Health and Poverty in the US

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Health and Poverty in the US

by Stephen Bezruchka; December 09, 2003

I want to talk about how healthy the people are in the United States of America,

why we are less healthy now than we should be, how we used to be much healthier,

in comparison to other countries, and what we need to do to regain our health

ranking. To consider the reasons, we have to address issues of poverty for that

is the critical concept that is related to health. I will talk a great deal

about one critical form of poverty, relative poverty, how you compare to others,

and how that affects our health. I will say that more than bringing the bottom

up, we have to bring the top down. I will give a prescription for health.

It is really difficult to talk about poverty in the United States of America,

because many people don't identify with being poor. We are mostly all

middle-class here, right? Being poor is a bad choice of words to use because it

stigmatizes. So I will deal with you who are families and working people, and

people with low income but who may still be struggling to make ends meet.

To admit that you are poor in America might mean that you will be permanently

poor, especially in the land of the American Dream, namely that before we die,

we will all achieve wealth, happiness and prosperity--own our home, the big car

and other symbols of success. It all depends on us, that we have to pull

ourselves up by our bootstraps, work hard, and we can achieve anything we want.

Arent we entitled to that?

That is all that Bill Gates did. Or Magic Johnson. Or Oprah Winfrey. I don't

know if that is true, some people would say that Bill Gates was born into a very

privileged family. The facts show we have much more poverty in the USA today

than in all the other rich countries. That is not good.

In the 1950s, my father repaired shoes, and we lived above the shoe repair store

in a tiny apartment. We didn't have a car for a long time. We also lived in a

working class neighborhood, where everyone else was pretty much in the same

shoes as we were. Although we had a TV by 1953, the programming back then was

pretty basic, and didn't display lifestyles of the rich and famous, so we didn't

get a sense of how little we had and we weren't made to want.

So I never thought of myself as having less than other people until I went to

college and made friends with people who went off to Europe in the summer. Who

had vacation homes. Then I thought of myself as working class or lower class. In

fact, I remember well having a discussion with a friend of mine in graduate

school at Harvard University in which I described myself as working class, or

lower class. He said, there was no way you could get to Harvard and be working

class as was the case in the 1960s.

After graduate school, I spent a year in Nepal, a little country sandwiched

along the highest mountains in the world, where Mount Everest sits. There were

no roads there then, and still there are very few so to get somewhere you had to

walk. There were no lodges or hotels then, so the few travelers there stayed in

people's homes, ate their food, and slept around the fire on the mud floor, just

as the families did together with the children and grandparents. These people

had next to nothing, yet they didn't seem to want anything. I know now why they

didn't want anything. There was no advertising of the things they should want. I

spent a whole year totally without any form of advertising. It was a profound

experience. So these people had the basics, food, water and shelter, and the

love and company of their family and community. And they shared this with me.

They laughed, played, never let their children cry and seemed happy, and I know

they were. But you would call them desperately

poor if you saw their situation today.

Some of you might say I am romanticizing the situation, describing the noble

savage. I used to think maybe I was wrong, but I'm now convinced that happiness

and satisfaction are not something you buy.

What about poverty and health? I have been working as a medical doctor for 30

years, much of that spent in emergency rooms, trying to look after people's

health problems that arise quickly, I started doing emergency care in 1977

because I thought that is was really helpful for people.

I've continued to practice in emergency rooms in the US for the ensuing 25

years. I occasionally thought about the kind of people that I would see in the

ER, the kind of people having accidents, or heart attacks, or as parents of sick

kids. Mostly they seem to have one thing in common, they are not rich people,

they aren't wealthy.

Now much of my time has been spent working in ER's in Burien, White Center,

Tacoma, and Lakewood, as well as near the Central District in Seattle. There are

a lot of low-income people living there, struggling to make ends meet. But I

also worked in Bellevue, near where the richest person in the world lives, as

well as the home of other billionaires, and multi-millionaires. What kind of

patients did I see in the ER in Bellevue? Were they rich? Well, occasionally, I

would see someone that I would surmise was well off, but for the most part, the

rich didn't come, even to a hospital in a rich neighborhood. You might say that

when they were in a hospital gown, or strapped to a stretcher, that it would be

hard to tell if they were rich or not. But even stripped naked, it isn't hard to

tell. For one thing, people with low incomes often interact with people

differently. Often they don't make eye contact with you, but look down. And when

they do look at you, their eyes betray a tough life.

Sometimes they are angry and rushed, wondering why they have to wait for so

long. For another, they tend to be more obese, sometimes much more.

They tend to use words differently, when we talk. They might say " Doc I have

this serious pain in my stomach, " for example, rather than saying " Doctor, I'm

having some discomfort in my abdomen that is associated with some loose

movements. " You might think I am saying that low-income people are dumb, and

didn't do well in English at school. They are certainly not stupid, and they

speak English different from the rich, but it ain't wrong to speak that way.

