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Illness and Inequality

What’s Missing from the Health Care Debate

by SUSAN ROSENTHAL, MD

The latest report by the Commonwealth Fund confirms what we already know; Americans pay more for health care and have poorer health compared with people living in nations that spend less on health care yet enjoy better health.

It is generally assumed that lack of access to medical care is to blame for America’s abysmal health statistics and that improved access will remedy the situation. This is mistaken. Lack of access is just one indicator of the social inequality that is driving America’s health crisis.

The myth that good health is a product of the health-care system was fueled by the expansion of the welfare state after World War II. The establishment of the British National Health Service (NHS) in 1948 was accompanied by improved population health and a reduction in the difference in death rates between the social classes. Politicians claimed that the NHS had produced these benefits, but later studies revealed that improved health follows a rise in the general standard of living and a reduction in class inequality, as occurred in Britain after the war.

To investigate the link between health and inequality, researchers examined workers in the highly stratified British civil service. Despite all the subjects enjoying decent pay and equal access to health care, the risks of illness and premature death increased as one moved down the social hierarchy. These health differences were significant and could not be accounted for by differences in smoking, diet or exercise.

Over the past 50 years, numerous studies have confirmed that social inequality is not only an independent factor in determining health, it is the most important factor. As social inequality increases, health deteriorates. This holds true for everyone living in an unequal society, not just those on the short end of the stick.

In 1998, the American Journal of Public Health published a study comparing income inequality with death rates in 282 American cities. Greater inequality was associated with higher death rates at all income levels. Areas with the greatest inequality suffered 140 additional deaths for every 100,000 people per year compared to areas with the lowest inequality. The difference in death rates was comparable to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide. There is no consensus on why inequality is so health-damaging, but there is no longer any question that it is.

Class inequality in the U.S. has risen steadily since the 1970s, when Corporate America pushed to raise productivity by driving down workers’ living standards. The result has been growing inequality, deteriorating health and the emergence of poverty epidemics like HIV/AIDS and tuberculosis in the world’s richest nation.

The U.S. has the worst health statistics in the industrialized world because it is the most unequal society in the industrialized world. This inequality is the source of America’s economic success and its continued position as global super-power. Forced to compete with the U.S., other industrialized nations including the U.K., Canada and the European Union are dismantling and privatizing their own national health-care systems.


Breaking the stalemate

In matters of health, Corporate America is caught between a rock and a hard place. Increasing productivity requires a basic level of fitness within the working class; however, paying for this in the form of higher wages, employee benefits or higher taxes decreases productivity. This conflict finds expression in the demand for a more effective health-care system and the failure to provide one. Simply arguing that the current system is unfair, ineffective and overly expensive will not be enough to break this stalemate.

In the past, universal health care was won through mass struggle. Germany established the first European national medical plan in 1883 to avoid a revolutionary upheaval like the one that shook France in 1871. In Britain, the 1911 National Insurance Act was rushed through Parliament during a mass strike wave. In 1943, a Conservative member of the British Parliament warned, "If you don’t give the people reform they are going to give you revolution." The British NHS was part of a social welfare program to stabilize relations between capital and labor after the war. Canadian unions won a national health plan in 1972, the year of the Quebec General Strike.

In the U.S., the Congress of Industrial Organizations and the American Federation of Labor pushed for a national health program after World War II. The ruling class preferred to build the world’s biggest military machine. America’s Cold War with Russia provided the opportunity to attack the unions and gut them of militants. That defeat explains why there is still no labor party in the U.S. and no national health plan.

The accumulation of profit at the top of society creates an accumulation of sickness at the bottom. No form of health-care system can reverse the health-damaging effects of rising inequality. The current debate on health-care must go beyond discussions of the best way to manage the carnage created by capitalism.

At the Cannes screening of Sicko, Michael Moore states, "The bigger issue in the film is, ‘Who are we as a people?’" Human health is not a commodity that can be churned out by the right kind of health-care system. Human sickness is a product of sick social relationships, and human health is a product of healthy social relationships. The quality of our medical system is a result and a reflection of those relationships.

Dr. Susan Rosenthal has been practicing medicine for more than 30 years and has written many articles on the relationship between health and human relationships. She is also the author of Striking Flint: Genora (Johnson) Dollinger Remembers the 1936-1937 General Motors Sit-Down Strike (1996) and Market Madness and Mental Illness: The Crisis in Mental Health Care (1999) and Power and Powerlessness. She is a member of the National Writers Union, UAW Local 1981. She can be reached through her blog: www.powerandpowerlessness.typepad.com