Health and mortality inequalities in the US

How unequal are we when it comes to inequalities of health and mortality? Richard Florida (CreativeClass) points to an important new study on this question by public health researchers at Harvard and UCSF. (This is one of many items that Florida references in his Twitter feed -- it's certainly worth following. This bears out the academic value of Twitter!) The study is "Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States". And the answer the researchers provide to the question above is -- very. The study is worth reading in detail.

The authors analyze mortality statistics by county, and they break the data down by incorporating racial and demographic characteristics. The data groups fairly well around the eight Americas mentioned in the title:


Here is how they describe their findings:

The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.

And here is their conclusion:

Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

For example, their data show that "the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001." This is an enormous difference in longevity for the two groups; and it is a difference that tags fundamental social structures that influence health and risk across these two populations.

Here is a time-series graph of the behavior of longevity for the eight Americas:
So what are the factors that appear to create these extreme differences in mortality across socioeconomic and racial groups in America? They consider health care access and utilization; homicide; accidents; and HIV as primary potential causes of variations in mortality for a group. Most important of all of these factors for the large populations appear to be the health disparities that derive from access and utilization. And here they offer an important set of recommendations:

Opportunities and interventions to reduce health inequalities include (1) reducing socioeconomic inequalities, which are the distal causes of health inequalities, (2) increasing financial access to health care by decreasing the number of Americans without health plan coverage, (3) removing physical, behavioral, and cultural barriers to health care, (4) reducing disparities in the quality of care, (5) designing public health strategies and interventions to reduce health risks at the level of communities (e.g., changes in urban/neighborhood design to facilitate physical activity and reduce obesity), and (6) designing public health strategies to reduce health risks that target individuals or population subgroups that are not necessarily in the same community (e.g., tobacco taxation or pharmacological interventions for blood pressure and cholesterol).

These findings are squarely relevant to the healthcare debate currently underway in the United States. The country needs to recognize the severity of the "health/mortality justice" issue, and we need to reform our healthcare system so that these disparities begin to lessen.

Comparative life satisfaction

We tend to think of the past century as being a time of great progress when it comes to the quality of life -- for ordinary people as well as the privileged. Advances in science, technology, and medicine have made life more secure, predictable, productive, educated, and healthy. But in what specific ways is ordinary life happier or more satisfying for ordinary people in 2000 compared to their counterparts in 1900 or 1800 -- or 200, for that matter?

There are a couple of things that are pretty obvious. Nutrition is one place to start: the mass population of France, Canada, or the United States is not subject to periodic hunger, malnutrition, or famine. This is painfully not true for many poor parts of the world -- Sudan, Ethiopia, and Bangladesh, for example. But for the countries of the affluent world, the OECD countries, hunger has been largely conquered for most citizens.

Second, major advances in health preservation and the treatment of illness have taken place. We know how to prevent cholera, and we know how to treat staph infections with antibiotics. Terrible diseases such as polio have been eradicated, and we have effective treatments for some kinds of previously incurable cancers. So the basic health status of people in the affluent 21st-century world is substantially better than that of previous centuries -- with obvious consequences for our ability to find satisfaction in life activities.

These advances in food security and public health provision have resulted in a major enhancement to quality of life -- life expectancy in France, Germany, or Costa Rica has increased sharply. And many of the factors underlying much of this improvement is not high-tech, but rather takes the form of things like improvement of urban sanitation and relatively low-cost treatment (antibiotics for children's ear infections, for example).

So living longer and more healthily is certainly an advantage in our quality of life relative to conditions one or two centuries ago.

Improvements in labor productivity in agriculture and manufacturing have resulted in another kind of enhancement of modern quality of life. It is no longer necessary for a large percentage of humanity to perform endless and exhausting labor in order to feed the rest of us. And because of new technologies and high labor productivity, almost everyone has access to goods that extend the enjoyment of life and our creative talents. Personal computing and communications, access to the world's knowledge and culture through the Internet, and ability to travel widely all represent opportunities that even the most privileged could not match one or two centuries ago.

