Inequality and Illness: What’s Missing from the Health-Care Debate

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“Medicine for All” —a 1936 mural done by Artists for the People, a WPA-funded project during Franklin D. Roosevelt’s last term (NYC).

Despite its fantastic wealth-generating capacity, the U.S. has higher infant death rates and lower life expectancies than many poorer nations. This fact is used to support major reform of an American medical system that denies health care to millions.

Improved access to medical care would save many lives. A 1997 study in the New England Journal of Medicine calculated that lack of access causes almost 100,000 additional deaths every year — triple the number of deaths due to AIDS. However, improving the health of populations is more complicated. Even the best medical system cannot stop the health-damaging effects of class inequality.

Those who insist that “you can’t reduce everything to class” do not understand how profoundly class affects every aspect of life, from birth to death.* When it comes to health, class has proved to be more important than any other factor, including race, sex and access to medical care. The reason is simple.

The higher up the social ladder you go, the more power you have to choose where and how you live, where you go to school, where and how you work, and how you relate to others — all of which affect your health. Race, sex and access to medical care do play a role, but class has more impact on infant mortality, longevity and overall quality of life. Furthermore, the greater the difference between the classes, the more everyone’s health suffers, not just those on the short end of the stick. The United States is a prime example.

Inequality kills

A 1998 study compared income inequality with death rates in 282 American cities. Greater inequality was associated with higher death rates at all income levels. Compared to areas with the lowest inequality, areas with the highest inequality suffered 140 additional deaths per year for every 100,000 people. This elevated death rate is equivalent to the loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide combined. The benefits of eliminating inequality entirely can only be imagined.

Inequality is so harmful to human health that poor people living in more equal nations can be healthier and live longer than better-off people living in less equal nations. Bangladesh is one of the poorest countries in the world, yet the average Bangladeshi man is more likely to reach age 65 than the average Black man living in Harlem, New York. Harlem men have higher incomes than Bangladeshi men; however, the U.S. is a much more unequal society.

Oppression not only damages the health of the oppressed, it also harms the health of those who love them. Men whose wives have stressful jobs and unsupportive bosses are seven times more likely to develop heart disease regardless of the conditions of their own jobs. When women are better off, so are men. Having a wife with more education lowers a husband’s risk of smoking, being overweight, having high blood pressure and dying of heart disease. One study found that male mortality rates were more strongly linked to the status of women than female death rates!

America has the worst health statistics in the industrialized world because it has the greatest class inequality. In the thirty years between 1970 and 2000, the benefits of a growing economy went almost exclusively to those at the top. Average CEO pay rose $660 per hour, while the average worker’s pay rose five cents an hour. In the world’s richest nation, more than one in four Americans with children under age 12 do not earn enough to support their families. Class inequality is a social sickness with broad health-damaging effects. 

Medical systems do not produce health

Health is not a commodity that can be churned out by the right kind of medical system. After the British National Health Service was launched in 1948, the difference in death rates between the classes began to decline. Politicians credited the NHS with producing these benefits, but later studies revealed that a rise in the general standard of living was responsible. The NHS was one aspect of this rising standard of living, but better health was related more to improved housing and nutrition.

While class inequality creates sickness, strong social ties produce health. Stronger social connections may explain why Hispanic Americans with lower incomes suffer less chronic illness than White Americans with higher incomes. It’s not hard to see why.

Human beings are the most social species on the planet. For most of human history, equality, cooperation and reciprocity were protected by g taboos against snobbery, selfishness and greed. More equal societies are healthier (and happier) because they share social resources and use their surplus to raise everyone’s living standards. Class-divided societies are sicker because they enrich the elite by holding down living standards for the majority.

Universal access to health care would reduce some of the sickness created by class inequality. However, no medical system can eliminate the health-damaging impact of stress-filled jobs, inadequate housing, toxic pollution, poverty, malnutrition, social discrimination and isolation.

We must fight as a class

The current health-care debate sidesteps the sickness generated by class divisions. Instead, it concentrates on how best to manage this sickness. We deserve better than that. To improve our health and win universal health care, we must fight as a class.

The health of a population and the quality of its medical system are directly related to the strength of the working class. Where the capitalist class is stronger, as it is in America today, class inequality is greater, the health of the population is poorer and the medical system is more likely to be run as a get-what-you-pay-for business. Where the working class is stronger, as it is in much of Europe, there is less class inequality, the health of the population is better and the medical system is more likely to be run as a government-funded service. Europeans don’t enjoy better health and more access to health care because they are more sensible; they had to fight for it.

The German elite established the first European national medical plan in 1883 to avert a popular revolution like the one that shook France in 1871. In Britain, the 1911 National Insurance Act was rushed through Parliament during a wave of mass strikes. The British NHS was part of a social welfare program designed to restore social stability after the war. As a Conservative member of the British Parliament warned in 1943, “If you don’t give the people reform they are going to give you revolution.”

