This essay was an address to the 2003 graduating class of the Johns Hopkins Medical School.
The growing inequalities we are witnessing in the world today are having a very negative impact on the health and quality of life of its populations. It is true, as many conservatives and neoliberal authors continue to stress, that health indicators are improving in many parts of the world, including in many underdeveloped countries. But what these authors are not saying is that the rate of improvements in these indicators have slowed down in most countries that have experienced a growth of inequalities, and in many of them, including the United States, these indicators have even reversed. According to the last report of the National Center for Health and Vital Statistics, infant mortality in the United Staes has increased, reversing the decline that had occurred since 1953.1 The growth of inequalities is thus bad for people’s health. But why?
One answer, which is only partially true, is that the growth of inequalities is usually accompanied by the growth of poverty. When inequalities increase, some people’s standard of living becomes much better, while other’s becomes worse. It is within these latter groups that health indicators deteriorate. But although there is an element of truth in this explanation, it is not the whole truth. As a matter of fact, it is a very small part of the whole truth.
What is the truth then? The answer is that inequality is in itself bad, i.e., the distance among social groups and individuals and the lack of social cohesion that this distance creates is bad for people’s health and quality of life. Studies performed among civil servants in Great Britain have shown, for example, that life expectancy (the years that people can expect to live) among the top civil servants, grade 32, is longer than the life expectancy of civil servants of grade 31, who have longer life expectancy than civil servants of grade 30, and so on, reaching the lowest life expectancy at grade 1. There is no poverty among British civil servants, but there are significant differences in their life expectancies. The same finding has been replicated in other countries. In Spain, for example, we performed a similar study, looking at life expectancy by social class, and we found that the members of the bourgeoisie (the European term to define the corporate class) live an average of two years longer than the petit bourgeoisie (the term to define the upper middle class), who live two years longer than the middle class, who live two years longer than the skilled working class, who live two years longer than the members of the unskilled working class, who live two years longer than the unskilled working class that has been chronically unemployed. The difference between the two poles—the corporate class and the chronically unemployed—is ten years. This average distance in the European Union is seven years. In the United States, it is 14 years.2
Why these differences in life expectancy? A lot of research has been done in the attempt to answer that question. And we have enough evidence to provide an answer: social distance and how that distance is perceived by people, in addition to the lack of social cohesion that it produces, is at the root of the problem. This situation appears clearly when we compare the life expectancy of a poor person in the United States (who makes $12,000 a year) with the life expectancy of a middle-class person in Ghana. The poor person in the United States is likely to have more material resources than the middle-class person of Ghana (who makes the equivalent of $9,000). The U.S. resident may have a car, a TV set, a larger apartment and other amenities that the middle-class person in Ghana does not. As a matter of fact, if the world were considered a single society, then the poor in the United States would be a member of the worldwide middle class and the middle-class person of Ghana would be part of the worldwide poor—certainly poorer than the poor in the United States. And yet, I repeat, the poor citizen of the United States (although of the worldwide middle class) has a shorter life expectancy than the middle-class person (although of the worldwide poor) in Ghana (two years less, to be precise).
Why? The answer is simple. It is more difficult to be a poor person in the United States than a middle-class person in Ghana. For the poor person in the United States, the worst component of his or her existence is not primarily the absence of material resources, but rather his or her social distance from the rest of society. He or she feels frustrated, a failure, unable to fulfill the expectation of becoming a successful member of the mainstream and attaining its standard of living, which incidentally, for those depicted in the media as mainstream (and very much in particular in the broadcast industry), is higher than the national average. Indeed, the image of the mainstream does not correspond with the reality of the average person in our society. Most TV program characters, for example, are professionals in the upper middle class. Very rarely are blue-collar workers, nurse’s aides, carpenters, or taxi drivers, for example, the main characters in TV programs. The establishment’s media has, in general, a wrong view of how average U.S. citizens live and work. In the United States, the American Dream imparts an idealized vision of what Americans really are. The frustrations of those who do not see themselves a part of that mainstream in America are indeed a source of pathology. It is very difficult—emotionally as well as materially—to be outside of what the U.S. establishment defines as mainstream, which, I repeat, has a much higher than average pattern and standard of living. Moreover, the massive poverty that exists in terms of political and collective resources available to defend the interests of the majority of working people in the United States explains their enormous feeling of powerlessness and lack of social cohesion, both of which give rise to disease.
