|
|
Volume 4: No.
4, October 2007
EDITORIAL
Do We Have Real Poverty in the United States of America?
Paula Braveman, MD, MPH
Suggested citation for this article: Braveman P. Do
we have real poverty in the United States of America? Prev Chronic Dis 2007;4(4). http://www.cdc.gov/pcd/issues/2007/
oct/07_0124.htm. Accessed [date].
Consider the images of starving children in Africa, Asia, or Latin America accompanying appeals for humanitarian aid. It is not difficult to understand why people deprived of the most basic material necessities for subsistence — adequate food, clean water, shelter from extreme heat or cold — would suffer high rates of preventable disease, disability, and premature
death. Poverty in developing countries is often defined as living on less than
$2.00 per person per day (1). By those terms, very few people in the United States would be poor. But poverty criteria for poor countries are not applicable in affluent countries with far higher living costs. The official U.S. poverty
guideline in 2005 was an
annual income of $19,350 for a family of four (2), which would
represent wealth in many poor countries (3). Why, then, are Preventing Chronic Disease and other U.S. journals participating in this multi-journal issue,
to be released October 22, 2007, on poverty and human development? Is it simply a magnanimous gesture to support fighting poverty and its adverse health consequences in poor countries, or is poverty an issue we must address at home?
In the days after Hurricane Katrina, televisions around the world revealed many desperate New Orleans residents, too poor to leave before the storm, who were without food, shelter, or clean water days later. The post-Katrina revelations were even more shocking because they exposed not only an inadequate disaster relief response, but also poverty and long-standing neglect of
public services affecting poor African Americans that predated the hurricane. The depth of deprivation reached levels that many Americans had thought existed only in poor countries, not here. By official U.S. criteria, widely considered too low, more than one in eight individuals overall and one in five children
younger than 5 years in the United States were poor in 2005 (2). We have the highest
rates of poverty and child poverty among affluent nations (4). New Orleans’ poverty was not an anomaly, but a reflection of widespread conditions in our country. Still, one might question: is U.S. poverty real, in the sense that it is associated with worse health? How could poverty affect one’s health in a rich country?
In the now-famous Whitehall studies (5-7), British civil servants were categorized into several socioeconomic groups according to their occupational standing, ranging from unskilled manual workers at the bottom to the highest executives at the top. A stepwise gradient in morbidity and mortality rates over time was seen across the entire socioeconomic hierarchy, with health
improving as position in the hierarchy rose. This result was surprising because none of the civil servants was poor in absolute terms, and all had free medical care. Even the professional/managerial group, just below the top executives, had worse health than the top group. The gradient persisted, although less markedly, after adjusting for smoking, diet, and exercise; thus, these behaviors could
not entirely explain the socioeconomic gradient (5-7). What else could explain it?
The socioeconomic gradient in health has been observed across many different health outcomes, populations, and settings (5,8,9), including in the United States overall (10-13) and within different racial/ethnic groups (12). One explanation is that
variations in health behaviors by income, education, and occupational standing (7,12)
reflect differences in a range of
socioeconomic resources in households and neighborhoods that can encourage and facilitate (or discourage and obstruct) healthier behaviors (14). For example, although racial discrimination can limit the benefits of higher income for some groups, higher income
often permits one to live
in an area that is safe and pleasant for exercising and is near markets selling healthy food. A higher-status
job often means more control over one’s work schedule and better transportation, permitting one to exercise,
to shop for and cook healthy food rather than rely on fast food, and to find
good childcare. Behaviors can explain some of the gradient, but they do not remove it (7,15). Access to and use of medical care also could contribute to the socioeconomic gradient in
health (16,17).
Psychological factors also appear to be important to health outcomes (18). For example, higher income can mean less ongoing struggle to make ends meet and hence less ongoing stress (19). Chronic stress can lead to health damage through neuroendocrine, sympathetic nervous system, vascular, and immune pathways (20-22). Lack of control at work may be another piece of the puzzle explaining the socioeconomic gradient (23,24), along with psychological states associated with one’s position in a social pecking order (25). Living in a highly unequal society may damage the health of everyone in it, not only the poor, at least in part through psychological phenomena (25). Poverty in childhood may be particularly harmful to health through both material
and psychosocial pathways (26), with serious health consequences across the entire life course (27).