I began to think that maybe poorer people got sick more than rich people. You

might counter that and say no, the rich have their own private doctors and don't

go to ER's but call their doctors anytime of the day or night. Surely that

wouldn't be true in the middle of the night, whether at a hospital that serves

the poor or one that serves the rich. You have to come to the hospital when your

appendix bursts in the middle of the night, whether youre rich or poor.

What do YOU think? Are rich people as sick as working class people or people

with low incomes? Raise your hands if you think so?

The studies overwhelming show that for every health condition, for every

disease, for every cause of death, those who have lower incomes have it much

worse than those who have fatter paychecks. In other words, if you work where

you have to see sick people, such as in emergency departments, you are going to

see poorer people for the most part, no matter whether your hospital sits in a

wealthy neighborhood, or a poor one. Coming to see that, namely that poorer

people had poorer health, was a major revelation for me. Now I'm not saying that

all rich people live long healthy lives and the people of more modest means live

shorter sicker lives. We all know of counter-examples to that. The tragedy of

Princess Diana comes to mind. But as a statement about populations, about

communities, wherever you look at it, poorer people have poorer health. The next

question I asked was WHY this was so.

So why do people with lower incomes get sick more? Is it because they smoke

more, which they do? Is it because they drink more, which they may do? Is it

because they shoot up more heroin, which is true? Is it because they eat more,

which is true? Is it because they don't exercise as much, because they don't?

Well, the studies show, that such behaviors that we consider bad for health

explain only about 10% of the reason that poorer people have poorer health.

Learning this has been a revelation for me over the last ten years. I used to

get complaints in the ER for keeping harping on people to quit smoking. For a

chronic lunger who continues to deteriorate and keeps his two pack a day habit,

patient's families would say to the administrator that all I would do is tell

him to quit. Isn't there something else you could do, he's trying to quit but

can't. Like most of us, I used to blame sick people for their behaviors that

made them sick. But I don't now, I blame myself for allowing the rules that

govern our society change to produce the behaviors that are bad for us.

Is it because lower income people can't afford health care? Is that why they get

sick more? It is tempting to say that is the reason, but it isn't. I know some

of you here may not have health insurance. Perhaps some of you have huge medical

bills that you are struggling to pay. Health care, or the lack of it, doesn't

explain why poorer people have poorer health. Consider the Hispanic population.

They don't access health care much, they tend to not have medical insurance,

they tend not to go to the doctor. Countless studies show this and it represents

a cause for concern. What is often not stated is that Hispanic people tend to be

healthier than non-Hispanic whites. And it isn't because they don't go to see

doctors, although that is a tempting thought. As a rule, most Hispanics are

comparatively less well off than non-Hispanic whites, so later we will consider

why they may be an exception to the poorer people have poorer health concept.

I expect you to be skeptical on this, but I would like to proceed with the

observation that it is people of lesser means that are sicker, and it is not

their behaviors such as smoking or diet that makes them sicker, for the most

part. And it isn't access to medical care, or the kind of medical care people

receive that accounts for the difference. Again, there are a lot of studies and

science on the subject, and I'm asking you to suspend your disbelief and let me

go on.

By its very nature, medical care can't have much to do with health. To consider

why, I make the analogy that medical care's role is the same as that of the army

medical corps in keeping us healthy. You've been reading about all these

soldiers that are coming home from Iraq with legs blown off, or other serious

injuries. Our media has been forbidden to show coffins of our troops coming

home, but there have been many deaths, as you know. Now the army medical corps

goes in after the blast and picks up the victims, splints the limbs, starts

IV's, transports them to where they can get blood, and then to a field hospital

station where bullet holes are closed. There heroics are carried out and

hopefully the stricken soldiers survive. We feel grateful in such cases. But

most casualties, those who die, are killed outright by the blast, by the bullet

or bomb. The army medical corps can't do anything for them. The army medical

corps did not decide that we were going to invade Iraq, they didn't

decide the battle strategies, that we were going to bomb targets including

civilians, from the air, that later we would send in ground troops. They didn't

decide on the day-to-day combat decisions. They didn't decide on the protective

gear that troops would wear. All they do is go in and pick up the pieces, those

fortunate ones who still have signs of life. That is the best that medical care

can do, try to keep the survivors alive. So by its nature, medical care can't

have much of an impact on health, despite what you are led to believe. In my

courses at the University of Washington, I go into great detail about this, and

as a practicing doctor, I believe this is true. Colleagues of mine, who have

considered the issue of what medical care does in making communities healthy,

agree, as do the experts who write papers and books on this subject. That is not

to say that I don't believe in medical care. I work as a doctor providing

medical care, and I teach young doctors as well. And if I

get sick, I see a doctor. And if I collapse here on the podium, I want you to

call 911. But we should not deceive ourselves that this is what makes us healthy

as a population. I'm sure you think this sounds weird, counter-intuitive if you

will.

