Unequal Health: How Inequality Contributes to Health or

Illness

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 Unequal Health
How Inequality Contributes
to Health or Illness

Grace Budrys

R O W M A N & LITTLEFIELD PUBLISHERS, I N C .

Lanham Boulder New York Toronto Oxford
ROWMAN & LITTLEFIELD PUBLISHERS, INC.
Published in the United States of America
by Rowman & Littlefield Publishers, Inc.
A wholly owned subsidiary of The Rowman & Littlefield Publishing Group, Inc.
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www.rowmanlittlefield.com
PO. Box 317, Oxford OX2 9RU, United Kingdom

Copyright 0 2003 by Rowman & Littlefield Publishers, Inc.

All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior permission
of the publisher.

British Library Cataloguing in Publication Information Available

Library of Congress Cataloging-in-Publication Data

Budrys, Grace, 1943-
Unequal health : how inequality contributes to health or illness / Grace
Budrys.
p. cm.
Includes bibliographical references and index.
ISBN 0-7425-2740-9 (cloth : alk. paper)-ISBN 0-7425-2741-7 (paper :
alk. paper)
1. Social medicine. 2. Medical statistics. 3. Health behavior. 4.
Health status indicators.
[DNLM: 1. Health Status-United States. 2. Socioeconomic
Factors-United States. WA 900 AAl B8995u 20031 I. Title.
RA418.B83 2003
306.4’61-dc21 2003000482

Printed in the United States of America

@ TM The paper used in this publication meets the minimum requirements of

American National Standard for Information Sciences-Permanence of Paper for
Printed Library Materials, ANSI/NISO 239.48-1992.
 Contents

Preface vii

Introduction 1
The Tools: Definitions, Measures, and Data Sources 11
The Causes of Death 33
Age and Sex 47
Race and Poverty 63
Lifestyle and Health Behavior 85
Medical Care 107
8 Genes 125
9 Stress 143
10 Social Inequality 161
11 Population Health 181
12 Policy 207

Bibliography 235
Index 267
About the Author 271

V
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 Preface

T his book took shape over several years. It was born out of my need
to assemble reading material for a course I teach that considers
factors affecting health and illness. Up until about five years ago, I
simply chose from a selection of textbooks and added a few extra
readings. That worked well enough. About four years ago, I decided
to forget the textbook and rely solely on articles because I could not
find a textbook that devoted enough attention to the latest findings in
the field. The volume of research on the topics I had been addressing
in the course had expanded exponentially in just a few years’ time. In
my estimation, the findings were momentous. I was convinced that
the course would be incomplete if students did not have the opportu-
nity to consider the interpretations that the researchers conducting the
latest research were presenting. However, the articles were scattered
among a wide range of journals and were written for a sophisticated
audience of fellow researchers. In spite of the difficulties involved,
there was no question in my mind that this body of work was so
important that I had to integrate it into my course.
Just as I was struggling with the logistics involved in compiling the
reading materials for my class, a company that obtains copyright per-
missions for articles that it assembles into electronic sets of readings
offered to help me. Because this was a new subject area to the com-
pany, the company representative agreed to develop a package of
readings with no cost to the students in my class during a trial basis.
The outcome turned out to be a mixed blessing. The articles offered
recent information, which was great. However, they built on earlier
research with which students were not familiar, making the articles
hard to comprehend. The company suggested filling in with popular
press accounts, which were certainly much easier to understand, but

