July 21, 2022 in PHW Vol. 8, No. 29

By Stephen Bezruchka


An allegory that has been told for many decades distinguishes upstream from downstream factors. 

Imagine, if you will, three people standing alongside a river on a brisk afternoon. They suddenly hear a cry for help from someone caught in the river’s fast-moving current.

Our three bystanders react in different ways.

The first bystander becomes angry at the unfortunate person’s irresponsibility. 

“Don’t you know how to swim?” this bystander shouts. “You never should have jumped in!” 

The second bystander wants to be more helpful. She waves to our desperate victim and displays a discount coupon for swimming lessons. “Quick, grab this,” she pleas, “With this you’ll be able to afford the lessons!”

Finally, our third bystander — a rescue worker — jumps in the water and pulls the flailing floater out of the water. Paramedics soon make it to the scene. They administer CPR and transport the victim to the hospital.

That rescue, unfortunately, doesn’t end the crisis. The next day sees more flailing people floating down the river and more still the day after. Researchers take notice. They start tabulating how many people are floating by. They survey the survivors, compare their educational levels and race, and construct elaborate personal risk-taking profiles. But this research doesn’t stem the tide of flailing floaters. Pulling them out of the water is rapidly becoming an expensive proposition. Just extracting victims from the river, people soon realize, is never going to eliminate the problem. Too many keep falling in!

What’s causing all the tragic river traffic? No one really knows. A few public health workers decide to head upstream to find out. They soon spot billboards with glamorous and fetching pictures marketing the river’s many recreational opportunities. One public health worker concludes that legislation is needed to require all riverside billboards to carry notices warning people about the rapid river currents. 

But another contends that warning notices won’t be enough and recommends a ban on all billboards as a means of protecting those most vulnerable to the marketing messages. 

Executives of the river billboard association quickly erupt in predictable fury. They can’t believe what they’re hearing. “We demand freedom of speech!” they cry. “Let’s not allow people who can’t swim to ruin the fun for everybody else!”

“Amen,” chimes in the local newspaper editor. “We don’t need new government regulations. The responsibility for river safety lies with families, not the government. 

This back-and-forth debate frustrates still other public health workers on the original fact-finding mission up the river. They opt to continue even farther up the river and discover that the riverbanks where people walk have eroded into steep and slippery, uneven slopes. No one walking these banks can gain a stable foothold. 

At the steepest points of the riverbank, desperate people are even pushing others into the water to secure their own safety. In less steep sections, the public health workers see less chaos. People in these somewhat safer spots seem more secure. Some of them are even helping those around them negotiate the hazardous terrain. 

The diligent public health workers soon see a solution. They proceed to build a retaining wall that enables everybody to walk safely along the river.  They also excavate some of the steepest parts of the slope to make it safer for all. In short order, no one’s flailing in the water anymore. 

Does anything in this story sound familiar? Has our path become more secure over time? Have we become safer?

We are living in a period of many new ideas entering the public mind. Much of the Planetary Health Weekly content was not considered even a few decades ago.  How did thinking about economic inequality enter public consciousness?

In 1979 an academic paper was published in a demography journal:  Rodgers, G. B. (1979). “Income and inequality as determinants of mortality: an international cross-section analysis.” Population Studies 33: 343-351.  This seminal study was reprinted in another journal in 2002 where it can be accessed.  The 2002 version has a range of commentaries by others.  Rodgers’ study looked at life expectancy (at birth and at age 5) and infant mortality among 56 countries and found an association with a measure of income inequality for those nations.  The relationship was strongest for rich countries but also present for those poorer. 

Richard Wilkinson had been interested in the relationship between class and health.  He edited a 1986 publication where he included a chapter on investigations of income and mortality after discovering the Rodgers study. He presented further results in a 1992 paper in the British Medical Journal titled Income Distribution and Life Expectancy where he found a strong association between life expectancy and income distribution for 9 rich countries as well as demonstrating that increases in inequality were linked to weaker improvements in life expectancy. 