I expect you to be skeptical on this, but I would like to proceed with the

observation that it is people of lesser means that are sicker, and it is not

their behaviors such as smoking or diet that makes them sicker, for the most

part nor is it access to health care.

I hope by now you are asking why poorer people have poorer health. That is the

right question to be thinking of. Thomas Pynchon wrote in Gravity's Rainbow: " if

they can get you asking the wrong question, the answers don't matter. " I think

we ask too many wrong questions in America today. What does matter most is the

nature of our relationships with each other, the social nature of ourselves, the

psychosocial element, if you will. Let's explore that.

Think of health as the expression of our life experiences. We all know the

physical effect that stress has on our minds and bodies, our immune systems and

our ability to fight off diseases. The reason poorer people have poorer health

has something to do with the basic nature of living with and in poverty,

especially what you live amidst plenty and have that rubbed in your face. That

is what being a family living with low income is all about.

If I were to ask you in this room, how many of you consider yourselves poor, I

think fewer hands would go up, than if I asked you if you were middle class.

What is that all about? If you admit you are poor, you are shaming yourself, and

feeling shamed is the essential human emotion when it comes to understanding an

important aspect of health. Now many people with lower incomes, many

disadvantaged people, won't admit feeling shame, but feel the shame deep inside,

nevertheless. Doesnt it make sense that these feelings would have a strong

impact on our physical, as well as mental health?

So what does being poor mean? What is poverty, or living with lower incomes all

about in the USA? Or in Seattle? Let's start by leaving out the homeless. There

are more than a million homeless children in the USA, the richest and most

powerful country in world history. I don't know how many homeless there are in

total in the US, but I've seen statistics quoting 1.5 million in California

alone. The 2001 One Night Count accounted for 7,350 people who are homeless in

King County. I would imagine the number for the whole country is probably

somewhere between 10 and 20 million, and could be a lot higher. For those of you

who are older like me, if you think back 25 years and reflect on whether or not

you saw any homeless people, you would probably find that you didn't. And the

studies show that as well. Not that there weren't any then, but you might see

one in a week or a month instead of one every few minutes in some areas. . The

reason for the homeless is that Ronald Reagan cut funding

for low-cost housing in 1981, and right after that, there they were on the

streets. But I said I wasn't going to delve into poverty among the homeless and

will stop at this point.

So what about the poor, people who are almost homeless, for that is what the

situation is like. These people are often one paycheck away from being evicted.

In Washington, a worker earning the minimum wage (7.01 per hour) must work 86

hours per week in order to afford a two-bedroom unit at the states median Fair

Market Rent But even if you are not so poor, is it because you don't have enough

to eat? A roof over your head? Central heating? Is it because you don't have a

microwave, or a refrigerator? Is it because you don't have a TV and VCR? Is it

because you don't have a cell phone? No, many low income people have all these

items, they aren't close to being evicted, and yet they feel disadvantaged.

Fifty years ago, the rich didn't have microwaves ovens, or VCR's or cellular

phones. But now many low-income families have them. So it is important to note

that being less well off is not about not having stuff such as items like

cellular phones and VCR's that might have been considered

science fiction devices fifty years ago. Being less well off is about feeling

that you don't have the choices that the more well off do. It is not about the

stuff you have. I said that it is people with low incomes who are obese, so they

have enough to eat. People in the subsidized housing areas have a lot of stuff.

Still they feel disadvantaged, and as my years of experience in emergency

departments demonstrated, they are the ones who get sick. And so in a very

profound sense, these people are disadvantaged in the most important way, namely

they don't live as long or as healthy lives as do the rich.

Take me at this point. I'm certainly not poor now. As I said, I grew up in a

working class neighborhood, and my father repaired shoes. We lived above his

shoe store. I mentioned how I didn't feel poor until I left my neighborhood and

was amongst people who had more than me and had greater choices than I did. Then

I began to feel poor. In other words, I began to feel poor when I began to make

comparisons of myself and my situation, with other people. By now, I have

flooded you with the concept of class, I'm waging class warfare as some

politicians might say. We have to be honest, this is what today is all about. It

is class warfare. There is a war going on right now and it is the rich who are

attacking everybody else. In fact this war has been going on for the last ten

thousand years. Class Warfare is worse these last few years although our leaders

would deny that it even exists. The weapons of class warfare are symbolic

missiles, shot through our media-- TV, movies, magazines, and

the internet. And it starts at a very young age. What are really pornography

internet sites that our children are exposed to are not the crass sex that dirty

old men like me would like to look at, but the Nike websites, or the movie stars

web sites. The Nike sites display their shoes and the stars their environments.

