Health-onomics

Source: CIA World Factbook (life expectancy) and
Wilkinson and Pickett, 2009 (income inequality) 

Higher inequality means poorer health outcomes. The US is a case in point. It has the highest level of income inequality in the industrialised world. And at birth, Americans can typically expect to live shorter lives - around 79 years compared to 82 years in Switzerland (Figure 1) and nearly 90 years in Monaco (not shown in Figure 1). So why is inequality associated with adverse health?

In health, it's all about hierarchies, whether by income, education, social status or race. Those higher up the hierarchy report more favourable health outcomes than those lower down. Even those at the very top report better health than people just a notch below them. There is a 'gradient' effect of your position in society on your health (Adler et al, 1994;  Marmot et al, 1991).

Towards the middle and top of the income distribution, this is attributed to a 'keeping up with the Jones'' mentality. People are under pressure to compete with each other in jobs, wealth and possessions. These behavioural factors cause stress and stress-related illness.    

Towards the bottom, this is attributed to the more straightforward relationship between absolute deprivation and health. Material factors matter. The conditions of modern-day poverty in the US - working two jobs to make ends meet, living in over-crowded accommodation, living in neighbourhoods with few healthy eating options, low probability of having health insurance - all contribute to poor health outcomes. This becomes self-reinforcing for today's working families. Those who suffer from poor health are less likely to be able to hold down a long-term job. It also impacts on tomorrow's workforce. Children born into deprivation are more likely to suffer short and long-term health problems like obesity and asthma.

Healthcare reform will go some way to fixing these problems for the poor and uninsured. By opening up the market for healthcare, expanding government-funded medical programs and subsidising insurance premiums, coverage has already ticked up. The hope is that as more people sign up for medical insurance, they will be able to access timely and cost-effective care [a future blog will provide critique of the US healthcare system].

But tackling the hierarchies that generate unequal health outcomes requires reform of a wider set of institutions. That is because health is simply a window into the world of inequality. We need to flatten structures elsewhere. That might be in our schools and universities, where we need to ensure equality of opportunity. That might also be in our workplaces, where we need to ensure fair pay and progression. That might be in our neighbourhoods, where we lean against the creation of wealthy and less wealthy clusters. All of these actions would help break down the hierarchies that create inequality. Fixing health is only the first step.

Subsidise fruit not fries: addressing food insecurity in America

1 in 6 American families are food insecure. Put simply, they are going hungry.

The Federal government has relied on food assistance programs to meet the needs of the poorest families. Last year, it spent $80 billion on its Supplemental Nutritional Assistance Program alone. But budgets have been cut, reducing the amount of money in people's pockets. Reliance on non-profit food banks has increased sharply but they are unable to provide nutritionally-balanced food, like fruit and vegetables, because they are perishable.

In addition, hunger is no longer confined to the poorest or those who are unemployed. Two-thirds of food-insecure families with children have at least one adult in work. The problem, once again, is that wages have failed to keep up with the rising cost of living. After rent, bills and other necessities have been paid, there is often little left over for food.

The consequences of food insecurity are greatest for children, because health problems that set in early on are difficult to reverse. In areas where money is tight, the demand for luxuries falls, reducing the supply of supermarkets and increasing the prevalence of cheap fast-food restaurants. For this reason and others, hungry children are at a higher risk of obesity. Over a lifetime, child obesity costs $19,000 per child in medical costs ($14 billion for all current 10 year olds). Worse, many will have shorter lives than their parents.

Obesity, caused by food insecurity, has the potential to reduce the capacity of the future US workforce exactly at the time when a larger, more skilled workforce is required to support an ageing population. This is a multi-faceted problem, that captures costs, family income, lifestyle and parental education. But here are just two solutions that would tackle it at source.

To deal with rising costs, subsidise the production of fruit and vegetables. Currently, agricultural subsidies for US corn production end up inadvertently reducing the price of corn-based products like fizzy drinks or corn-fed meat, which results in cheap meat and snacks in our shops. So an adjustment to expenditure (not new money) could change consumption behaviour.

To deal with falling real incomes, raise wages. Company profitability would be supported because the workforce can afford a healthier lifestyle and are less likely to take sick days. Government finances would be boosted because higher wages lead to higher tax contributions and falling levels of income support. And tomorrow's growth is secured because higher take-home pay increases investment into children, reducing the future burden, and increasing the future capacity, of tomorrow's workforce.