High Inequality Results in More US Deaths Than Tobacco, Car Crashes and Guns Combined

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A casket at the Museum of Funeral Customs, Springfield, Illinois, 2006. (Wikimedia Commons: Robert Lawton.)

A casket at the Museum of Funeral Customs, Springfield, Illinois, 2006. (Wikimedia Commons: Robert Lawton.)

In 2009, the British Medical Journal (BMJ) published a study that revealed what seems to be a shocking truth: those who live in societies with a higher level of income inequality are at a greater risk for premature death.

Here in the United States, our high level of income inequality corresponds with 883, 914 unnecessary deaths each year. More specifically, the report concluded that if we had an income distribution more like that of the Netherlands, Germany, France, Switzerland — or eleven other wealthy countries — every year, about one in three deaths in the US could be avoided.

Put that into perspective. According to the Centers for Disease Control (CDC), tobacco, including second-hand smoke, causes approximately 480,000 deaths every year, and in 2010, traffic accidents killed 33,687 people and 31,672 others died of gunshot wounds.

The mechanism by which a bullet or a car crash kills is readily apparent. Inequality is lethal in ways that are less obvious. It’s a silent killer – a deadly plague that we, as a society, tend not to acknowledge.

In Divided: The Perils of Our Growing Inequality, a new book edited by Pulitzer Prize-winning journalist David Cay Johnston, Stephen Bezruchka, a former emergency room physician who is now a professor of public health at the University of Washington, explains the connection. (An excerpt from his chapter titled “Inequality Kills” can be read at Boston Review.)

This week, BillMoyers.com asked Bezruchka about the relationship between inequality and mortality. Below is a transcript of our conversation that’s been lightly edited for clarity.

Joshua Holland: The US is among the richest countries in the world. Before we get into the issue of inequality, how do we stack up when it comes to health outcomes?

Stephen Bezruchka: What we seem to be very good at in this country is dying young. That is, if you look at the average length of life, 35 to over 50 countries do better than we do. The CIA World Factbook counts countries with tiny populations such as Gibraltar and Tristan da Cunha in the South Atlantic, and it comes up with 50. If you take only significant countries, like the UN rankings, then we were 34th in life expectancy in 2011, meaning the citizens of 33 countries have longer average lives. It’s quite startling.

And we not only die younger than people in all the other rich countries; by some measures our overall health is actually on a par with poor countries.

Holland: What’s the link between the very high levels of inequality we see right now and our short average life spans?

Bezruchka: Studies over the last 40 years have demonstrated a very strong link between economic inequality in countries and their health status. So, for example, a meta-analysis — that is, a study putting all the studies on inequality together — by researchers at the Harvard School of Public Health and published in the British Medical Journal concluded that about one death in three can be attributed to America’s high level of inequality. So if you accept the hypothesis, it’s the leading killer.

Holland: This is the only wealthy country without a universal health insurance scheme. Or, if you want to be an optimist about Obamacare, you could say that our universal health insurance scheme is in its infancy. How can we be sure that it’s inequality leading to these poor outcomes, rather than other factors like a lack of access to health care?

Bezruchka: I worked as a clinical doctor for 35 years, as an emergency room physician. So I was the person of last resort. And I can tell you that medical care is a small player in producing good health in societies.

Certainly no more than 10 percent of our health is related to the provision of medical services. Medical care is very good at treating illness and injury, but a lack of medical care is not what causes that illness and injury. That’s something else, and a lot of that relates to inequality.

Holland: What about lifestyle factors? We often hear that Americans are making unhealthy choices — we’re too fat, or we smoke too much, or we drink too much. That would seem to let the systemic issues you’re talking about off the hook.

Bezruchka: Let’s consider what I call the Health Olympics, the ranking of countries by length of life. As I said, we were 34th in 2011. If you look at the countries ahead of us and ask, “out of all those countries, which one has the smallest proportion of men smoking — is it Japan, the longest-lived country?” Well, no, as a matter of fact, out of all the countries on that list, Japan has the highest percentage of men smoking. Close to half of all Japanese men smoke. It used to be almost 80 percent but they’ve been trying to eliminate smoking. And only 20 percent of American men smoke. So Japanese men smoke at twice the prevalence that we do, and yet they’re among the longest-lived. That’s not to say the fact that half of Japanese men smoke is the reason for their good health. But it suggests we have to look at other factors, and smoking is the most obvious and egregious example that I can use to portray that. But the same thing is true for diet and exercise and all the behavioral things we do.