vii
viii Preface

that did not work very well because those accounts tended to be
incomplete. There were also technical problems-for example, the
tables in the scholarly articles were difficult to print. A couple of years
of experience that I spent trying to perfect the list of articles and work-
ing on filling in the background information required to understand
the articles laid the foundation for this book.
I must acknowledge the importance of the role played by students
in my classes all along in shaping the contents of the book. In the
spring of 2002, my class read a draft of this book. I asked the students,
mostly undergraduates, to point out where they thought I should
revise and clarify the writing. They were also very good at finding
typos, inconsistencies, and other errors. I am grateful to them for
doing this, although there were times when I thought they could have
tried to be a little less cheerful about it.
I would like to express my appreciation to DePaul University for
allowing me to take time away from my teaching responsibilities to
work on the first draft of the manuscript. I received additional support
in the form of a summer research grant from the university, which
was both financially and psychically rewarding.
A number of people read and commented on the manuscript and I
am very appreciative of their generosity. Genevieve Birkby, Gretchen
Fleming, and Susan Reed read the manuscript in its entirety. The
questions they raised and the changes they suggested were invalu-
able. I also asked several people to read portions of the book because
of their particular expertise. I am grateful to Michael Ash, Kiljoong
Kim, and Paul Knepper for their advice and comments on topics on
which there is a great deal of recent research that I wanted to be very
careful not to misrepresent. I also benefited from the comments and
suggestions made by two anonymous reviewers.
Special thanks go to Dean Birkenkamp, the executive editor at Row-
man & Littlefield, who has been enormously supportive and encour-
aging. Colleagues have told me that he is the single best editor in the
field. I feel very fortunate to have the opportunity to work with him
and his staff. The willingness of Alison Sullenberger and Heather
Armstrong at Rowman & Littlefield to respond so cordially to all my
questions and concerns has made the work of getting the manuscript
into print a pleasure.
Finally, I wish to acknowledge my husbands, Dan Lortie’s, contri-
bution. He read and commented on the earliest, most poorly orga-
nized versions of the manuscript, which was, of course, particularly
helpful. He was always willing to discuss at great length the material
 Preface ix

I was especially enthusiastic about, which happened a lot. However,

it was one of his passing comments that I cherish most. He noted that
the discussion of inequality in the final chapters of the book illustrates
the significance and practical consequences of social inequality that
discussion at the theoretical level has rarely succeeded in accomplish-
ing. My fondest wish is that everyone else who reads the book ends
up saying something like that.
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Unequal Health
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 1
4-
Introduction

A s we all learned in grade school, America, specifically Florida,

was ”discovered” by explorers searching for the fountain of
youth. When they did not find it, most concluded that it might not
exist. Five hundred or so years later, many of us are still not willing
to give up the quest. If anything, we seem to be even more determined
in our pursuit of the secrets leading to perpetual youth. What spurs
on this quest is the fact that we can all see that some people do, in fact,
age better than others. Not only do they look younger, but they really
are healthier and live longer. Maybe there really is some kind of foun-
tain of youth secret that accounts for it. That is one way of stating the
basic question that this book aims to address. In actuality, we will try
to find the answer to the question of why some people are healthier
and live longer by looking at it from the other end of the spectrum-
finding out why some people get sick and die so much earlier than
others.
Many Americans are convinced that they already know what the
answer is. Don’t most of the people you know think that a person’s
health depends on eating right, exercising, not smoking, learning to
overcome stress, and getting good medical care? When someone lives
to a ripe old age after happily violating all this good advice, we smile
and say it’s genetic. Similarly, when someone dies before what we
think is ”their time” despite following all of these rules, we all nod
knowingly, shake our heads, and again say that it must be genetic.
And that settles that!
That is known as conventional wisdom. What is so satisfying about
this explanation for longevity is that it is widely shared, which makes
us all feel that we are really “with it” because we are tuned in to what