These are signs that the rich are winning the class warfare battles. Another

sign is that people with low incomes are naming their newborns Gucci and Armani

and other icons found on designer labels. In ER's I see people who have been

attacked and robbed, and the key thing the robber got away with were their fancy

new Nike tennies.

The essence of class warfare is that the rich make you compare yourself with

others that you consider better off than you are. That is their weapon, their

scud missile. IF you are rich, it doesn't mean you have more stuff, necessarily.

It means that you can have it if you want it. You can do what you want. My

friend Raymond, who made a lot of money, said he took care of his problems with

the check principle. If he had a problem, he would find someone to take care of

it and write them a check. Most of us can't do that.

Our societies today are like baboon troops in Africa, for example. There is the

alpha male, or the top dog, and there are those in the pecking order below the

alpha male. The alpha male gets the best food, and the pick of the females to

mate with. The beta and gamma males have very different lives. Those lower down

are always on alert that the alpha male will take the choice bit of food they

have found, or chase them away from the female they were going to mate with.

Their lives are under constant stress. We know that the alpha male is healthier

than the beta and gamma males, the alphas have different physiology, a different

stress response, than the baboons lower down. The gamma males, the lower ranking

baboons are less healthy than the high ranking ones. Human studies show the same

thing, that is people with low incomes have the stress responses of low ranking

baboons.

So with baboons or humans, being lower down in the status ladder means you

suffer more from chronic stress. This results in higher blood pressures, less

ability to control glucose in the blood and so more adult onset diabetes, which

we are seeing in younger and younger children as they are under more stress.

This results in fat deposition around the waist and hips. This results in more

plaque in coronary arteries that supply the heart and so we have more heart

attacks in poorer people. Those lower down the status ladder have less ability

to fight infection because their immune systems aren't as efficient. They are

less able to search and destroy cancer cells.

So having low income in America is knowing that you aren't in the same league

with those having higher status in our society. You generally don't do as well

in school. You are more likely to be raised in a home where your mother has to

work at several jobs to make ends meet. You may not know who your father is. You

won't have the fancy car, or designer-label clothes, and won't go to France for

the weekend. Or more likely, you will have the status Nike shoes, and will spend

for those icons of status, and not be able to afford health care. You will tend

to eat at fast food places, and shop in convenience stores. If you have a car,

you will pay more money for gasoline, unless you travel to the cheaper gas

stations, which are often not in poorer parts of town. If you don't have a car,

you will be riding the shame train, or the bus. And you won't feel so secure

walking down the street.

It begins way back when you were just a gleam in your parent's eyes. That is the

effects of class and ranking and social status began to effect your parent's

physiology and thus your biology to have an affect on your health. The most

important time is from conception to age 2.

Perhaps you have a job, doing work that needs to be done. You do it well. Jobs

that some might consider menial, such as working as custodian in a building

after hours when the executives go home. Or you may work as a nurses aid in a

nursing home. Or you may work at that convenience store, or be flipping burgers.

You may find yourself suppressing your rage when the boss goes by. But if you

are nice enough, you might get a Christmas present at the end of the year. Even

if you are nice enough, you might get laid off in the next economic downturn.

Most likely, you will have two or three jobs, all of them part-time, with no

security or benefits. Alan Greenspan, the chairman of the Federal Reserve Bank,

talked about the booming economy in the 1990s being partly because of a flexible

labor force. Namely, workers worked for very low wages and could be laid off at

will. I'm sure you will agree that it is good for the economy to be flexible

like that but it sure isn't good for you or for your

health to feel that insecure.

One thing that has happened in the last 30 years is that more people are not

doing well in America. Not only are the homeless out in droves, but poverty, no

matter how you measure it, has increased dramatically over this period of

incredible prosperity in America. This isn't just true in America, but worldwide

as I'm sure you are aware. There are many more poor people, the biblical promise

is true " the poor ye shall always have with ye " only it might say the poor shall

be ever more with you. This in a time of phenomenal wealth.

So my main point is that the culture of poverty, the culture of inequality that

surrounds us is what has the most significant effect on our health. Let me

clarify this idea a little bit. Those at every rung of society's ladder from the

top to the bottom will have their health determined by where they stand in the

ladder of social status in society. The poorer you are the worse your health in

comparison to others.

Stated very simply, societies with a bigger gap between those on top and those

on the bottom will be less healthy than societies where there is a smaller gap.

To illustrate this, let us look at the health of the United States of America,

measured by life expectancy, say, the average number of years lived in this

country. Fifty-five years ago, we were one of the healthiest countries in the

world by this measure. Today, there are some 25 countries that are healthier

than we are. Think of it, all the other rich countries are healthier than we

are, and a number of poor ones as well. It isn't just this one measure of

health--life expectancy-- in which we do poorly, but in every other measure,

when we rank ourselves with other countries. We are living longer but not so

long as people in 25 other countries, all of them poorer than we are. For

example, we have the highest infant mortality rate, the highest child poverty

rate, the highest teen pregnancy rate, the highest child abuse death

rate, and so on. There are no indicators in which we excel, except in spending

money on health care, for we spend half of the world's total health care bill.

