Health and Poverty in the US
by Stephen Bezruchka; December 09, 2003
I want to talk about how healthy the people are in the United States of America, why we are less healthy now than we should be, how we used to be much healthier, in comparison to other countries, and what we need to do to regain our health ranking. To consider the reasons, we have to address issues of poverty for that is the critical concept that is related to health. I will talk a great deal about one critical form of poverty, relative poverty, how you compare to others, and how that affects our health. I will say that more than bringing the bottom up, we have to bring the top down. I will give a prescription for health.
It is really difficult to talk about poverty in the United States of America, because many people don't identify with being poor. We are mostly all middle-class here, right? Being poor is a bad choice of words to use because it stigmatizes. So I will deal with you who are families and working people, and people with low income but who may still be struggling to make ends meet.
To admit that you are poor in America might mean that you will be permanently poor, especially in the land of the American Dream, namely that before we die, we will all achieve wealth, happiness and prosperity--own our home, the big car and other symbols of success. It all depends on us, that we have to pull ourselves up by our bootstraps, work hard, and we can achieve anything we want. Arent we entitled to that?
That is all that Bill Gates did. Or Magic Johnson. Or Oprah Winfrey. I don't know if that is true, some people would say that Bill Gates was born into a very privileged family. The facts show we have much more poverty in the USA today than in all the other rich countries. That is not good.
In the 1950s, my father repaired shoes, and we lived above the shoe repair store in a tiny apartment. We didn't have a car for a long time. We also lived in a working class neighborhood, where everyone else was pretty much in the same shoes as we were. Although we had a TV by 1953, the programming back then was pretty basic, and didn't display lifestyles of the rich and famous, so we didn't get a sense of how little we had and we weren't made to want.
So I never thought of myself as having less than other people until I went to college and made friends with people who went off to Europe in the summer. Who had vacation homes. Then I thought of myself as working class or lower class. In fact, I remember well having a discussion with a friend of mine in graduate school at Harvard University in which I described myself as working class, or lower class. He said, there was no way you could get to Harvard and be working class as was the case in the 1960s.
After graduate school, I spent a year in Nepal, a little country sandwiched along the highest mountains in the world, where Mount Everest sits. There were no roads there then, and still there are very few so to get somewhere you had to walk. There were no lodges or hotels then, so the few travelers there stayed in people's homes, ate their food, and slept around the fire on the mud floor, just as the families did together with the children and grandparents. These people had next to nothing, yet they didn't seem to want anything. I know now why they didn't want anything. There was no advertising of the things they should want. I spent a whole year totally without any form of advertising. It was a profound experience. So these people had the basics, food, water and shelter, and the love and company of their family and community. And they shared this with me. They laughed, played, never let their children cry and seemed happy, and I know they were. But you would call them desperately poor if you saw their situation today.
Some of you might say I am romanticizing the situation, describing the noble savage. I used to think maybe I was wrong, but I'm now convinced that happiness and satisfaction are not something you buy.
What about poverty and health? I have been working as a medical doctor for 30 years, much of that spent in emergency rooms, trying to look after people's health problems that arise quickly, I started doing emergency care in 1977 because I thought that is was really helpful for people.
I've continued to practice in emergency rooms in the US for the ensuing 25 years. I occasionally thought about the kind of people that I would see in the ER, the kind of people having accidents, or heart attacks, or as parents of sick kids. Mostly they seem to have one thing in common, they are not rich people, they aren't wealthy.
Now much of my time has been spent working in ER's in Burien, White Center, Tacoma, and Lakewood, as well as near the Central District in Seattle. There are a lot of low-income people living there, struggling to make ends meet. But I also worked in Bellevue, near where the richest person in the world lives, as well as the home of other billionaires, and multi-millionaires. What kind of patients did I see in the ER in Bellevue? Were they rich? Well, occasionally, I would see someone that I would surmise was well off, but for the most part, the rich didn't come, even to a hospital in a rich neighborhood. You might say that when they were in a hospital gown, or strapped to a stretcher, that it would be hard to tell if they were rich or not. But even stripped naked, it isn't hard to tell. For one thing, people with low incomes often interact with people differently. Often they don't make eye contact with you, but look down. And when they do look at you, their eyes betray a tough life. Sometimes they are angry and rushed, wondering why they have to wait for so long. For another, they tend to be more obese, sometimes much more.