The behaviors that really matter for our health include a range of social connections and family support. The studies and meta-analyses show they’re way more important than smoking and exercise and those kinds of things. And in American society, the economic gap that divides us also limits the range of support that we have. Basically, in a more unequal society, there’s less caring and sharing, and that’s what really matters for your health.

Holland: And you write that there’s a key period in our lives that has a huge impact on our long-term health. Can you tell me about that?

Bezruchka: Studies show that roughly half of our health as adults has been programmed in the first thousand days after conception. In other words, it’s the nine months in the womb, and the next two years after that which are critical for writing the software in our biology that will determine how healthy we’re going to be. So societies that privilege those first thousand days are healthier than societies that neglect them.

What do I mean by privilege or neglect? There are only three countries in the world that don’t have a paid maternity leave policy. One of those countries is Papua New Guinea, half of a big island north of Australia. The second country is Liberia, in West Africa. And you can guess the third. We do not have a federal paid maternity leave policy. All the other countries do, except for those other two. We’re in a league with two countries that aren’t very healthy, and our medical care system isn’t going to bail us out.

All the other rich countries have paid perinatal leave policies, meaning if you’re a working woman and pregnant, you get to take as many as 18 weeks off work with pay.

So what do the healthier countries do? Sweden spends more public money on the first year of life than in any subsequent year. We spend our public money on people my age and older. And what does Sweden do to spend so much money in the first year of life? In Sweden, it is mandatory to take a year’s maternity/paternity leave at full pay — if you have a baby, the mother and father have to take a combined year off. If the mother takes the whole year, then the father’s got to take three months. That’s at full pay. The Swedish government pays you during that period of time, not your employer.

Then, the second year is optional — you can take it off to nurture a baby at 80 percent pay.

In the third year of life, if you want to go back to work, you can put your child in a public daycare center that’s essentially free. And to work in a public Swedish daycare center, you have to have an advanced degree in play. Because what’s daycare all about? It’s about socializing the kids. You need experts.

Contrast that with our expectations — we require only somebody who will work at minimum wage and doesn’t have a recent history of child sexual abuse. That’s all we ask of our daycare workers. So we get what we pay for. We compromise the first thousand days and then we spend a fortune on medical bills later on.

Holland: You write in the excerpt at Boston Review, “There is a dose-response relationship, meaning more inequality leads to worse health.” What are the specific mechanisms that make that the case?

Bezruchka: What happens is those lower down the economic ladder experience more stress. Their lives are much more stressful, and they secrete more stress hormones until they’re burned.

Stress is our twenty-first century tobacco. As we understand more about stress biology and the impact it has on our lives, we are going to have to wage a campaign to reduce the amount of stress in our lives. In one survey, people in the US reported the fourth highest levels of stress in the world. That’s true despite all our smartphones and gadgets and conveniences and the ease of everyday life. It’s incredibly stressful for those who own all these gadgets, but the ones on the bottom suffer the most stress. Surveys of stress hormones find that they have the highest levels and they have the worst health outcomes. So the bigger the gap between the rich and the poor, the greater the stress on those lower down, and the higher you are up the economic ladder, the better off you are.

The interesting thing is that there’s no privileged subpopulation in the United States that has really excellent health. The Institute of Medicine’s “Shorter Lives, Poor Health Report” said clearly, on page three, that even those of us who are white-skinned, college educated and in upper income brackets — and exhibit all the right behaviors — die younger than our counterparts in the other rich countries. And it’s inequality that’s killing us.

Holland: We also work around 30 percent more hours, on average, than the citizens of other wealthy countries, which obviously leads to more stress.

You call poor health outcomes resulting from economic inequality, “structural violence.” Can you explain your use of that term?

Bezruchka: Sure. When we hear the word ‘violence,’ we think of collapsing towers in New York, or you think of somebody with an AR-15 mowing down children in a school. That’s behavioral violence. But if inequality is killing us—one death in three, as I intimated—it’s like an odorless, colorless, highly toxic gas that we’re just not aware of. And it kills us from the usual diseases: heart disease, cancer, diabetes, high blood pressure. It’s the structure of our society, the gap between the rich and the poor, that creates the inequality that kills us from all the usual diseases. And that term came about in about 1969, in the Journal of Peace Research, and they called it ‘structural violence.’

Structural violence kills far more people than the behavioral variety. That’s what we need to change.