That paper catalyzed important studies in 1996 looking at the relationship within U.S. states and later among large U.S. cities.  Much more research confirmed these initial studies appearing in 1999 and 2000 volumes spanning the findings.  (Kawachi I, Kennedy BP, Wilkinson RG, editors. The Society and Population Health Reader, Volume I:  Income Inequality and Health. New York: New Press; 1999.  Tarlov AR, St. Peter RF, editors. The Society and Population Health Reader, Volume II:  a state and community perspective. New York: New Press; 2000.) 

A landmark book appeared in 2009 by Wilkinson and Kate Pickett:  The Spirit Level:  why more equal societies almost always do better.   This popular book has been translated into many languages, yet it remains mostly unknown in the U.S.  It has been the textbook for my courses since its publication.  The Equality Trust was created to spread these ideas especially focusing on the United Kingdom.  There you can download a slide file of important contents

Where do we stand now after almost 45 years since the original Rodgers study?  Income and wealth inequality have increased enormously around the world, especially in the U.S. where it is at record levels in the post-slavery epoch.  That is at least part of the explanation why so many other countries have healthier and longer lives than those who live in the United States.

Let’s explore trends in income and wealth inequality. 

At present income and wealth inequality is skyrocketing globally, Thomas Piketty argues in A Brief History of Equality that genuine progress had been made in decreasing inequality in the last several hundred years.  In the 1950s and early 1960s it was the poorest fifth that saw the largest income growth in the United States. U.S. wealth inequality reached its lowest point in 1975.  Although the rich had more than before, their share was less and they wanted to get that back. The process was policy changes now termed neoliberal reforms.  An article in Business Week, Oct. 12, 1974 presaged the process.  “”It will be a hard pill for many Americans to swallow–the idea of doing less so that business can have more…. Nothing that this nation, or any other nation, has done in modern economic history compares in difficulty with the selling job that must be done to make people accept the new reality…Historian Arnold Toynbee, filled with years and compassion, laments that democracy will be unable to cope with approaching economic problems — and that totalitarianism will take its place.”

The belief was to give the rich more than ever before so they will invest it to create jobs for the rest of us and we will all be better off.  Non-sensical though that seems, it undermines many of today’s political policies.  Wages have not increased substantially since the 1970s despite greatly increased productivity.  Many reasons are given:  migration of jobs overseas that pay lower wages, immigrants in the U.S. will work for less, automation, among others.  At the same time the richest 1%, or especially the richest 0.1% or the 0.01% have made off like bandits.  You can download a file of figures and tables from Piketty’s book mentioned above and scroll through them to get a visual sense of his main points.  To see the hyper-concentration of US wealth go to figure 35 in that pdf.   We have replaced the kings and queens of yore with their opulent palaces and jewels pilfered from colonies abroad with Chief Executive Officers as the new monarchs.  They control much of the political process in the world, whether through strong-men governments, or huge campaign contributions or having a direct line to presidents and prime ministers. 

There is increasing acceptance of the inequality health relationship.  Consider studies of disease conditions among countries and inequality.  One considered heart failure outcomes among countries related to income inequality.  They found worse outcomes in more unequal nations similar to those in patients with major co-morbidities–namely other diseases being present.  Another way is to demonstrate that stronger primary health care systems buffer the adverse effects of income inequality in Europe.  That is creating stronger health care systems based on care provided by family doctors, nurse practitioners and other non-specialists, may help ease some of the bad aspects of increasing income inequality.  Since income and wealth inequality result from the political process we are led back to the upstream determinants of health presented by the Dept. of Health in Hawaii’ namely “political context and governance” presented in Blog #4.  We conclude that inequality kills!  Some might respond that demonstrating association does not imply causation. How to decide that something causes something else will be the subject of a future blog.

I see economic inequality as the upstream or root cause of most of the world’s problems, much as Hawaii’s Department of Health does that was described in Blog #4.  My blog next month will look at inequality’s role on planetary health.

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