They tend to use words differently, when we talk. They might say "Doc I have this serious pain in my stomach," for example, rather than saying "Doctor, I'm having some discomfort in my abdomen that is associated with some loose movements." You might think I am saying that low-income people are dumb, and didn't do well in English at school. They are certainly not stupid, and they speak English different from the rich, but it ain't wrong to speak that way.
I began to think that maybe poorer people got sick more than rich people. You might counter that and say no, the rich have their own private doctors and don't go to ER's but call their doctors anytime of the day or night. Surely that wouldn't be true in the middle of the night, whether at a hospital that serves the poor or one that serves the rich. You have to come to the hospital when your appendix bursts in the middle of the night, whether youre rich or poor.
What do YOU think? Are rich people as sick as working class people or people with low incomes? Raise your hands if you think so?
The studies overwhelming show that for every health condition, for every disease, for every cause of death, those who have lower incomes have it much worse than those who have fatter paychecks. In other words, if you work where you have to see sick people, such as in emergency departments, you are going to see poorer people for the most part, no matter whether your hospital sits in a wealthy neighborhood, or a poor one. Coming to see that, namely that poorer people had poorer health, was a major revelation for me. Now I'm not saying that all rich people live long healthy lives and the people of more modest means live shorter sicker lives. We all know of counter-examples to that. The tragedy of Princess Diana comes to mind. But as a statement about populations, about communities, wherever you look at it, poorer people have poorer health. The next question I asked was WHY this was so.
So why do people with lower incomes get sick more? Is it because they smoke more, which they do? Is it because they drink more, which they may do? Is it because they shoot up more heroin, which is true? Is it because they eat more, which is true? Is it because they don't exercise as much, because they don't?
Well, the studies show, that such behaviors that we consider bad for health explain only about 10% of the reason that poorer people have poorer health. Learning this has been a revelation for me over the last ten years. I used to get complaints in the ER for keeping harping on people to quit smoking. For a chronic lunger who continues to deteriorate and keeps his two pack a day habit, patient's families would say to the administrator that all I would do is tell him to quit. Isn't there something else you could do, he's trying to quit but can't. Like most of us, I used to blame sick people for their behaviors that made them sick. But I don't now, I blame myself for allowing the rules that govern our society change to produce the behaviors that are bad for us.
Is it because lower income people can't afford health care? Is that why they get sick more? It is tempting to say that is the reason, but it isn't. I know some of you here may not have health insurance. Perhaps some of you have huge medical bills that you are struggling to pay. Health care, or the lack of it, doesn't explain why poorer people have poorer health. Consider the Hispanic population. They don't access health care much, they tend to not have medical insurance, they tend not to go to the doctor. Countless studies show this and it represents a cause for concern. What is often not stated is that Hispanic people tend to be healthier than non-Hispanic whites. And it isn't because they don't go to see doctors, although that is a tempting thought. As a rule, most Hispanics are comparatively less well off than non-Hispanic whites, so later we will consider why they may be an exception to the poorer people have poorer health concept.
I expect you to be skeptical on this, but I would like to proceed with the observation that it is people of lesser means that are sicker, and it is not their behaviors such as smoking or diet that makes them sicker, for the most part. And it isn't access to medical care, or the kind of medical care people receive that accounts for the difference. Again, there are a lot of studies and science on the subject, and I'm asking you to suspend your disbelief and let me go on.