Joshua Holland is a senior digital producer for BillMoyers.com. He’s the author of The Fifteen Biggest Lies About the Economy (and Everything Else the Right Doesn’t Want You to Know about Taxes, Jobs and Corporate America) (Wiley: 2010), and host of Politics and Reality Radio. Follow him on Twitter or drop him an email at hollandj [at] moyersmedia [dot] com.
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  • http://www.southwesterntechnicalsales.com Jack Haesly

    This should not a revelation to anyone in this country that elects to open their eyes and look around. Who are the guilty parties that make the current situation possible? Have a closer look at the AMA, drug companies, heath insurance companies, the FDA, conglomerate food companies, and most of all government…or lack of it.

  • Anonymous

    Copy Sweden.


    Higher inequality also results in a less educated and erudite ‘pop-ewe-lation’… where the highest common denominator screams: “I tell you what!” and “What’s da score?”

    Indeed! See what has happened to the Amerikan corn syrup sheeple since the birth of talk-hate radio… touting the glorious capitalist-fascist system of student loans and perpetual war profiteering in distant lands.

  • Cali Curmudgeon

    I just love the virtual deaths. How about REAL death caused by energy poverty and green regulations? How about REAL inequality caused by high taxes and policies that are destructive to the middle class. Policies enacted by the Democrat oligarchy in the name of “equality” that always seems to ensure that the rent seeking wealthy end up with more and the hard working entrepreneurs end up footing the bill.

  • Cali Curmudgeon

    Gee, maybe you Commiecrats can correct that with a Ministry Of Information that only tells us proles what you want us to hear….


    DENIAL! DENIAL! DENIAL! will not attenuate or reverse the ominous $ocio-political decline of faster poo-food Amerika… where 95% of all the Ritalin manufactured on Earth ends up in the bodies of Amerika’s school children.


    Electoral reform… or ‘$ellectoral’ reform?

    Not to sound cynical, but how many Amerikans will be excited about ‘Hillary’ [Clinton]… $taged to run against ‘Jeb!’ [Bush] in 2016? Eh?

    Wow! Clinton and Bush again! Phhuck! Phhuck! Hooray!


    Copy Iceland!

  • Anonymous

    Think the transformation of the American people from brave, proud folks into cynical, uneducated/miseducated sheeple might be due to (among other things) the GMO’s which have turned once healthy, nutritious foods into “Frankenfoods” whose damaging effects on our physical and mental health are just now starting to manifest?

  • Joseph Ford

    If Life is a right, as the Declaration of Independence and other foundational documents give us to believe, then doesn’t inequality infringe insidiously on that right? And isn’t it government’s duty to uphold the Right of Life by eliminating inequality or be subject to abolition?

  • DeeDee12

    A very silly article. It talks about life expectancy but acts as if car accidents, tobacco use, etc. do not really affect those numbers substantially – when they actually do. The primary source of comparison data on mortality and health outcomes is
    the Organisation for Economic Co-operation and Development’s (OECD) health
    system performance data and reports. But, go read the data. Three main
    statistics the OECD uses to evaluate healthcare are infant mortality, life
    expectancy, and premature death. But, the basic definitions of live birth and
    infant mortality are not consistent across countries.

    Babies who are not viable and who die shortly after birth are far more likely to be classified as stillbirths in countries outside the United States, especially in Japan, Sweden, Norway, Ireland, the Netherlands, and France. When you don’t count those baby deaths in your mortality statistics, your life expectancy numbers greatly improve!

    In the United States, however, nonviable births are usually recorded as live births, making the US infant mortality rate appear misleadingly high. In a detailed study of medical records and birth and death certificates in Philadelphia, Gibson and colleagues found that infant mortality had been overstated by 40 percent, merely as a result of these nonviable births that were recorded as live births! We also spend far more on NICU than other
    countries and we perform more C-sections in efforts to save babies in distress,
    who might otherwise be stillborn. So, better care in this case actually worsens
    reported infant mortality rates in the United States.

    And infant mortality is counted in OECD calculations of life expectancy at birth, so US practices designed to try to save the baby skew that data. When life expectancy at later ages is considered, what appears to be slightly more favorable life expectancy by a year or two in other industrialized nations begins to disappear.

    Also skewing our life expectancy rates are the facts that we have the highest rate of death by violence and an astoundingly higher rate of death by car accident than all other industrialized nations. The US traffic accident death rate is 10.4 per hundred thousand people; in Germany it is 4.4, in the UK, 2.75, in France it is 6.4 and so on. if you remove deaths from fatal injuries from the life expectancy tables among the 29 members of the OECD, the U.S. jumps from 19th place to first place!

    Premature mortality, which is determined by potential years of life lost, is a measure that is also skewed by these factors.

    And if you really want to measure health outcomes, the best
    way to do it is at the point of medical intervention. On that measure, the US
    ranks at the top for 5-year survival rates for breast cancer, colon and rectal
    cancer, and prostate cancer.