But the question of life satisfaction doesn't reduce to an inventory of the gadgets we can use. Beyond the minimum required for sustaining a healthy human body, the question of satisfaction comes down to the issue of what we do with the tools and resources available to us and the quality of our human relationships. How do we organize our lives in such a way as to succeed in achieving goals that really matter?

Amartya Sen's economic theory of "capabilities and realizations" supports a pretty good answer to these questions about life satisfaction (Development as Freedom). Each person has a bundle of talents and capabilities. These talents can be marshalled into a meaningful life plan. And the satisfying life is one where the person has singled out some important values and goals and has used his/her talents to achieve these goals. (This general idea underlies J. S. Mill's theory of happiness as well in Utilitarianism.)

By this standard, it's not so clear that life in the twenty-first century is inherently more satisfying than that in the eighteenth or the second centuries. When basic needs were satisfied -- nutrition, shelter, health -- the opportunities for realizing one's talents in meaningful effort were no less extensive than they are today. This is true for the creative classes -- obviously. The creative product of Mill's or Hugo's generation was no less substantial or satisfying than our own. But perhaps it is true across the board. The farmer-gardener who shapes his/her land over the course of a lifetime has created something of great personal value and satisfaction. The mason or smith may have taken more pride and satisfaction in his life's work than does the programmer or airline flight attendant. The parent who succeeded in nurturing a family in 1800 County Cork may have found the satisfactions as great or greater than parents in Boston or Seattle today.

So we might say that the only unmistakeable improvement in quality of life in the past century is in the basics -- secure nutrition, decent education, and improved health during the course of a human life. And the challenge of the present is to make something meaningful and sustaining of the resources we are given.

Low income, strong community

We seem to work on the basis of a couple of basic assumptions about income, lifestyle, and community in this country that need to be questioned. One group of these clusters around the idea that a high quality of life requires high and rising income. High income is needed for high consumption, and high consumption produces happiness and life satisfaction. Neighborhoods of families with high income are better able to sustain community and civic values. And symmetrically, we assume that it is more or less inevitable that poor communities have low levels of community values and low levels of the experience of life satisfaction.

All these assumptions need to be questioned. As any social service agency can document, there are ample signs of social pathology in the affluent suburbs of American cities. These suburban places aren't paragons of successful, happy human communities in any of the ways Robert Bellah talks about (Habits of the Heart: Individualism and Commitment in American Life, Good Society). And there is little reason to believe that the consumption-based lifestyles that define an American ideal of affluence really contribute consistently to life satisfaction and successful community.

But here I want to focus on the other end of this set of assumptions: the idea that non-affluent people and communities are necessarily less happy, less satisfied, and less integrated around a set of civic and spiritual values. So here is the central point: people can build lives within the context of low income that are deeply satisfying and rewarding. And communities of low-income people can be highly successful in achieving a substantial degree of civic and spiritual interconnection and mutual support. It doesn't require "affluence" to have a deeply satisfying human life and a thriving community.

There are many reasons for thinking these observations are likely to be true. One is the example of other societies. Consider village life in Spain or Italy, for example, where many families still live on incomes that are a fraction of American affluence, who incorporate gardens into their regular lifestyle and household economy, and who enjoy admirable levels of personal and social satisfaction. Or think of stable farming communities in India or Africa that have successfully achieved a balance of farm productivity, a degree of social equality, and a strong sense of community. Or consider examples of communities in the United States that have deliberately put together lives and communities that reject "affluence" as a social and personal ideal.

Of course it's true that extreme poverty is pretty much incompatible with satisfaction and community. Malnutrition, illiteracy, and untreated disease are counterparts of extrme poverty and destroy happiness and community. But "non-affluence" isn't the same as extreme poverty.

What everyone needs, at every level of income, is decent access to the components of a happy life: healthcare, nutrition, shelter, education, dignity, and security. These are what an earlier generation of development thinkers called basic needs. And it is self-evident how these fit into the possibility of a decent and satisfying life. But access to these goods isn't equivalent to the American dream of affluence.

So here is a fairly profound question: what steps can be taken to promote the features of personal wellbeing and robust community relations that can make "non-affluence" a sustainable social ideal? And how can we help poor communities to strengthen their ability to nurture these positive values according to their own best instincts?