Sick of It All
Economic equality: good for what ails you
By Stephen Bezruchka

Most of us hear that we don't do enough to stay healthy. The doctor is always on our backs to quit smoking. We leave the clinic or E.R. hearing their advice: give up the pleasure of a smoke. Is smoking all that bad anyway?

Suppose there was a mythical place, Smoke-utopia, where people puffing away enjoyed good health. Not possible, you say? It happens that the world's healthiest country has the most smokers per capita. It's not the United States, since we don't have that many smokers. Smoke-Utopia is Japan.

Three times as many men smoke in Japan as in America, yet more than twice as many American men die of lung cancer. Yes, smokers in Japan have worse health than non-smokers, but not that much worse.

Despite being the most powerful and wealthiest country in history, the U.S. isn't such a healthy place to live.

To understand why, let's define the health of a country as its life expectancy: born today, at the mortality rates today, how long can you expect to live? If we rank countries this way, it may be no surprise that Japan has the highest life-expectancy of any country in the world, and we've fallen from 13th among all nations in 1960 to 25th by 1997 - behind all the other rich countries, and a few poor ones as well.

How could we be so unhealthy? We have the most expensive and sophisticated health care system in the world; it costs us one-seventh of our total economy. Could it be that our health care system doesn't buy us health? Can any health care system make a population healthy? The answer to both questions is, apparently not.

To understand that, ask the question: what makes a population healthy? The answer is clear. Countries with healthy citizens enjoy a relatively small gap between rich and poor.

This has been carefully studied on many different populations, including in the U.S. If you live in Louisiana or Mississippi, your chances of dying early are 50 percent higher than if you live in Utah or New Hampshire. That is because the healthier states are those in which income is better shared than the worst states. The healthier states have a smaller gap between the rich and the poor - people share more equally in the pie. Those states spend less money on health care, have a greater focus on primary care, and spend less on specialty care.

Another study of U.S. cities shows that among rich cities, as well as cities in the middle, and those that are poor, the health of their populations depends on the gap between high and low incomes within rich, middle or poor groupings of cities. So the gap affects all of us, not just the poor.

What kind of a society will have a smaller gap between the rich and the poor? One in which people see one another as equals. The norms of behavior are those of friendship, support, cooperation, trust, sociability, and community. Those are healthy-sounding words.

In societies where there is a big gap between the rich and poor, the way to get things done is through power, coercion and domination. People with no power feel resignation, submission and resentment. These aren't healthy feelings. The quality of the psychosocial environment determines a population's health.

Japan's lung cancer death rates are so low because Japan has the most equal society of any rich country. Japan restructured its society after the Second World War to be more egalitarian. The Prime Minister makes four times what an average worker makes. Bosses make 10 times what an entry level worker makes. (In the U.S. now, CEOs make 475 times what a factory worker makes). During their recent economic crisis, Japanese bosses and managers have taken cuts in pay, rather than lay off workers. Could you imagine that happening here? Japan attains health by having an egalitarian society, and this allows it to deflect the (pardon the pun) smoking gun.

The income gap in the U.S. has increased immensely, beginning in the 1970s, when there were few homeless people on the streets. Our gap, while always higher than most rich countries, has now become extreme. The richest one percent of the U.S. now controls 42 percent of the wealth in the country. Seattle houses three of the four richest people in the world! Such a situation has come about because the rich have not had to face "market discipline." There have been no reforms in the system that produces the rich. Reforms are necessary for the poor, but apparently not for the rich.

It is difficult to abandon the notion that if, as a country, we all went to the doctor and did what she said, we would be much healthier. There are no studies to support that idea, and plenty of information to suggest that medical care may in fact cause harm than good. In the U.S. alone, perhaps one in 10 deaths may be related to medical care. We have all heard of mistakes made in hospitals, but that is less than a quarter of the harm caused by health care. Japan is no better here. They spend about half as much money on health care, and probably do comparable amounts of harm. At surgery for appendicitis, a normal appendix is often removed, about six times more frequently than in the U.S. It isn't their health care system that accounts for "Smoke-utopia" it is the structure of their society.

To change our dismal standing will take structural medicine, the kind a doctor can't give you. It will only happen when the poorer people in society organize for changes in the economy that require the rich to conform to market discipline, not just the poor. Everyone should have their share. Then we will all benefit from America's economic growth, not just the rich. Everyone's health will improve. We must work to close the gap.

Stephen Bezruchka is a doctor who works in the emergency departments of Group Health and Virginia Mason Hospitals and teaches at the University of Washington's School of Public Health and Community Medicine. For more information, check out his web site (, where the scientific studies underlying these assertions are available.

Published October 15, 2000 in
Real Change News
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