    Yes! Amerika’s poisionous, corp-rat demon food culture is one of the many factors explaining the devolution of the United States (of Perpetual War Profiteering). The concentration of Amerika’s capitalist-fascist media machine is another. Rome is burning.

  • BentDemocrat

    I think you have a basic misunderstanding about “life-expectancy” and “avoidable death.” In all cases, auto accidents, gun-shots, no health care, and poverty level malnutrition, are all avoidable. Read that again, all are avoidable.

  • BentDemocrat

    So, when can we charge the elite 1% with manslaughter?

  • big ed 59

    Nice! Let’s drag our political superstitions into a health blog. Democrats have been trying to take steps to reduce the wealth gap in America. It is the Republicans who think that if we just make the wealthy wealthier, then everybody will benefit from the “trickle down”. Well, Reagan started the tax cuts for the wealthy in the1980s. When do you expect the benefits to trickle down to you? The wealthy pay next to zero taxes, and they ship jobs overseas. If Repubs had passed some of the jobs bills the president proposed, and raised minimum wage rate, things might get a little more balanced. And, maybe even begin to narrow this unhealthy wealth gap.

  • big ed 59

    You got some evidence that GMOs are unhealthy, or do you just hate new things?

  • big ed 59

    People might take you more seriously, if you spelled America correctly. Show a little respect, if you want respect.

  • big ed 59

    The point of the article is that if you don’t make people so sick, then you don’t have to worry so much about “survival rates”. An ounce of prevention, etc. ….

  • Anonymous

    Obviously, the researchers controlled for other factors.


    1. I am not an Amerikan or an American.

    2. Like the majority of people on this planet, I view the United States of Perpetual War Profiteering as a violent capitalist-fascist empire that preys upon all the peoples of the world.

    3. Ewe (in lieu of you) haven’t a clue what’s coming.

  • Big Oil Conspiracy Theory

    What the hell is inequality? And why is this term thrown around so liberally? Can we define inequality, because society cannot always be equal. Even in the soviet union where markets were for the large part outright banned, you still had central planners, the so-called 1%, being more unequal than everyone else.

  • Big Oil Conspiracy Theory

    you aren’t going to reduce ‘wealth gaps’ by putting the next generation into debt.

  • Anonymous

    Income inequality, in this case, if you read the article. The 1% is defined as the top 1% in income. It wouldn’t be a problem if some things, such as health care and education, were provided by the government, but they’re not anymore, it’s all being privatized, so income has a great effect on lifespan.

  • big ed 59

    Been “putting the next generation into debt” since FDR borrowed hugely to get us out of The Depression. Did you scream at W, when he started two wars, and reduced taxes on the wealthy, to pay for them? Did you hector Reagan, when he nearly doubled the national debt, while cutting taxes on the wealthy? Didn’t think so. Meantime, can we try to stick to the artivcle? Did you actually read the article? Then you read how spending money for maternity/paternity leave, and infant and young child medical care SAVES MOBEY, in the long run! Now, go troll somewhere else, and let serious people discuss this in peace.

  • big ed 59

    Nonetheless. Spelling America with a “k” may make you feel good, but it brands you as what we call here “a low information commenter”, and makes you sound like a mouth breather. Friendly advice.

  • Lila Hw

    Exactly why I advocate for a resource based economy and why it is absolutely necessary to get money out of politics

  • Lila Hw

    Whose “we”????? You mean you…..! After reading Richards comments, I highly doubt he is a low information commenter….I also doubt he was looking for advice from someone such as yourself…. Friendly advice ;)

  • Lila Hw

    Someone speaking truths…. Couldn’t agree more. This tyrannical oligarchy is slowly going to crumble…. I hope

  • Lila Hw

    Tear down the war for profit corporation, and rebuild. Look into a resource based economy if you are seeking answers. Down with The Fed and our bought elections to start. It’s the source of every problem we face.

  • moderator

    Lila Hw, big ed 59, Richard,

    It is time to move on, this thread is off-topic. You will have to all agree to disagree.

    Sean @ Moyers

  • moderator

    big ed 59, Lila Hw, Richard,

    It is time to move on, this thread is off-topic. You will have to all agree to disagree.


    Sean @ Moyers

  • moderator

    RIchard, big ed 59, Lila Hw

    It is time to move on, this thread is off-topic. You will have to all agree to disagree.