In fact, we have found that countries with strong labor movements, with social democratic and socialist parties that have governed for long periods of time, and with strong unions (Sweden, for example), have developed stronger redistribution policies and inequality-reducing measures of a universalistic type (meaning that they affect all people) rather than antipoverty, means-tested, assistence types of programs. These worker-friendly countries consequently have better health indicators than those countries where labor movements are very weak, as is the case in the United States, a corporate-class-friendly country. The reason for this difference is that the sense of social cohesion is larger in the worker-friendly countries, the sense of power and participation is higher, and the feeling of social distance is smaller than in the corporate-class-friendly countries. The evidence for this conclusion is plainly overwhelming.3 However, you would not know it by reading the scientific medical literature in the United States, which focuses on the biological, genetic, and behavioral aspects of health but rarely on the social and political determinants, thus revealing the ideological bias of most scientific, medical, and even public health research at our U.S. institutions.
This neglect of the social and political determinants of health persists despite the fact, known for some time, that social distance is bad for your health. Researchers in the UK, for example, have found that the period in the 20th century during which the most significant increases in life expectancy occurred in the UK was, paradoxically, the years of the Second World War. And although improvements in nutrition (due to government rationing of food) contributed to this situation, the fact is, the most important factor was the reduction of social distances that occurred as a result of people of all classes committing themselves to the same project (the war to defeat Nazism) and making sacrifices in the pursuit of a cause the majority of people believed in. Those who lived during that period in Great Britain will tell you that never before had people felt so much camaraderie toward one another. Complimenting this sense of togetherness were the public policies that curtailed some of the privileges of the establishment, policies that were developed to garner popular support for the war effort, and which reduced the inequalities that existed in that country. Needless to say, classes and class differentials still existed, but the social distances were significantly reduced, resulting in the improvement in life expectancy for the majority of classes.
As an example of the other extreme in social cohesiveness, we can look at Great Britain during the Thatcher years—when neoliberal policies were implemented, resulting in significantly higher social inequalities in that country—and see how the rate of decline in mortality that had occurred during the previous 20 years slowed down for all ages and for the majority of classes. The increased lack of social cohesion, the sense of insecurity and the Darwinian competition that the Thatcher policies created negatively affected the health of the majority of the British population.
It is likely that the same thing happened during the same period of time, the 1980s, in the United States. Unfortunately, however, the United States does not collect or tabulate mortality statistics by social class. The United States is one of the very few countries that do not include class in its national health and vital statistics. It collects health and vital statistics by race and gender but not by class, even though, as I have shown, class mortality differentials are far larger than race or gender differentials.4 Class discrimination is the most frequent and least spoken of type of discrimination in the United States. The U.S. establishment (including the scientific establishment) does not document the existence of classes, even though class is the most important variable in predicting ways of living and dying in this country. Still, although we do not publish mortality statistics by class, we can see how the enormous inequalities we are experiencing in the United States are affecting our population’s health indicators. Infant mortality, for the first time since 1953, has increased, and this is not only the result of increased poverty but is also caused by the increase of inequalities, with the subsequent growth in sense of distance and lack of cohesion that leads to ill health. This is the reality behind mortality statistics of which you should be aware, and yet, you are not. The most effective public intervention in reducing mortality in the United States would be to reduce the social inequalities among our people. The scientific evidence shows this. But in this case the science is ignored.
1. Infant Mortality Tables 19462002, National Center for Health Statistics, U.S. Department of Health and Human Resources, Washington, D.C., 2004.
2. Vicente Navarro, ed., The Political Economy of Social Inequalities: Consequences for Health and Quality of Life (Amityville, N.Y.: Baywood, 2002).
3. Vicente Navarro, ed., The Political and Social Context of Health (Amityville, N.Y.: Baywood, 2004).
4. Vicente Navarro, Race or Class versus Race and Class: Mortality Differentials in the U.S., Lancet 336 (1990): 12381240.
For further reading on inequalities and health see Vicente Navarro, ed., The Political and Social Context of Health (Amityville, N.Y.: Baywood, 2004); and Vicente Navarro & Carles Muntaner, eds., Political and Economic Determinants of Population Health and Well-Being: Controversies and Developments (Amityville, N.Y.: Baywood, 2004).
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