provide the time with the child, and in the end that is the critical factor. For early childhood to lead to health as an adult, secure attachment to a parent is a strong, health promoting, factor. It is important preventive medicine. Perhaps the most important aspect of preventive health care we could ever do. But Clinton decided to end welfare as we know it, and our children are paying the price with their poorer health and the greater likelihood of ending up in a coffin. If you are a single mom please don't think I'm trying to make you feel guilty for doing so by suggesting your child won't do as well as if you were married. My son, now 21, was not raised in a two-parent family and I wish it were otherwise, as I think he would be healthier. But the reasons families split up are most basically political and economic, and could be changed. But most of us would think that personal reasons are involved. While this is true at an individual level, it is the structure of society that makes it happen and helps us understand why family breakup has become more common.
In other words, in the last 55 years we have drastically changed the rules of who gets what share of the pie in the United States of America. For our health, yours and mine, and that of the rich, we have to change them again, so we all get pretty equal pieces of the pie.
To summarize at this point. Poverty is bad for your health. Relative poverty, living in a large gap society, is the worst part of poverty. Poverty is not a certain amount of goods, but a form of invidious comparison between those who have more and those who have less. If the gap between the rich and poor is smaller, then the comparisons we make are milder. When the playing field is more level, it is easier to play. This is what justice is all about, avoiding having one part of society bearing all the burden but reaping none of the benefits.
So what can we do about this? As I said, I learn a great deal from comparing ourselves with people in other countries. I was surprised to learn that we have the lowest voter turnout of all democracies. In other words, fewer people vote in this country than in any other democracy. In the last King County election only 29% of the voters cast their ballots. Who doesn't vote you might ask? The answer: the young and those with less income. Think of it. Poorer people don't vote. If they don't vote, then there is no need to have any policies that favor those with less income, and the president can limit his actions to those that benefit the voters, namely the rich. Hence we have the tax relief for the rich, the end of the death tax which only benefits the very rich, and handouts for Enron, Bechtel and Haliburton among others. We need to have our voices heard!
Has any major leader every drawn attention to the fact that the working class doesn't vote, and tried to encourage them to vote, or designed programs to get poorer people more involved in the process of democracy? No way, why would they want to shoot themselves in the foot. So no, your leaders are not going to look out for your interests, unless you force them to do so. They aren't going to make voting day a holiday, as is the case in most other rich countries. They aren't going to make it easier to register to vote. And they will continue to have laws excluding people such as felons from voting. The rich are not dumb. Low income people are not dumb either, but they have been demoralized and think their vote doesn't count.
Some of you may recall the 1960s when riots occurred in inner cities in America, there was the anti-Vietnam war movement, and the civil rights movement was in full swing. The leaders of the free world considered that this was a crisis of democracy. The Trilateral Commission published a book entitled the Crisis of Democracy in which they pointed out that if people continued to take matters into their own hands, it would be a continuation of this crisis. They wrote about the problems when you have an excess of democracy. So the Trilateral Commission laid down the steps we had to take to avoid this excess of democracy, and these have been followed so we have the present problem of low voter turnout, but no crisis.
Things are only going to change when we work together for our interests, not the interests of the rich. We must say NO to more handouts for the rich. They have enough, and they really don't need more, although whenever I am around rich doctors, all they ever do is talk about how they need more money. The rich are always like that, after more.
If the poor organized, if the working class got together, it would be a piece of cake to change things. After all the poor and the working class are the majority in this country. If you remember that, if you recognize that all you have to do is talk amongst yourselves about these ideas, to speak up and begin to voice your needs, and push for policies that restore the status that working class people had in America before we gave it all away to the rich, then our health will begin to improve compared to other countries.
We need to shape the world that creates our life experiences and, hence, shape our health. This is not the land of equal opportunity. Unless you believe that a few people are naturally born to ride while most of us are born to be saddled, it's a sign that opportunity is less than equal. The only way out that I know of for those of us who are saddled today, is to throw off those saddles, and chase after the riders and put them in their place. We vastly outnumber those riders. Working together and organizing is our hope for improving our health as a nation. We need to bring back the crisis of democracy.
In other words, people like those of you gathered today and those you speak for, those who aren't rich, those who work, are this country's population health doctors. You are the people who need to prescribe the medicine that will get more assets into the hands of your children, that will increase the taxes on the rich, that will break down the power of the corporations, that will restore power to labor, that will give subsidies to those who need them rather than those who already have too much. The way to fight organized money is with organized people.
It was Mahatma Gandhi who said First they ignore you; then they laugh at you; then they fight you; then you win. And Martin Luther King Jr. said "True compassion is more than flinging a coin at a beggar; it comes to see that an edifice which produces beggars needs restructuring."
I talked about Doctor MacArthur, the greatest population health doctor ever. You out there can administer the MacArthur Medicine, remember the three ingredients: the three D's of demilitarization, democratization and decentralization--bring down the Walmarts. We can take the same medicine we gave Japan, that is we can take our own medicine, or we can ask Japan to administer it to us.
I will end by reading a poem
THE LOW ROAD
By Marge Piercy
What can they do to you? Whatever they want. They can set you up, they can bust you, they can break your fingers, they can burn your brain with electricity, blur you with drugs till you can't walk, can't remember, they can take your child, wall up your lover. They can do anything you can't stop them from doing. how can you stop them? Alone, you can fight, you can refuse, you can take what revenge you can but they roll over you.
But two people fighting back to back can cut through a mob, a snake-dancing file can break a cordon, an army can meet an army.
Two people can keep each other sane, can give support, conviction, love, massage, hope, sex. Three people are a delegation, a committee, a wedge. With four you can play bridge and start an organization. With six you can rent a whole house, eat pie for dinner with no seconds, and hold a fund raising party. A dozen make a demonstration. A hundred fill a hall. A thousand have solidarity and your own newsletter: ten thousand, power and your own paper: a hundred thousand, your own media; ten million, your own country.
It goes on one at a time, it starts when you care to act, it starts when you do it again after they said no, it starts when you say WE and know who you mean, and each day you mean one more.
Thank you.
Stephen Bezruchka MD, MPH Senior Lecturer: International Health Program Department of Health Services School of Public Health and Community Medicine University of Washington Box 357660 Seattle, Washington 98195-3576, (206)932-4928, Fax (206)685-4184
sabez@u.washington.edu