1
2 Chapter One

everyone around us knows to be true. In other words, what makes

conventional wisdom explanations so popular is that they are
grounded in a much bigger belief system that unites us all as Ameri-
cans. The American cultural value system has well-developed views
about what foods are most tasty, and what kinds of leisure activities
are most popular and most enjoyable. Most, but not all, of us have
views on how women should look-thin! And we have some deeply
seated attitudes (read that as prejudices) about whole groups of other
people, in other words who is hardworking, smart, and honest as
opposed to clusters of people who we are quick to label as lazy. We
will be examining prevailing conventional wisdom explanations for
many of the topics we take up to see if they hold up in the face of hard
evidence based on research.
In order to get past conventional wisdom explanations and discuss
the topics that come up based on actual facts, we will be looking at a
lot of tables, especially in the first few chapters. I know that statistics
are sometimes intimidating. But I expect that you will overcome that
feeling pretty soon and find the tables really interesting because the
realities they reveal are not only surprising-they are shocking.
You should expect to encounter fewer tables as we move through
the book. Instead, you will see a steady increase in the number of ref-
erences to the interpretations of the data offered by experts. The shift
is logical. The tables in the early chapters present factual information
that you can interpret yourself. As we move through the chapters, the
interpretations of the data become more complicated and arguable.
That happens because the subject matter becomes increasingly harder
to capture, that is, to define and measure. Furthermore, as we move on
in our discussion, you will find fewer tables reporting on information
gathered by the government on the population as a whole. The gov-
ernment does not collect data on such things as how much stress peo-
ple experience. The topic is, however, clearly important and of interest
to many people, so researchers study this and other similar topics by
designing their own studies, gathering their own statistics, and report-
ing the conclusions they reach. We will devote most attention to the
health of the U.S. population, but we will consider the health of people
in other societies as well.
Because researchers are always trying to find better ways to collect
data, there is constant innovation in how this kind of research is con-
ducted, which means that new measures are continuously being intro-
duced. Whether they end up being regarded as improvements over
older, more established measures is resolved through discussion and
 Introduction 3

debate. More information means that there is more to disagree about.

Rather than becoming clearer, the picture keeps getting more com-
plex. That helps to explain why conventional wisdom explanations
are so much more satisfying to those people who have a low tolerance
for complexity.
The pervasiveness of conventional wisdom explanations is attribut-
able, in part, to the fact that the media never cease in reminding us of
the beliefs we are supposed to share as Americans. Not only is there
the chatter coming from “talking heads” on the TV screen, but there
are all those commercials. As I am sure you will agree, there is an end-
less parade of products and services aimed at helping us attain not
only better health but also great looks to boot. There are products to
help us quit smoking, exercise machines and clubs that promise ”buns
of steel,” and, if all else fails, medical treatments like liposuction,
which might be very useful after we consume those enormous por-
tions of fried, fatty food we are being encouraged to eat by so many
of the other commercials. Lately, we have been told to ask our doctors
to prescribe pharmaceuticals designed to bring complete relief from
ailments that are never identified in the TV commercials that promote
them. In short, the vast amount of media attention devoted to health
issues means that it is hard to ignore hearing what we should and
should not be doing to stay healthy.
It is also hard to avoid hearing about the negative health conse-
quences associated with smoking, abusing drugs, and engaging in
risky sex. So why do people who engage in risky behaviors do it? That
is a crucial question. If we knew the answer, then changing people’s
behavior to make it healthier would be a lot easier. Of course, the
majority of us would have to be convinced that the answer is accurate.
As it is, there is little consensus about how we might go about helping
those people change their behavior. And, in the opinion of some, there
is no need for the rest of us to be involved anyway-it is, after all, a
matter of personal choice, isn’t it? Of course, there are those who point
out that the rest of us will end up footing the bill for the medical care
that people who engage in various kinds of risky behavior will very
likely require. Looking at it from that perspective means that there are
consequential and practical reasons for figuring out how to get those
people to change their behavior.
Maybe if we knew more about the kinds of people who engage in
particular kinds of behavior we could target the message better and
get better results. Unfortunately, as most of us already know, targeted
messages seem to be highly successful when used to market all those
4 Chapter One