By its very nature, medical care can't have much to do with health. To consider why, I make the analogy that medical care's role is the same as that of the army medical corps in keeping us healthy. You've been reading about all these soldiers that are coming home from Iraq with legs blown off, or other serious injuries. Our media has been forbidden to show coffins of our troops coming home, but there have been many deaths, as you know. Now the army medical corps goes in after the blast and picks up the victims, splints the limbs, starts IV's, transports them to where they can get blood, and then to a field hospital station where bullet holes are closed. There heroics are carried out and hopefully the stricken soldiers survive. We feel grateful in such cases. But most casualties, those who die, are killed outright by the blast, by the bullet or bomb. The army medical corps can't do anything for them. The army medical corps did not decide that we were going to invade Iraq, they didn't decide the battle strategies, that we were going to bomb targets including civilians, from the air, that later we would send in ground troops. They didn't decide on the day-to-day combat decisions. They didn't decide on the protective gear that troops would wear. All they do is go in and pick up the pieces, those fortunate ones who still have signs of life. That is the best that medical care can do, try to keep the survivors alive. So by its nature, medical care can't have much of an impact on health, despite what you are led to believe. In my courses at the University of Washington, I go into great detail about this, and as a practicing doctor, I believe this is true. Colleagues of mine, who have considered the issue of what medical care does in making communities healthy, agree, as do the experts who write papers and books on this subject. That is not to say that I don't believe in medical care. I work as a doctor providing medical care, and I teach young doctors as well. And if I get sick, I see a doctor. And if I collapse here on the podium, I want you to call 911. But we should not deceive ourselves that this is what makes us healthy as a population. I'm sure you think this sounds weird, counter-intuitive if you will.
I expect you to be skeptical on this, but I would like to proceed with the observation that it is people of lesser means that are sicker, and it is not their behaviors such as smoking or diet that makes them sicker, for the most part nor is it access to health care.
I hope by now you are asking why poorer people have poorer health. That is the right question to be thinking of. Thomas Pynchon wrote in Gravity's Rainbow: "if they can get you asking the wrong question, the answers don't matter." I think we ask too many wrong questions in America today. What does matter most is the nature of our relationships with each other, the social nature of ourselves, the psychosocial element, if you will. Let's explore that.
Think of health as the expression of our life experiences. We all know the physical effect that stress has on our minds and bodies, our immune systems and our ability to fight off diseases. The reason poorer people have poorer health has something to do with the basic nature of living with and in poverty, especially what you live amidst plenty and have that rubbed in your face. That is what being a family living with low income is all about.
If I were to ask you in this room, how many of you consider yourselves poor, I think fewer hands would go up, than if I asked you if you were middle class. What is that all about? If you admit you are poor, you are shaming yourself, and feeling shamed is the essential human emotion when it comes to understanding an important aspect of health. Now many people with lower incomes, many disadvantaged people, won't admit feeling shame, but feel the shame deep inside, nevertheless. Doesnt it make sense that these feelings would have a strong impact on our physical, as well as mental health?
So what does being poor mean? What is poverty, or living with lower incomes all about in the USA? Or in Seattle? Let's start by leaving out the homeless. There are more than a million homeless children in the USA, the richest and most powerful country in world history. I don't know how many homeless there are in total in the US, but I've seen statistics quoting 1.5 million in California alone. The 2001 One Night Count accounted for 7,350 people who are homeless in King County. I would imagine the number for the whole country is probably somewhere between 10 and 20 million, and could be a lot higher. For those of you who are older like me, if you think back 25 years and reflect on whether or not you saw any homeless people, you would probably find that you didn't. And the studies show that as well. Not that there weren't any then, but you might see one in a week or a month instead of one every few minutes in some areas. . The reason for the homeless is that Ronald Reagan cut funding for low-cost housing in 1981, and right after that, there they were on the streets. But I said I wasn't going to delve into poverty among the homeless and will stop at this point.
So what about the poor, people who are almost homeless, for that is what the situation is like. These people are often one paycheck away from being evicted. In Washington, a worker earning the minimum wage (7.01 per hour) must work 86 hours per week in order to afford a two-bedroom unit at the states median Fair Market Rent But even if you are not so poor, is it because you don't have enough to eat? A roof over your head? Central heating? Is it because you don't have a microwave, or a refrigerator? Is it because you don't have a TV and VCR? Is it because you don't have a cell phone? No, many low income people have all these items, they aren't close to being evicted, and yet they feel disadvantaged. Fifty years ago, the rich didn't have microwaves ovens, or VCR's or cellular phones. But now many low-income families have them. So it is important to note that being less well off is not about not having stuff such as items like cellular phones and VCR's that might have been considered science fiction devices fifty years ago. Being less well off is about feeling that you don't have the choices that the more well off do. It is not about the stuff you have. I said that it is people with low incomes who are obese, so they have enough to eat. People in the subsidized housing areas have a lot of stuff. Still they feel disadvantaged, and as my years of experience in emergency departments demonstrated, they are the ones who get sick. And so in a very profound sense, these people are disadvantaged in the most important way, namely they don't live as long or as healthy lives as do the rich.