    Sean @ Moyers



  • Anonymous

    There have been a few studies carried out by non-corporate sponsored scientists concerning problems with crops which have the pesticides ‘built in’ to them (like strange illnesses ocurring when the GMO grains have been fed to study animals), so it’s not a matter of me hating new things. I want those new things to be safe to use, and if there are doubts about their safety, I’d rather err on the side of caution and not use them until I have enough reasonable proof that they’re safe

  • Sue Ellen Bradley Weaver

    Association is not causation.

  • Anonymous

    my Aunty Sienna recently got a stunning red
    Nissan Maxima by working part time online… find out here now F­i­s­c­a­l­P­o­s­t­.­ℂ­o­m

  • Lila Hw

    Didn’t realize it was off topic….??? I just love censorship. Didn’t realize people weren’t allowed to debate about issues. Richard made an excellent point, and it was on topic. Give me a break. The moderator acts as if that debate took over the thread . It was 2 comments right ON topic. Forget free speech…. Sorry. Disagree. Bye!!

  • Anonymous

    Correlation — true in general!

    In this case, here’s how Bezruchka describes this body of research in the book:

    “The claim that economic inequality is a major reason for our poor health
    requires that several standard criteria for claiming causality are
    satisfied: the results are confirmed by many different studies by
    different investigators over different time periods; there is a
    dose-response relationship, meaning more inequality leads to worse
    health; no other contending explanation is posited; and the relationship
    is biologically plausible, with likely mechanisms through which
    inequality works…

    “Those studies confirm that all the criteria for linking inequality to poorer health are met…”

  • DeeDee12

    Commenters, just click on the “study” link and you can read it and then click on the links to papers it cites and you can read many of them.

    First of all, they use “mortality and self-rated health” as their parameters. The mortality figures are not adjusted in any way to eliminate violence, car fatalities, etc. or to adjust for differences by country in under-reporting newborn deaths. Secondly, how scientific is it to use a parameter called “self-rated health?” That alone is meaningless unless you account for psychological factors in whether a person considers the same disease/physical infirmity in the same way. I might have arthritis but say my health is good; another might have the same condition and say their health is poor. It’s meaningless scientifically.

    It’s just another example of garbage-in/garbage-out.

    As to arguments such as, “little to no funding or other support is provided for infants and children and their parents.” Really? US federal outlays on children (federal only – not state, which is where Medicaid is spent!) were about $350 billion in 2012, with an additional $100 billion in the form of tax credits for families with children. The states spend more than double that on children, which includes educational expenditures.

    Our rate of teens giving birth is over 3 times the OECD average. For how many more of these babies must we expect our taxes to pay? I was a single mom and brought up two wonderful children without state or federal aid. I went back to work when they were young after a divorce at a low-paying job, and worked my way up. No tax credits, no food stamps, Medicaid or anything else. It’s called personal responsibility.

  • Lila Hw

    The precautionary principle?? Ha! It seems to make sense to everyone besides biotech

  • Lila Hw

    Hahaha!! So sad but true

  • Anonymous

    Death by design. In previous oligarchies and feudal societies all those who did not produce more than they ate – died. Why can’t people see that is where we have been headed for a half century, at increasing speed? The true definition of “evil” is simply “uncaring” and for those who have reached the uncaring stage it makes perfect sense to apply death by design. Oh, called by other names, of course. Same same.

  • Anonymous

    “Secondly, how scientific is it to use a parameter called “self-rated health?”

    How would the person being interviewed know if they’re healthy or not? Is that your question? Who else would know?

  • Spencer Brown

    These people died in part because they were poor. If they were in a country where everyone was poor, they would have had similar problems. Their problem was not inequality — the existence of rich people did not cause their deaths. Their problem was that they were poor.

  • Anonymous

    No, it’s not just poverty. The poor do worse in countries with greater inequality than they do in countries with less inequality.

    “Preston showed that life expectancy increased with income across
    countries, but at a rate that became progressively lower as income increased— there are diminishing health returns to income—and noted that, if similar relationships between income and health held within countries, a country with a more equal distribution of income would have higher life expectancy, other things being equal. Rodgers tested Preston’s conjecture using a sample of 56 (unnamed) developed and developing countries, and found, indeed, that the Gini coefficient of income inequality had a significant negative effect in a (non-linear) relationship between average income and life expectancy (and infant mortality).”

    Commentary: The convoluted story of international studies of inequality and health
    (2002) 31 (3):546-549.
    International Journal of Epidemiology

  • jamiejoy

    Even assuming all your cites are accurate, IMO you’ve missed the point of this big-picture article. Sure it’s ok to measure outcomes from the point of “medical intervention, that’s a much smaller focus than looking at overall US health measures the way this article does. It would be great to have your knowledge and intelligence looking at even bigger trends!