Think of it - for every dollar in the world spent on healthcare, 50 cents is

spent here. Yet our citizens are less healthy than those in all the other rich

countries. And by less healthy, I don't just mean in how long we live, but in so

many other indicators of health, such as teenage pregnancy rates, such as in

homicides, or incarceration rates. Indeed we house one quarter of the world's

prisoners in America, which says something quite significant about how we deal

with petty crime in this country.

What has happened to cause this huge disaster? Stated simply, it is because we

have changed the rules in this country as to who gets what share of the pie.

Back fifty years ago, it was the poorest families that saw the biggest gains in

income. Now, as you all know, it is only the rich and super-rich that are seeing

gains in income, while the rest of us all have to tighten our belts. This may

not seem right in explaining the reason for our poor health, yours and mine.

However, it is true, it is because we have changed the rules in society and

created many more poor people and that is why your health and my health is not

as good as it could be.

Racism is another way that the gap operates to create worse health. Racism is

all about difference and power. Minorities have always been put down, and feel

the shame, even if they don't think about it. The rich want to continue to put

people down, but use ever more subtle means. If you can put people down, if you

can make them afraid, if you can make them want things, then you have power over

them. An African American male in Harlem lives less long than a man in

Bangladesh, one of the world's poorest countries. Or that a black man in

Washington, DC lives less long than a man in Ghana, a country in West Africa.

Women tend to be healthier and live longer than men. As well, studies show that

where women play a bigger role in political life of communities, they are even

healthier. What is more astounding is how men's health improves in those

situations even more than the gain for women. In other words, we all do better

where women do better, and I'm sure most of you here know that.

It is important to recognize how much our health relative to other countries has

deteriorated in the last 55 years. Consider that if we won the war on heart

disease, the plague that will kill almost half of us in this room, if we had no

more deaths from heart attacks, we still wouldn't be the healthiest country in

the world. And yet 55 years ago, we were one of the healthiest. The difference

now is that we live under more stressful conditions, a stress caused by the big

gap between the rich and the rest of us. And when we go shopping at The GAP,

that symbolic store, we don't even realize that this is the key problem in

America.

How is it that a bigger gap society has worse health than a more egalitarian

society. Consider two extremes: an egalitarian society where everyone is more or

less equal, and a very hierarchical one where there are a few fabulously wealthy

rich and the rest of us, sort of like the USA. What is life like in an

egalitarian society? What are the prevailing relationships and feelings.

Wouldn't they be those of friendship, support, trust, caring, helping, sharing,

and community? Don't those words sound healthy? What about the other extreme, a

very hierarchical society? What is it like inside such a population? Well, those

on top with the wealth have power and can dominate, compel and coerce those

beneath them to get things done. The rest of us resign ourselves to our job and

role, but feel humiliated and shamed. Shame is the important emotion at work.

None of these feelings such as shame or relationships of power and domination

sound healthy, do they? But in countries such as the USA,

these are the prevailing mechanisms at work, even though we think we are all

middle class there is an ever increasing gap between the rich and poor here. In

a society with a bigger gap, those above put down those below, and this is

related to the amount of violence in society and helps explain why we have so

much homicide. Costa Rica is an example of a nearby country that is pretty

egalitarian, and even though it is much poorer than the US, it is healthier than

we are. Canada is another example, our neighbor to the north, which is much much

healthier than the USA. The final example is Cuba, a country that we have been

strangling for 44 years with trade sanctions and embargoes. Cuba is as healthy

as we are, despite, or maybe because of our policies.

Consider the healthiest country in the world, Japan. Fifty-five years ago when

we were one of the healthiest countries in the world, right after World War II,

Japan was less healthy compared to other countries than we are today. Yet the

USA gave it the medicine it needed to become the healthiest country in the world

by 1978. The medicine was prescribed by the greatest population health doctor

who ever lived, General Douglas MacArthur. The medicine administered during our

occupation of that country from 1945 to 1950 had 3 ingredients and I will review

them here. The first was demilitarization. Japan was forbidden to have an army.

The second ingredient was democratization, as MacArthur wrote the country's

constitution, providing for a representative democracy, free universal

education, the right of labor unions to organize and engage in collective

bargaining, and the right of everyone to a decent life. The third D was

decentralization, as MacArthur broke up the 11 family zaibatsu that

ran the huge corporations that controlled the country. He legislated a maximum

wage for the country of the equivalent of $4333 in US dollars. He also carried

out the most successful land reform program in history. What this did is bring

down the economic hierarchy, and level the playing field. The resulting rise in

health is the most rapid ever seen on the planet.