Take me at this point. I'm certainly not poor now. As I said, I grew up in a working class neighborhood, and my father repaired shoes. We lived above his shoe store. I mentioned how I didn't feel poor until I left my neighborhood and was amongst people who had more than me and had greater choices than I did. Then I began to feel poor. In other words, I began to feel poor when I began to make comparisons of myself and my situation, with other people. By now, I have flooded you with the concept of class, I'm waging class warfare as some politicians might say. We have to be honest, this is what today is all about. It is class warfare. There is a war going on right now and it is the rich who are attacking everybody else. In fact this war has been going on for the last ten thousand years. Class Warfare is worse these last few years although our leaders would deny that it even exists. The weapons of class warfare are symbolic missiles, shot through our media-- TV, movies, magazines, and the internet. And it starts at a very young age. What are really Mediaography internet sites that our children are exposed to are not the crass sex that dirty old men like me would like to look at, but the Nike websites, or the movie stars web sites. The Nike sites display their shoes and the stars their environments. These are signs that the rich are winning the class warfare battles. Another sign is that people with low incomes are naming their newborns Gucci and Armani and other icons found on designer labels. In ER's I see people who have been attacked and robbed, and the key thing the robber got away with were their fancy new Nike tennies.
The essence of class warfare is that the rich make you compare yourself with others that you consider better off than you are. That is their weapon, their scud missile. IF you are rich, it doesn't mean you have more stuff, necessarily. It means that you can have it if you want it. You can do what you want. My friend Raymond, who made a lot of money, said he took care of his problems with the check principle. If he had a problem, he would find someone to take care of it and write them a check. Most of us can't do that.
Our societies today are like baboon troops in Africa, for example. There is the alpha male, or the top dog, and there are those in the pecking order below the alpha male. The alpha male gets the best food, and the pick of the females to mate with. The beta and gamma males have very different lives. Those lower down are always on alert that the alpha male will take the choice bit of food they have found, or chase them away from the female they were going to mate with. Their lives are under constant stress. We know that the alpha male is healthier than the beta and gamma males, the alphas have different physiology, a different stress response, than the baboons lower down. The gamma males, the lower ranking baboons are less healthy than the high ranking ones. Human studies show the same thing, that is people with low incomes have the stress responses of low ranking baboons.
So with baboons or humans, being lower down in the status ladder means you suffer more from chronic stress. This results in higher blood pressures, less ability to control glucose in the blood and so more adult onset diabetes, which we are seeing in younger and younger children as they are under more stress. This results in fat deposition around the waist and hips. This results in more plaque in coronary arteries that supply the heart and so we have more heart attacks in poorer people. Those lower down the status ladder have less ability to fight infection because their immune systems aren't as efficient. They are less able to search and destroy cancer cells.
So having low income in America is knowing that you aren't in the same league with those having higher status in our society. You generally don't do as well in school. You are more likely to be raised in a home where your mother has to work at several jobs to make ends meet. You may not know who your father is. You won't have the fancy car, or designer-label clothes, and won't go to France for the weekend. Or more likely, you will have the status Nike shoes, and will spend for those icons of status, and not be able to afford health care. You will tend to eat at fast food places, and shop in convenience stores. If you have a car, you will pay more money for gasoline, unless you travel to the cheaper gas stations, which are often not in poorer parts of town. If you don't have a car, you will be riding the shame train, or the bus. And you won't feel so secure walking down the street.
It begins way back when you were just a gleam in your parent's eyes. That is the effects of class and ranking and social status began to effect your parent's physiology and thus your biology to have an affect on your health. The most important time is from conception to age 2.