health-damaging products but is completely unsuccessful when used

to promote public health messages, but that’s an entirely different
topic. Why people behave the way they do, especially why they
indulge in self-destructive behavior, is a complex issue but an impor-
tant one. We will discuss some very convincing answers that keep
accumulating as we move forward in the book.
We will compare the behavior of groups of people according to age,
sex, and a dual category of race and ethnicity to see if we can find
any patterns. Those who conduct market research in order to create
advertising campaigns that are so successful in promoting all those
negative behaviors know this very well. To illustrate, cigarette compa-
nies spend a lot of money finding out who is and who is not smoking
their brand: young or old, rich or poor, women or men, and so on. We
will be considering who is more likely to be overweight. Who is get-
ting appropriate medical care, who is not getting it, and why not? In
fact, once you start thinking about it, the basic information we need
goes beyond knowing who is less healthy and at greater risk of dying.
We need to determine whether these things are randomly distributed
or if there is some kind of identifiable pattern. Does life expectancy
vary by sex? Race? Then there are all those factors that matter but are
not always easy to measure such as stress, medical care, and genetic
inheritance.
Just in case the thought has crossed your mind that all this could be
interesting in the abstract, but is pretty far off from anything that
might be of primary interest to you, and just in case you are wonder-
ing why you should expend time and energy trying to understand any
of it, you will surely be surprised at the answer. It will not take long
for you to see that the questions we will be exploring regarding varia-
tions in death rates are related to a far greater range of issues than you
might think at first glance. To illustrate, there is strong evidence to
indicate that the rate of violent crime-but not theft-is directly corre-
lated with mortality rates on a state-by-state basis. The distribution
of income, voting behavior, and women’s rights are associated with
variations in mortality rates. Curiously, although the public may not
be aware of the existence of such linkages on the domestic front, a
growing number of entities that focus on international policy issues
are quite concerned about the implications revealed by this kind of
material for foreign policy. A particularly graphic example of this
point comes from research carried out on behalf of the CIA, which
finds that political instability in developing countries is not a matter
 Introduction 5

of chance-it is predictable. A country’s infant mortality rate is the

single best predictor. We will review the evidence on this topic in
addition to many others. In short, expect to find the ramifications of
what we discuss to go well beyond an exclusive focus on health.
So now you know where this discussion is going. Prepare yourself
to embark on a largely uncharted journey. In a way, this is the scien-
tific, twenty-first century version of the search for the fountain of
youth. This time we are not looking for some magical elixir, but for
knowledge. The objective is to identify the factors that enhance peo-
ple’s chances of having a healthier, longer life while dooming others
to a greater chance of illness and early death.
We will approach the quest for information using a systematic
approach. We will address each of the topics that we have already
touched on here in the following sequence: age, sex, race and ethnic-
ity, poverty, lifestyle or health behavior, medical care, genetics, stress,
and, at the end, a topic that is receiving a great deal of attention cur-
rently, namely, social inequality. As is clear from this list, there are
other topics we might have considered-environmental pollutants for
example or mental illness. However, I had to draw the line somewhere
and decided that there is more than enough material to digest if we
limit ourselves to the topics I have identified so far.
We will start by assembling the information that is already available
on health status and life expectancy. In an effort to interpret this infor-
mation, we will consider as much of the relevant research and analysis
by experts as we can accommodate in this relatively short book.
Because the measures used by researchers are always being critiqued
and debated, we will stop regularly to reflect on those measures and
discuss the pros and cons of any alternative approaches we might
think of. We will end with a summation of what we have learned-
with the understanding that the search for conclusive and definitive
answers to all the questions that researchers pose, plus those that you
and I come up with, should provide work for scores of researchers for
many years to come. The fact that the search for answers is ongoing
indicates that it is incomplete. That means that the facts we will be
reviewing probably do not constitute a definitive answer. This does
not mean, however, that we cannot consider the policy implications of
what is known now. We will do that because the policies being
advanced currently by those in a position to promote and enact them
may have profound effects, possibly positive and possibly negative, on
the health and life expectancy of the entire population.
6 Chapter One