Japan presents some interesting issues about population health. Japanese men

smoke the most of all rich countries. Yet they are the healthiest population on

the planet. It seems you can smoke in Japan and get away with it. It's not that

smoking is good for you, but that compared to other things, it isn't that bad.

Smoking is much worse for you in the US than it is for the Japanese in Japan,

where the gap between the rich and poor is much less. So I tell people that if

they want to smoke they should be born in Japan. Similarly, it isn't Japan's

health care system that is responsible for its remarkable health. Anyone who has

looked at their system will tell you it isn't much to write home about. I talked

before about designer labels, and if you probe, you will find that everyone in

Japan shops at designer stores and buys the Gucci icons. That is the key

element, everyone wears them. In the USA, everyone wants them, and that is the

difference. Japan is a caring and sharing society that

looks after everyone and that matters most for your health.

Let me give my opinion now on why Hispanics have better health in the USA than

non-Hispanic whites. It has to do with the support they give one another and

their strong family lives that counter the adverse effects of the gap and their

poverty. Much has been written about this so-called Hispanic Paradox. I came to

understand the reasons by reflecting on Hispanic patients I see in the ER. I

never see a single Hispanic patient. There is always a group of people huddled

together. I have to go and figure out who the patient is, for everyone comes to

offer support. By contrast, I'm much more likely to see a white person lying

there writhing in pain alone. So we can conclude that it is the nature of

psychosocial relationships, the support people have and give in a society, that

is more responsible for their health as communities, than any other factor.

So what has happened in America to bring about our health decline? We have

changed the rules in America that decide who gets what share of the pie. How we

decide where to spend tax dollars, how we decide who to tax and how much, how we

decide to fund basic research and development. How we decide to give subsidies

to various elements of our society. Instead of trying to make the rules level

the playing field, we have decided to let the rich have as much as they can

grab, and we'll be happy to share the crumbs. I say we'll be happy, because if

you ask many if not most Americans whether they feel the rich should get as much

as they do, you'll get an answer something like: " of course the rich deserve it

because they work hard, and are better than we are " or something like " yes I'm

in favor of having a big gap between the rich and the poor, because someday I'm

going to strike it rich and I want to have it all then. "

We have been seduced into believing in the American Dream, the rags to riches

myth, the Horatio Algier stories, where if we just work hard enough we can

attain anything we want. The American Dream, ladies and gentlemen, is a

nightmare. Among all countries studied, we have the lowest percentage of people

making it, in the sense of going from rags to riches, whether in one generation

or two. That is what the economists who have studied this show.

And the price we pay for believing in the American Dream is, I say, the ultimate

price. Namely, you and I die younger than we need to, so much younger that it is

equivalent to winning the war on heart disease. Our president, speaks of the

estate tax as the death tax, and it really should be called the Death Averting

Tax, since it helps narrow the gap a little and avert deaths. As he signs more

tax cuts on the rich into law, he should be honest and tell you that this is a

small price to pay for living in this richest and most powerful country in world

history, namely you live less healthy and die much younger than you need to. But

the rich are appreciative, all the way to the bank. What even they don't know is

that even they die younger than they need to by living in this country.

So if we are going to ask the right question at this point, it may be something

along the lines of " what happened, how did we let things get to this point? " Our

story begins at the end of the Second World War. It was a difficult period for

the world, and for Americans. We lost many lives in that conflict, and many

people suffered without dying by serving in the war effort. So it was felt that

such people needed to be taken care of. The oldest amongst you may remember

GI-loans, housing loans, education bills that allowed vets to go to school. Our

tax structure was very different then. Compared to today, the rich paid over 90

% on their top chunk of income instead of around 35% today. The tax rate on the

bottom income category has remained about 25% through all this time period. So

the rich have taken proportionately more home, than the rest of us have. And the

gap grows.

After the Second World War, our businesses and industry did very well, with

technological advances, and work in rebuilding Europe. They enjoyed high profit

margins on revenue. They were happy. But towards the end of the 1960s and in the

1970s, their profits declined because of competition from Japan and other East

Asian economies that began in earnest then. In 1940, corporations paid 40% of

the federal tax bill. But with declining profits, they managed to demand lower

tax rates, just as the rich did, so by 1960 they paid 26% of the federal tax

bill. But with further declining profits, they wanted even more government

handouts, and so by 1990 they were paying 13% of the federal tax bill. They also

enjoyed huge government subsidies, in other words the taxes we paid went into

their coffers in many ways that are probably familiar to you here. Of course the

rich and powerful have only wanted one thing through history, and that is

everything. So by 2002, last year, corporations paid only

7% of the federal tax bill. As Greg Palast says, we have the best democracy

money can buy, and so these rich corporations buy themselves tax breaks and huge

government subsidies by funding so-called democracy.

