[Pophealth] the fading of the American dream where seldom is heard a discouraging word

[Stephen Bezruchka]

There have been a spate of articles in the current issue of the 
International Journal of Eidemiology (August) dealing with important 
issues for population health.  Two by Gopal Singh look at increasing 
health disparities by deciles of socioeconomic status and the better 
health of immigrants in the US.

Singh, G. K. and R. A. Hiatt (2006). "Trends and disparities in 
socioeconomic and behavioural characteristics, life expectancy, and 
cause-specific mortality of native-born and foreign-born populations in 
the United States, 1979-2003." Int. J. Epidemiol. 35(4): 903-919.

Singh, G. K. and M. Siahpush (2006). "Widening socioeconomic inequalities 
in US life expectancy, 1980-2000." Int. J. Epidemiol. 35(4): 969-979.


This commentary below on the increasing disparities makes the important 
point that there seems to be no end in sight for the lack of concern about 
how much younger we die in this country than we need to.    STephen


Commentary: The fading of the dream: widening inequalities in life 
expectancy in America
Danny Dorling International Journal of Epidemiology Volume 35, Number 4 
Pp. 979-980 2006
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]

References
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inequality of life expectancy due to AIDS. BMJ 2006;332:662-64.
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).