What are the implications for how we think about and address poverty in the United States? Poverty and “near poverty” (income up to twice the federal poverty
guidelines) in the United States are prevalent and
are associated with worse health outcomes among the population overall and among non-Hispanic whites and among blacks considered separately (12). These
poor health outcomes may help
explain the low ranking of the United States among affluent countries in life expectancy and infant mortality (4). But can anything be done in the United States? A full-time U.S. worker supporting a family of four on a minimum wage job is poor and will remain so even with proposed legislation
on wages and taxes. We could directly reduce poverty by raising the minimum wage, the Earned Income Tax Credit,
or both to
levels that would lift working families out of poverty. However, not only do we have higher rates of poverty and child poverty and worse health indicators than other affluent nations but we also have weaker social safety nets. Social safety nets can reduce chronic stress among middle-class as well as low-income families even
during good times by reducing worries about health insurance,
childcare, educating one’s children, and old-age pensions, and by limiting how far one can fall in hard times. We could strengthen social programs, such as childcare, education, and housing subsidies,
along with community development efforts that reduce the impact of poverty. Social programs such as early childhood development interventions and good schools can indirectly but
powerfully reduce poverty by resulting in higher educational attainment, which is linked to higher earnings,
and education can help break the intergenerational transmission of poverty (28-30).
Real, health-damaging poverty affects a large proportion of the U.S. population and exacts an unacceptable toll in avoidable suffering, disability, and premature death. This
toll also mean a less productive workforce and less economic growth. Current understanding of
the damage caused by near poverty and absolute poverty underscores the urgency of
addressing poverty at home as well as globally. Effective action will require addressing not only the obvious material and logistical hardships associated with low income but also the adverse psychological consequences of living and working conditions that create ubiquitous stress and disempowerment and weaken families and communities. Effectively addressing poverty can improve the health and
well-being not only of the poor but also of the scores of millions of middle-class Americans who increasingly live in fear of slipping through the safety net (31).
Back to top
Author Information
Paula Braveman, MD, MPH, Professor of Family and Community Medicine and Director, Center on Social Disparities in Health, University of California,
San Francisco, UCSF Box 0900, 500 Parnassus Ave, MU3E, San Francisco, CA 94143-0900. Telephone: (415) 476-6839. Fax: (415) 476-6051. E-mail:
Braveman@fcm.ucsf.edu.
Back to top
References
- World Bank. World development report 2000/2001: attacking poverty.
Washington (DC): Oxford University Press; 2001.
- Current Population Survey, 2006 annual social and economic supplement.
Washington (DC): U.S. Census Bureau.
http://pubdb3.census.gov/macro/032006/pov/new01_100_01.htm . Accessed May 20, 2007.
- United Nations Development Programme. Human development report 2003. New
York (NY): Oxford University Press; 2003.
- Forster M, Mira d’Ercole M. Income distribution and poverty in OECD
countries in the second half of the 1990’s. Paris (FR): Organisation
for Economic Co-operation and Development; 2005.
- Marmot M, Ryff CD, Bumpass LL, Shipley M, Marks NF.
Social inequalities in health: next questions and converging evidence. Soc Sci Med 1997;44(6):901-10.
- Marmot MG, Rose G, Shipley M, Hamilton PJ.
Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 1978;32(4):244-9.
- Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, et al.
Health inequalities among British civil servants: the Whitehall II study. Lancet 1991;337(8754):1387-93.
- Borrell C, Muntaner C, Benach J, Artazcoz L.
Social class and self-reported health status among men and women: what is the role of work organisation, household material standards and household labour? Soc Sci Med 2004;58(10):1869-87.
- Mackenbach JP, Howden-Chapman P.