The Canadian labor movement won national medicare in 1972, the year of the Quebec General Strike. In response to workers’ demands, the province of Quebec established a government-funded and managed health care system. The other provinces soon followed.

In the United States, the Congress of Industrial Organizations and the American Federation of Labor pushed for a national health plan after World War II. Preferring to establish global dominance, the ruling class attacked the unions, gutted them of militants and passed anti-labor laws like Taft-Hartley. American workers have won Social Security, Medicare and Medicaid. However, the relative weakness of the labor movement is the main reason why America has no national health program. To reverse this situation, we must break through the legal and customary barriers that prevent American workers from fighting for their rights as a class.

The time is now

As the class divide deepens in the U.S., more people are feeling the pain. A 1988 Gallup poll asked if Americans thought their country was divided between the “haves” and the “have-nots.” Just 26 percent said yes, and only 17 percent identified as “have-nots.” A huge shift has occurred over the past two decades. Last summer, the Pew Research Center asked the same question. This time, 48 percent of Americans thought their country was divided between the “haves” and the “have-nots,” and 34 percent thought of themselves as “have-nots.” This number is sure to grow, as a deeply unpopular war, shameless corruption at the top and falling living standards fuel a rise in class consciousness.

When more than one in three Americans identifies as a “have-not,” it exposes the lie that American workers are “bought off” or “too comfortable” to rebel. When one-third of the population thinks they have nothing to lose but their chains, then the only thing holding them back is not being organized enough to break those chains.

How we organize is the critical question. We cannot win better health or universal health care simply by making moral arguments or by backing one group of politicians over another. None of the three Democratic Party front-runners support national medicare or HR 676, which combines public financing of medical services with private delivery. Removing all profit from the medical system is nowhere near the agenda.

The capitalists fight as a class to promote their “right” to pursue profit at any cost. The obscene amount of wealth they have accumulated is a measure of their success. We can reverse this injustice only if we also fight as a class. If we do, we could win more than universal health care. We could replace capitalism with an egalitarian, socialist society, democratically run by all of us for all of us. The health benefits of such a society would be beyond imagining.

At the Cannes screening of SiCKO, Michael Moore states, “The bigger issue in the film is, ‘Who are we as a people?’” Human sickness is a product of sick social relationships, and human health is a product of healthy social relationships. The quality of our medical system is also a result and a reflection of those relationships.

* For a social definition of class, see POWER and Powerlessness, pp.146-152. Available at

Note: This is a revised version of an article published last May on Counterpunch.

Susan Rosenthal is a practicing physician and the author of Market Madness and Mental Illness (1998) and POWER and Powerlessness (2006). She is a contributing editor to Cyrano’s Journal Online and a member of the National Writers Union, UAW Local 1981. She can be reached through her web site: her blog: or by email:

4 comments on “Inequality and Illness: What’s Missing from the Health-Care Debate
  1. A wonderful article! I’ll post it at the library and on my office billboard. Dr. Rosenthal is right that the key to advance in all these matters is organization. Culturally speaking, few cultures have a heavier tradition of individualism than the anglo group, with the US of course now in the lead with this kind of mental affliction, aversion to “class struggle” (which is denounced by many Americans in compliance with the received indoctrination) hence the extra troubles we encounter in this nation. And it is a measure of the degree of control that this utterly perfidious upper class has been able to carve in America that even obvious areas that should be regulated on behalf of the commonwealth, such as medical services, remain firmly in the hands of the naked profiteers.

  2. A powerful indictment, irrefutable in any reasonable debate about the issues. Ms. Rosenthal is obviously not only a fine physician but a good social physician as well. I wonder how some people are able to surmount careerist pressures and do the right thing, like the author of this piece, and so many others fall by the wayside. It’s fortunate that such people exist! IN ANY CASE, AMERICANS MUST FIND A WAY TO REBUILD THEIR WORKING CLASS ORGANIZATIONS. WITHOUT THEM, THERE IS NO WAY TO FIGHT BACK.

  3. Disunity of the vast majority makes it possible for the overlords to keep us at loggerheads with one another and subjugated to a system that no rational, self-respecting person should ever accept. Your point about the “sociability” aspect of humans and its connection to health is important. As Americans become ever more “atomized” in what Philip Slater aptly denominated “The (individualistic)Pursuit of Loneliness” the quotient of morbidity climbs. Nothing good ever came from standing alone and against all others, nor from elevating such madness to the status of revered social organization, as we have seen in America. In their blind allegiance to capitalism, Americans have succeeded in building a pathetically unhealthy society. How long can the media cover up this obvious truth?

  4. Just finished reading this terrific article on medicine, illness, inequality here at Cyrano, and wanted to say thank you. I don’t think I can add anything to it, as it stands perfectly well, and self-contained in what it aims to say. This kind of knowledge allows us all to defend ourselves better. It makes the kind of points that we should have been receiving all along from our public education system, media, etc., but we know why that isn’t gonna happen, right?

    Look forward to more of your inspiring writing. —WM

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