ANALYTICAL FRAMEWORK

Now that the course of our journey has been laid out, we need to do
one more thing in preparation. We need to develop a clearer, shared
understanding of the kind of things we are searching for. Committing
oneself to using a scientific approach means that one can not settle
for something like the definition of pornography employed by some
members of Congress, namely, "I know it when I see it." Accordingly,
chapter 2 is devoted to outlining the tools we will be using throughout
the book, giving special emphasis to definitions. Chapter 3 focuses on
the extent of the variation in health status that is revealed in data for
the population as a whole. Each of the remaining chapters focuses on
one or more of the factors or variables that we identified above and on
their roles in determining health and life expectancy.
So far, I have suggested that we will deal in facts, data, and research
findings. As you know, saying that something is a fact will not neces-
sarily convince all listeners of the truth of that assertion. We regularly
see and hear experts arguing about interpretations of facts, even the
validity of the facts. In some cases, experts come at the same issue
from different perspectives, use complicated measures, and empha-
size distinctive aspects of the issue. It is not so much that they dis-
agree, but that they are trying to answer somewhat different questions
even as they address similar topics. This happens because the experts
in one field do not read what the experts in other fields have to say
about the topic. Experts in related fields end up creating separate bod-
ies of knowledge that, under ideal circumstances, should come
together to create a more fully developed set of answers. In many
fields, this scenario persists without anyone becoming overly con-
cerned.
What is happening in the area that we are about to launch into is
special because, in this case, experts from different fields of study are
very much aware of each other's work. Anyone associated with this
body of research will tell you this is a very exciting time to be focusing
on the questions we will be addressing. Researchers with very differ-
ent kinds of expertise are not only aware of the findings on related
topics produced by researchers in other fields, but they are also incor-
porating those findings into their own work. The knowledge base is
becoming broader and complex explanations are becoming more
widely accepted by researchers who come to this area of work bring-
ing with them very different analytical perspectives.
My training is in sociology, and it is the sociological perspective
 lntroduction 7

from which I see the world, so what I say will certainly proceed from
this worldview. However, the material you will be encountering here
will include research produced by epidemiologists, practicing physi-
cians, basic science researchers, public health researchers, statisticians,
political scientists, economists, and social psychologists, to indicate a
few of the disciplines that contribute to the body of knowledge that is
becoming known as the study of population health. Others label it social
epidemiology, which describes the primary focus of what we will be
looking at very well. What you will not find in the body of the text is
much effort to interpret findings from any particular theoretical per-
spective. This is especially true of later chapters, which is where the
health status of large groups of people, rather than of individuals,
becomes the central focus of discussion. At that point, we will be com-
paring the differences in the health status of large populations of peo-
ple by city, state, and country.
The explanation for why researchers from so many different disci-
plines have been able to come together to address questions in this
field, unlike so many other fields, is interesting. It seems that research-
ers from each of the disciplines I just mentioned kept coming up with
partial answers to the questions they were asking. Reports kept end-
ing with statements indicating that the researchers were frustrated by
the lack of more complete and satisfying explanations. Their reports
repeatedly concluded with statements advocating further research on
questions that they readily admitted fell outside of their own areas of
expertise.
The biggest hurdle that stood in the way was the contrast between
the focus on the individual patient’s problems that medicine has tradi-
tionally employed and the focus on patterns exhibited by entire
groups of people that is employed by researchers in many of the other
fields that are now involved. This is not to say that doctors did not
understand that all those other aspects of a person’s life were impor-
tant. It is just that they were convinced that the physical indicators
exhibited by individuals were the crucial ones. Many doctors continue
to think that, even as the research published in medical journals indi-
cates that some medical scientists are now very interested in the
results found in the population health literature. Medical researchers
who are considering a broader range of factors affecting patient’s lives
are finding that such an approach helps explain why the same disease
proceeds faster and is more devastating in the case of some patients
than others. Findings reported by researchers in other countries, who
8 Chapter One