Another way to look at this is how much we pay our CEO's - the heads of our

corporations. In 1980, we paid them 40 times what an entry level worker made. By

1999, they were being paid 478 times what an entry level worker made, and in

2001, for the Fortune 100 companies, the CEO's made a thousand times what an

entry level worker made. If we ask what is the maximum wage in the US, it is

around $150,000 an hour, and this person got a $10,000 an hour pay raise over

the year before, while his company performed poorly and the stock price dropped

67%. As we say in America, nice work if you can get it, and you can get it if

you try. Now in Canada, our much healthier neighbor to the north, the CEO/worker

pay gap is twenty to one, while in Japan, the world's healthiest country, it is

eleven to one. In the recent economic downturn in Japan, what did CEOs and

managers do? Lay off workers and take pay raises? No, they took pay cuts rather

than laying off workers. This isn't what our CEOs do. They

lay off 40,000 workers and give themselves a bonus for increasing efficiency.

This is not good for our health!

If corporations used to pay 40% of the tax bill and now only pay 7%, where is

the rest coming from? Look in the mirror. Since the 1950s, the working class

have paid proportionately more taxes than the rich. And today's tax relief for

the rich, boy the rich are really hurting and need tax relief, is just the

latest example. As an example, I'm sure that all of you in this room paid more

income tax than our biggest employer in Washington State did in 1995. You all

paid more tax than Boeing did in 1995. That is, unless you received or than a

$33 million tax credit that year. In other words, we paid Boeing, you and I paid

Boeing, $33 million as their tax bill that year.

It is one thing to talk about income, the take home pay-check, which you are all

familiar with. But what really matters is assets, wealth. Remember, you are

sitting on your assets. The gap in wealth is even more obscene than the gap in

income. The richest ten percent have almost 80% of the assets in this country.

The richest one percent have almost half. So there isn't much left for you and

I. In fact, from 1983 to 1995, the bottom 40% of families in America actually

lost assets. The cushion under you became harder to sit on during that time

period.

At the same time, we have done everything we can to make life worse for the

working class. As I mentioned, we cut funding for low cost housing, throwing

millions on the street. We have cut funding for public schools with the result

that our students score worse on international achievement test comparisons. We

have done everything to decimate the family, at the same time as we preach

family values. We have the highest percentage of single-person households among

all rich countries and the great number of children being raised in

single-parent families. It would be nice if the parent was there to raise the

child, but instead we force the parent to work at several low-paid, insecure

jobs, and leave the child rearing to the wolves. Studies have shown in Sweden

that being raised in a single-parent family is bad for the child's health. Not

only do such children become sicker, spend more days in hospitals, and have more

behavioral problems, they also have higher mortality. In other words,

in a country like Sweden, which has social supports unimagined in the United

States, kids being raised in single-parent homes die more. Why? Well, as I said,

in Sweden, it isn't that these homes lack enough stuff. But the mother isn't

there to provide the time with the child, and in the end that is the critical

factor. For early childhood to lead to health as an adult, secure attachment to

a parent is a strong, health promoting, factor. It is important preventive

medicine. Perhaps the most important aspect of preventive health care we could

ever do. But Clinton decided to end welfare as we know it, and our children are

paying the price with their poorer health and the greater likelihood of ending

up in a coffin. If you are a single mom please don't think I'm trying to make

you feel guilty for doing so by suggesting your child won't do as well as if you

were married. My son, now 21, was not raised in a two-parent family and I wish

it were otherwise, as I think he would be healthier.

But the reasons families split up are most basically political and economic,

and could be changed. But most of us would think that personal reasons are

involved. While this is true at an individual level, it is the structure of

society that makes it happen and helps us understand why family breakup has

become more common.

In other words, in the last 55 years we have drastically changed the rules of

who gets what share of the pie in the United States of America. For our health,

yours and mine, and that of the rich, we have to change them again, so we all

get pretty equal pieces of the pie.

To summarize at this point. Poverty is bad for your health. Relative poverty,

living in a large gap society, is the worst part of poverty. Poverty is not a

certain amount of goods, but a form of invidious comparison between those who

have more and those who have less. If the gap between the rich and poor is

smaller, then the comparisons we make are milder. When the playing field is more

level, it is easier to play. This is what justice is all about, avoiding having

one part of society bearing all the burden but reaping none of the benefits.

So what can we do about this? As I said, I learn a great deal from comparing

ourselves with people in other countries. I was surprised to learn that we have

the lowest voter turnout of all democracies. In other words, fewer people vote

in this country than in any other democracy. In the last King County election

only 29% of the voters cast their ballots. Who doesn't vote you might ask? The

answer: the young and those with less income. Think of it. Poorer people don't

vote. If they don't vote, then there is no need to have any policies that favor

those with less income, and the president can limit his actions to those that

benefit the voters, namely the rich. Hence we have the tax relief for the rich,

the end of the death tax which only benefits the very rich, and handouts for

Enron, Bechtel and Haliburton among others. We need to have our voices heard!

