IJE Advance Access originally published online on July 26, 2006
International Journal of Epidemiology 2006 35(4):979-980; doi:10.1093/ije/dyl126
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Commentary |
Commentary: The fading of the dream: widening inequalities in life expectancy in America
Department of Geography, Sheffield University, UK.
E-mail: daniel.dorling{at}sheffield.ac.uk
‘Oh give me a home, where the buffalo roam
And the deer and the antelope play
Where seldom is heard a discouraging word
And the skies are not cloudy all day.’
[Popular Cowboy Song, undated, verse 1]
Studies of health inequalities in the United States are relatively rare, especially considering the extent of those inequalities in comparison with other countries1; the population size of the United States in comparison with far smaller but more studied peoples2; the concentration of resources available to academics in that country3; and the hegemonic status of the world's ‘leader’4 making it odd that it does not lead in this field. Health and wealth are old acquaintances, but best related where riches are best shared.5 If riches were to trickle down naturally anywhere, they should have done so in the land where they have been most abundant. That they have not done so can be counted in years of lives lost as well as in dollars. That is not in dispute, even if the precise mechanism is keenly debated.6 Thus Singh and Siahpush7 have demonstrated what many long suspected: that health inequalities within the United States have widened considerably in recent decades. At the county level of geographic discrimination there has been a 60% [(4.5–2.8)/2.8] increase in the size of the gap in life expectancy between the poorest and richest tenths of the population from 1980 to 2000. The poorest tenth of the population, by area, can now only expect to live to just under 75 years of age while the people living in the best-off counties live on average to almost 80. Some counties are as populous as Los Angeles city. This is not a fine-grained analysis. That is not possible as much detailed demographic data is concealed in many States of the Union. Thus the 4.5 year life expectancy difference is a very wide gap considering the degree of averaging involved.
One reason for not being surprised to find widening inequalities in mortality in the United States is that inequalities have been widening in many Western European countries over the same period—albeit assessed more often as measured between socioeconomic groups within countries8 rather than between areas. However, when geographical comparisons have been made, similar results of increasing inequalities have been found, but usually not as rapid increases as in America.9 Inequalities within the United States also appear to be much larger than within most countries in Western Europe and to have grown more rapidly. When compared internationally, Western European inequalities are found to be larger again than those prevailing in Japan10 and are comparable or can be exceeded by those found elsewhere in the rich world.11 And if poorer countries are included also it becomes increasingly clear that where there is higher inequality, especially income inequality, there is higher inequality in health12 and that occurs as much between groups of people arranged by occupational social class as it does amongst groups arranged by class as indicated by place of residence.13 It is worth highlighting that no other rich country with such a large population has such wide inequalities as the United States, a country that can be considered a natural experiment for studying the effects of exposing millions of human beings to relatively high levels of the various insults of inequality.
The detail that Singh and Siahpush give on how the changing trends have differed for men and women, how they have had effects at different points in the life course, and which areas are doing worse, are all worth referring to in their original paper for clues to the processes that may well be occurring outside the United States as well as within. To reiterate, no other rich country has so large a population that such patterns could be as clear when disaggregated by area, age, sex, and time. To take one example, Singh and Siahpush find that in 1980 the best-off in the United States by county had a life expectancy of on average only 75.8 years (men and women combined). However, this was a year more than those from the poorest areas could expect to live almost a generation later. In general the poor, whether defined by occupational class, income, or residential area, tend not to experience the living standards of the rich until a generation has passed—but standards for both the rich and poor tend to rise in parallel and so too does life expectancy. It is when those parallel improvements diverge that inequality is most keenly felt: when you cannot even expect your children to have what you do not have (and there is a fear that their children might not too). And it is when those parallel rates of improvements converge slightly that great social progress is said to have occurred. Currently the trends worldwide are more often than not diverging, both within countries and between them.14 Given current trends within the United States we should expect the gap in living standards between future generations there to widen considerably—unless there are some radical changes to the structure of US society.
Perhaps the most stunning observation in the study by Singh and Siahpush is not the results—the direction of which was expected, if not the magnitude, but this observation:
‘To our knowledge, no attempt has yet been made to conduct a systematic analysis of how socioeconomic inequalities in US life expectancy have changed in recent decades.’ (page ?)
My view will be conditioned by my experiences of the United States, but I still find it amazing how inequality there can be ignored by so many. A dozen years ago I walked into a vast lecture theatre at a convention centre in San Francisco to join the audience to hear a series of plenary talks on ‘poverty in America’. These talks were being given at the annual Association of American Geographers' conference, which had just topped the 5000 delegates mark—I think then for the first time. I had only been to the States once before and was overawed with the vastness of the stage in front of me; by the then novel PowerPoint display playing (three times taller than the speaker standing in front of it); and the detail and pain of the geographies of destitution and despair being shown on it. The talks were illuminating. I learnt a lot about where those with least lived and why, as I guess did the other four members of the audience in the theatre that would seat many hundreds. At least two of the other four were from Britain. I don't know whether a single American saw a slide that day or heard a word about their country. That empty lecture theatre and the difficulty of walking though scores of beggars who were then allowed on the streets of San Francisco were the images I took away with me from one of my first visits to the US.
The country I come from is hardly a paragon of social virtue, progressive policy, or a world leader in reducing inequalities, far from it. However, the most important inequality of all (as it has been termed by British government ministers) is both more vast and more quickly widening between the places that people call home in the United States of America than has been recorded almost anywhere else in the rich world. So much of that increase has happened since 1980, the year in which Ronald Reagan was first elected as president, that these levels of inequality should not be seen as having been inevitable. They need not have risen, they need not be sustained, and they could be reduced. But unless inequalities in America are more studied and comparisons with other rich countries made and made frequently—why should we expect people in America to know that they have a problem costing them hundreds of millions of years of life each year—of their lives?
Without the evidence why not simply believe the old songs:
‘How often at night when the heavens are bright
With the light from the glittering stars
Have I stood there amazed and asked as I gazed
If their glory exceeds that of ours.’
[Popular Cowboy Song, undated—verse 215]
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References |
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8 Mackenback JP. Health Inequalities: Europe in Profile, Independent report commissioned by the UK Presidency of the EU. Available at: http://www.fco.gov.uk/Files/kfile/HI_EU_Profile,0.pdf (2006).
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15 Lyrics from http://www.kididdles.com/mouseum/h020.html (available for purchase on cassette on the album ‘Wee Sing in the Car’ from the KIDiddles Online Store).
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