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.

An economy that works together, stays together

Source: Steve Breen / Creators Syndicate

The US economy is experiencing its slowest recovery in 70 years. We just can’t seem to give the economy the kick-start it needs. Why? Because we are held back by inequality. Only by tackling inequality head-on can we secure the sustained economic recovery that we are looking for.

Inequality sends a signal about the economy’s potential to grow today. Income among the poorest can be stagnant if people have given up looking for a job because opportunities are so scarce. The recent fall in US unemployment masks record falls in the participation rate, the number of people actually looking for a job. Fewer people in the labour force leads to lower per head growth rates and lower social cohesion. We are wasting our best resource – people. 

Source: Chan Lowe / Tribute Content Agency

Inequality also matters for the economy’s growth potential tomorrow. Richer families can afford to spend more time with their children, investing in their learning and development. Poorer families, who are more likely to work longer hours in minimum wage jobs, simply don’t have the time. But if you think that talent is randomly distributed, then this means that many children's potential will be left untapped. These young people are also more likely to drop out of high school or college, either because of cost or because they simply don't believe that people like them can succeed. This impacts on their ability to secure a job and makes it more likely that they will also fall on hard times.  

What can be done? If inequality is defined as a gap, then let’s build bridges that enable people to close this divide. Raising the minimum wage would enable everyone to earn a basic income. On-the-job training would improve career progression and lifetime income for those in work, and back-to-work training would improve job prospects for those out of work. A more progressive tax and social security system would provide much-needed resources to low-income families to invest in themselves. 

None of these policies constitute a hand-out. Raising the wage, for example, would actually increase tax receipts and reduce welfare expenditure as fewer people require income support. All of these policies can help children as much as adults. For example, women who joined the workforce following welfare reform in the UK spent the extra income earned on books and activities for their children. And each one would increase the productive potential of the economy. An economy that can produce more is likely to grow.  

I think, therefore I learn

Source: US Census Bureau

Minorities in the US have a much higher chance of living in poverty than Whites. This has not changed materially for 40 years (Figure 1). In other words, poverty persists.

To tackle the inequality debate head on, we need to address this racial divide, starting by shifting the mindset of minority children themselves. Children show a strong understanding of racial stereotypes from an early age. By 3, they are aware of ethnicity and gender. By 6, they begin to infer beliefs held by an individual. By 10, they are able to relate these beliefs to a more broadly-held stereotype (McKown and Weinstein, 2003). 

These stereotypes become self-fulfilling.

"Stereotype threat", as this is known, is a belief that an outcome is pre-determined by the student's background. Experiments have shown that reminding children that they are black before they sit a test reduces their subsequent score. The same is true for females and other minorities. It is no wonder then that Black and Hispanic students are more likely to drop out of high school, despite the overall improvement to completion rates (Figure 2). They think they are going to perform badly. Therefore, they do. 

Source: US Department of Commerce, Census Bureau,
Current Population Survey (CPS)

But children can be persuaded to change perceptions about themselves. This comes from a realisation that intrinsic ability is not fixed or pre-determined by their ethnic background. For example, middle-school minority students who were encouraged to believe that knowledge and intelligence are malleable - that they can be grown over time - showed an improvement in test scores (Good, Aronson and Inzlicht, 2003). First-year college students who received letters from older students about their initial struggles and the way in which they overcame them, in turn were less likely to fall behind. 

These interventions are not costly. They can be carried out within the school or college gates, by teachers or older students (as David Yeager at the University of Texas has shown). But they are exceptionally powerful. By breaking the perceived link between background and intelligence, it is more likely that minority groups will do better at school and develop the emotional and psychological tools they need to succeed in the workplace. In time, this could go a long way in breaking the inter-generational persistence of poverty. 

I want YOU for the U.S. dream

The beauty of the American Dream is that the accident of birth does not determine a child's life chances. Those born into a poor family can become rich. Those raised by parents without education can go to college. Those growing up in rented homes can become homeowners. The future is in one's own hands.

Source:  The Pew Charitable Trusts (2012)

But there is strong evidence that the American dream is, well, just that, a dream. Social mobility is low. Children born into the poorest quintile are more likely to earn below average incomes (Figure 1, left, shows that 70 per cent of Americans born into the bottom quintile will remain below the middle in adulthood). They are less likely to go on to higher education. They are less likely to own their own home.

How then do we tackle a problem that appears to be ingrained in our society? One excellent suggestion is for Congress to create an Office for Opportunity. Establishing such a Federal institution would protect social mobility from the waxing and waning of political attention. The Office would define and target a single measure or set of measures. These could cover early childhood development, K-12 and college results, labour market participation and / or family circumstances, to track progress over a lifetime. It would also publish commentary on how well the USA was doing against these measures.

But this might not be enough. The UK government has set up a similar body, the Social Mobility and Child Poverty Commission. The Commission sets out targets for, and reports on progress against, a set of indicators. The trouble is that the general public have little awareness of its existence and so do not protest when goals are not met. Few know that the UK government has also committed in legislation to eradicate child poverty by 2020. Fewer still know that because of severe cuts to social security, the number of children in poverty could rise to 5 million by that time. For this reason, Save the Children UK recently launched its campaign, "A Fair Start for Every Child", asking for specific measures to ensure that a child's birth does not determine its chance in life. (Disclosure:  I was the lead author on their report).

What is required is a society-wide strategy to hold governments to account on their commitments. Such an approach was taken with the Millennium Development Goals (MDGs), which were publicly agreed by participating members. Armed with the knowledge of what their government had promised, developing country citizens were empowered to push leaders to deliver on specific promises. Learning from this, the US government should publicly commit to a set of SMDGs (Social Mobility Development Goals). It should undertake an extensive public awareness campaign to garner action by civil society. This would also ensure that ruling parties are held to account by the public. Only by doing so can we get America moving and have a decent shot of turning the American dream into a reality.