Has any major leader every drawn attention to the fact that the working class

doesn't vote, and tried to encourage them to vote, or designed programs to get

poorer people more involved in the process of democracy? No way, why would they

want to shoot themselves in the foot. So no, your leaders are not going to look

out for your interests, unless you force them to do so. They aren't going to

make voting day a holiday, as is the case in most other rich countries. They

aren't going to make it easier to register to vote. And they will continue to

have laws excluding people such as felons from voting. The rich are not dumb.

Low income people are not dumb either, but they have been demoralized and think

their vote doesn't count.

Some of you may recall the 1960s when riots occurred in inner cities in America,

there was the anti-Vietnam war movement, and the civil rights movement was in

full swing. The leaders of the free world considered that this was a crisis of

democracy. The Trilateral Commission published a book entitled the Crisis of

Democracy in which they pointed out that if people continued to take matters

into their own hands, it would be a continuation of this crisis. They wrote

about the problems when you have an excess of democracy. So the Trilateral

Commission laid down the steps we had to take to avoid this excess of democracy,

and these have been followed so we have the present problem of low voter

turnout, but no crisis.

Things are only going to change when we work together for our interests, not the

interests of the rich. We must say NO to more handouts for the rich. They have

enough, and they really don't need more, although whenever I am around rich

doctors, all they ever do is talk about how they need more money. The rich are

always like that, after more.

If the poor organized, if the working class got together, it would be a piece of

cake to change things. After all the poor and the working class are the majority

in this country. If you remember that, if you recognize that all you have to do

is talk amongst yourselves about these ideas, to speak up and begin to voice

your needs, and push for policies that restore the status that working class

people had in America before we gave it all away to the rich, then our health

will begin to improve compared to other countries.

We need to shape the world that creates our life experiences and, hence, shape

our health. This is not the land of equal opportunity. Unless you believe that a

few people are naturally born to ride while most of us are born to be saddled,

it's a sign that opportunity is less than equal. The only way out that I know of

for those of us who are saddled today, is to throw off those saddles, and chase

after the riders and put them in their place. We vastly outnumber those riders.

Working together and organizing is our hope for improving our health as a

nation. We need to bring back the crisis of democracy.

In other words, people like those of you gathered today and those you speak for,

those who aren't rich, those who work, are this country's population health

doctors. You are the people who need to prescribe the medicine that will get

more assets into the hands of your children, that will increase the taxes on the

rich, that will break down the power of the corporations, that will restore

power to labor, that will give subsidies to those who need them rather than

those who already have too much. The way to fight organized money is with

organized people.

It was Mahatma Gandhi who said First they ignore you; then they laugh at you;

then they fight you; then you win. And Martin Luther King Jr. said " True

compassion is more than flinging a coin at a beggar; it comes to see that an

edifice which produces beggars needs restructuring. "

I talked about Doctor MacArthur, the greatest population health doctor ever. You

out there can administer the MacArthur Medicine, remember the three ingredients:

the three D's of demilitarization, democratization and decentralization--bring

down the Walmarts. We can take the same medicine we gave Japan, that is we can

take our own medicine, or we can ask Japan to administer it to us.

I will end by reading a poem

THE LOW ROAD

By Marge Piercy

What can they do to you? Whatever they want. They can set you up, they can bust

you, they can break your fingers, they can burn your brain with electricity,

blur you with drugs till you can't walk, can't remember, they can take your

child, wall up your lover. They can do anything you can't stop them from doing.

how can you stop them? Alone, you can fight, you can refuse, you can take what

revenge you can but they roll over you.

But two people fighting back to back can cut through a mob, a snake-dancing file

can break a cordon, an army can meet an army.

Two people can keep each other sane, can give support, conviction, love,

massage, hope, sex. Three people are a delegation, a committee, a wedge. With

four you can play bridge and start an organization. With six you can rent a

whole house, eat pie for dinner with no seconds, and hold a fund raising party.

A dozen make a demonstration. A hundred fill a hall. A thousand have solidarity

and your own newsletter: ten thousand, power and your own paper: a hundred

thousand, your own media; ten million, your own country.

It goes on one at a time, it starts when you care to act, it starts when you do

it again after they said no, it starts when you say WE and know who you mean,

and each day you mean one more.

Thank you.

Stephen Bezruchka MD, MPH Senior Lecturer: International Health Program

Department of Health Services School of Public Health and Community Medicine

University of Washington Box 357660 Seattle, Washington 98195-3576,

(206)932-4928, Fax (206)685-4184 sabez

 

 

 

 

 

 

 

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