New perspectives on socioeconomic inequalities in health. Perspect Biol Med 2003;46(3):428-44.
- Deaton A.
Policy implications of the gradient of health and wealth. Health Aff (Millwood) 2002;21(2):13-30.
- Minkler M, Fuller-Thomson E, Guralnik JM.
Gradient of disability across the socioeconomic spectrum in the United States. N Engl J Med 2006;355(7):695-703.
- Pamuk E, Makuc D, Keck K, Reuban C, Lochner K. Socioeconomic status and health chartbook. Health, United States, 1998. Hyattsville (MD): National Center for Health Statistics,
Centers for Disease Control and Prevention; 1998.
- Winkleby MA, Cubbin C.
Influence of individual and neighbourhood socioeconomic status on mortality among black, Mexican-American, and white women and men in the United States. J Epidemiol Community Health 2003;57(6):444-52.
- Lynch JW, Kaplan GA, Salonen JT.
Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44(6):809-19.
- Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J.
Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;279(21):1703-8.
- Mackenbach JP.
An analysis of the role of health care in reducing
socioeconomic inequalities in health: the case of the Netherlands. Int J
Health Serv 2003;33(3):523-41.
- Arblaster L, Lambert M, Entwistle V, Forster M, Fullerton D, Sheldon T,
et al.
A systematic review of the effectiveness of health service
interventions aimed at reducing inequalities in health. J Health Serv Res
Policy 1996;1(2):93-103.
- John D. and Catherine T. MacArthur Research Network on Socioeconomic
Status and Health. Psychosocial network: table of contents. San Francisco:
University of California, San Francisco. http://www.macses.ucsf.edu/Research/Psychosocial/chapters.html.*
Accessed May 20, 2007.
- Ferrie JE, Martikainen P, Shipley MJ, Marmot MG.
Self-reported economic difficulties and coronary events in men: evidence from the Whitehall II study. Int J Epidemiol 2005;34(3):640-8.
- Cohen S, Doyle WJ, Baum A.
Socioeconomic status is associated with stress hormones. Psychosom Med 2006;68(3):414-20.
- McEwen BS.
Protective and damaging effects of stress mediators. N Engl J Med 1998;338(3):171-9.
- Steptoe A, Marmot M.
The role of psychobiological pathways in socio-economic inequalities in cardiovascular disease risk. Eur Heart J 2002;23(1):13-25.
- Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S.
Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997;350(9073):235-9.
- Theorell T, Karasek RA.
Current issues relating to psychosocial job strain and cardiovascular disease research.
[Published erratum in: J Occup Health Psychol 1998;3(4):369]. J Occup Health Psychol 1996;1(1):9-26.
- Wilkinson RG, Pickett KE.
Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 2006;62(7):1768-84.
- Evans GW.
The environment of childhood poverty. Am Psychol 2004;59(2):77-92.
- Hertzman C, Wiens M.
Child development and long-term outcomes: a population health perspective and summary of successful interventions. Soc Sci Med 1996;43(7):1083-95.
- Anderson E, O’Neal T. A new equity agenda? Reflections on the 2006
World Development Report, the 2005 Human Development Report and the 2005
Report on the World Social Situation. London (UK): Overseas Development
Institute; 2006.
- Knudsen EI, Heckman JJ, Cameron JL, Shonkoff JP.
Economic,
neurobiological, and behavioral perspectives on building America’s future
workforce.
Proc Natl Acad Sci U S A 2006;103(27):10155-62.
- Low MD, Low BJ, Baumler ER, Huynh PT.
Can education policy be health
policy? Implications of research on the social determinants of health. J
Health Polit Policy Law 2005;30(6):1131-62.
- Sullivan TA, Warren E, Westbrook JL. The fragile middle class: Americans in debt. New Haven (CT): Yale University Press; 2000.
Back to top
*URLs for nonfederal organizations are provided solely as a
service to our users. URLs do not constitute an endorsement of any organization
by CDC or the federal government, and none should be inferred. CDC is
not responsible for the content of Web pages found at these URLs.
|
|