Perhaps you have a job, doing work that needs to be done. You do it well. Jobs that some might consider menial, such as working as custodian in a building after hours when the executives go home. Or you may work as a nurses aid in a nursing home. Or you may work at that convenience store, or be flipping burgers. You may find yourself suppressing your rage when the boss goes by. But if you are nice enough, you might get a Christmas present at the end of the year. Even if you are nice enough, you might get laid off in the next economic downturn. Most likely, you will have two or three jobs, all of them part-time, with no security or benefits. Alan Greenspan, the chairman of the Federal Reserve Bank, talked about the booming economy in the 1990s being partly because of a flexible labor force. Namely, workers worked for very low wages and could be laid off at will. I'm sure you will agree that it is good for the economy to be flexible like that but it sure isn't good for you or for your health to feel that insecure.
One thing that has happened in the last 30 years is that more people are not doing well in America. Not only are the homeless out in droves, but poverty, no matter how you measure it, has increased dramatically over this period of incredible prosperity in America. This isn't just true in America, but worldwide as I'm sure you are aware. There are many more poor people, the biblical promise is true "the poor ye shall always have with ye" only it might say the poor shall be ever more with you. This in a time of phenomenal wealth.
So my main point is that the culture of poverty, the culture of inequality that surrounds us is what has the most significant effect on our health. Let me clarify this idea a little bit. Those at every rung of society's ladder from the top to the bottom will have their health determined by where they stand in the ladder of social status in society. The poorer you are the worse your health in comparison to others.
Stated very simply, societies with a bigger gap between those on top and those on the bottom will be less healthy than societies where there is a smaller gap. To illustrate this, let us look at the health of the United States of America, measured by life expectancy, say, the average number of years lived in this country. Fifty-five years ago, we were one of the healthiest countries in the world by this measure. Today, there are some 25 countries that are healthier than we are. Think of it, all the other rich countries are healthier than we are, and a number of poor ones as well. It isn't just this one measure of health--life expectancy-- in which we do poorly, but in every other measure, when we rank ourselves with other countries. We are living longer but not so long as people in 25 other countries, all of them poorer than we are. For example, we have the highest infant mortality rate, the highest child poverty rate, the highest teen pregnancy rate, the highest child abuse death rate, and so on. There are no indicators in which we excel, except in spending money on health care, for we spend half of the world's total health care bill. Think of it - for every dollar in the world spent on healthcare, 50 cents is spent here. Yet our citizens are less healthy than those in all the other rich countries. And by less healthy, I don't just mean in how long we live, but in so many other indicators of health, such as teenage pregnancy rates, such as in homicides, or incarceration rates. Indeed we house one quarter of the world's prisoners in America, which says something quite significant about how we deal with petty crime in this country.
What has happened to cause this huge disaster? Stated simply, it is because we have changed the rules in this country as to who gets what share of the pie. Back fifty years ago, it was the poorest families that saw the biggest gains in income. Now, as you all know, it is only the rich and super-rich that are seeing gains in income, while the rest of us all have to tighten our belts. This may not seem right in explaining the reason for our poor health, yours and mine. However, it is true, it is because we have changed the rules in society and created many more poor people and that is why your health and my health is not as good as it could be.
Racism is another way that the gap operates to create worse health. Racism is all about difference and power. Minorities have always been put down, and feel the shame, even if they don't think about it. The rich want to continue to put people down, but use ever more subtle means. If you can put people down, if you can make them afraid, if you can make them want things, then you have power over them. An African American male in Harlem lives less long than a man in Bangladesh, one of the world's poorest countries. Or that a black man in Washington, DC lives less long than a man in Ghana, a country in West Africa.
Women tend to be healthier and live longer than men. As well, studies show that where women play a bigger role in political life of communities, they are even healthier. What is more astounding is how men's health improves in those situations even more than the gain for women. In other words, we all do better where women do better, and I'm sure most of you here know that.
It is important to recognize how much our health relative to other countries has deteriorated in the last 55 years. Consider that if we won the war on heart disease, the plague that will kill almost half of us in this room, if we had no more deaths from heart attacks, we still wouldn't be the healthiest country in the world. And yet 55 years ago, we were one of the healthiest. The difference now is that we live under more stressful conditions, a stress caused by the big gap between the rich and the rest of us. And when we go shopping at The GAP, that symbolic store, we don't even realize that this is the key problem in America.
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