concluded exactly the same thing, further advanced this new research
agenda.
It is not that researchers had been ignoring data coming from other
countries in the past. It is just that a heightened interest in sharing of
knowledge began to evolve over the last few decades, possibly
because of the increasing ease with which it can be accessed thanks
to computers. Growing international interest in achieving answers to
similar questions accelerated the process of generating common indi-
cators and scales to measure health. That has made cross-national
research findings, which we will be examining, more comparable in
recent years. The amount of data that is accumulating and revealing
similar results make such findings impossible to ignore.
If it is not already very clear, I wish to emphasize the fact that we
will be looking at the health of large groups of people rather than the
health of individuals with particular health problems. Whether the
information that applies to groups can be translated into recommen-
dations that will benefit any of us as individuals any time soon is hard
to say. That is not the aim of this book. If you are looking for advice
that will improve your own health, you will have to look elsewhere.
There is certainly no shortage of advice, both sensible and “way out.”
I leave you to decide which is which and whose advice to follow.
What we will be doing is best described as a review of the literature
on the health of whole categories or populations of people. Research
that tells us about the health of large groups will, of course, benefit all
of us in the long run as it tells us about the factors that are most closely
linked to poor health and death among the largest numbers of people.
There is an enormous amount of research to which we could refer
that is both pertinent and interesting. Realistically, we can only skim
the surface of it all. In fact, every time we begin discussing each of the
factors identified thus far, we will be encountering a whole new set of
ideas and explanations for an even greater range of phenomena
related to that factor. We cannot do a thorough literature review in
each case; there is simply too much to cover. My objective is to identify
the basic ideas. I aim to bring those ideas together to develop a more
complete picture of how the factors combine to produce either good
health or poor health and premature death.
Because this area of research is moving at a very fast pace, there are
very few comprehensive texts. Accordingly, I will be referring to arti-
cles and reports presented in a wide range of publications. As you will
see, the vast majority of articles were published over the last few years.
This is not to suggest that earlier research is unimportant. It is just that
 Introduction 9

most of it has been incorporated into more recent work. If you decide
to search for additional information, be prepared to find a great deal
more and to find it in scattered places.
In case I have not made this perfectly clear, we will be examining
empirical evidence. We will not be using a set of theoretical frame-
works to interpret that evidence. This is not a textbook on health
issues that poses questions at the end of each chapter designed to rein-
force lessons on research methodology, data analysis, or theory pre-
sented from a particular disciplinary perspective. You will have to
develop your own assessment of the data and interpretations pre-
sented by researchers. I assure you that you will not have difficulty
doing that since the findings you will be confronting are so powerful
and convincing.
As I have said, it is an exciting time to be considering the topics we
will be discussing here. With that, let us begin this adventure.
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 2

The Tools: Definitions,

Measures, and Data Sources

T he primary objective of this chapter is to discuss the analytical

tools we will be using throughout the book. The first item on this
agenda is the matter of defining what we mean by such terms as
health and illness. This is an important step because the verbal defini-
tion is meant to pinpoint exactly what is being measured and how it
is measured. That turns out to be far more complicated than one
might think. We will also discuss data sources. Only then will we actu-
ally examine some tables that report on such things as life expectancy
and mortality. We end this chapter with a table that compares the
health status of Americans to that of people in other countries plus a
couple of other tables that provide some comparative information on
the health of people in this country.

EPIDEMIOLOGY

The tools we discuss in this chapter are basic to the work done by epi-
demiologists (Rockett, 1999). As long as we are going to be defining
concepts, we might as well begin by defining epidemiology. The root
word, "epidemic," pretty much explains it all. It is the study of the
spread of disease. It stems from the Greek words for "about or upon"
(epi), "people" (demos), and "study" (logos). Hippocrates, a physician
and philosopher writing during the fifth century B.c., is credited with
the earliest exposition of the factors implicated in the distribution of
illness. Modern epidemiology is generally traced back to John Snow.

11