[Pophealth] the fading of the American dream where seldom is heard
a discouraging word
sabez at u.washington.edu
Wed Sep 6 08:36:19 PDT 2006
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
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
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]
1 Wilkinson R. The Impact of Inequality: How to Make Sick Societies
Healthier. New York: The New Press, 2005.
2 Fawcett J, Blakely T, Kunst A. Are mortality differences and trends by
education any better or worse in New Zealand? A comparison study with
Norway, Denmark and Finland, 1980-1990s. Eur J Epidemiol 2005;20:683-91.
3 Carvalho R, and Batty M. 2006, The Geography of Scientific Productivity:
Scaling in U.S. Computer Science, Physics Abstracts:
arXiv:physics/0603242v1. Available at:
(Accessed March 28, 2006).
4 Wallerstein I. Decline of American Power: The U.S. in a Chaotic World.
New York: The New Press, 2003.
5 Ross N, Dorling D, Dunn JR, Henriksson G, Glover J, Lynch J, Weitoft GR.
Metropolitan income inequality and working-age mortality: a
cross-sectional analysis using comparable data from five countries, J
Urban Health 2005;82:101-10.
6 Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality and
mortality: importance to health of individual income, psychosocial
environment, or material conditions. BMJ 2000;320:1200-04.
7 Singh GK, Siahpush M. Widening socioeconomic inequalities in US life
expectancy, 1980-2000. Int J Epidemiol 2006;35:969-79.
8 Mackenback JP. Health Inequalities: Europe in Profile, Independent
report commissioned by the UK Presidency of the EU. Available at:
9 Shaw M, Orford S, Brimblecombe N, Dorling D. Widening inequality in
mortality between 160 regions of 15 countries of the European Union. Soc
Sci Med 2000;30:1047-58.
10 Nakaya T, Dorling D. Geographical inequalities of mortality by income
in two developed island countries: a cross-national comparison of Britain
and Japan. Soc Sci Med 2005;60:2865-75.
11 Pearce J, Dorling D. Increasing geographical inequalities in health in
New Zealand, 1980-2001. Int J Epidemiol 2006;35:567-603.
12 Ram R. Further examination of the cross-country association between
income inequality and population health. Soc Sci Med 2005;62:779-91.
13 Dorling D. Class alignment renewal. J Labour Polit 2006;14:8-19.
14 Dorling D, Shaw M, Davey Smith, G. HIV and global health: global
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
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