Too Much in Common With China

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

“We hold these truths to be self evident; that all men are created equal….”

These opening words of the Declaration of Independence never rang particularly accurate with me. We all know how long it took for “men” be construed as including women, Native Americans, persons of color. The list is terribly long. But for purposes of this column I’d like to focus on the inequalities that persist due to plain old money.

A mathematician named Corrado Gini working nearly 100 years ago described an elegant measure of the inequality of distribution of most anything within a population as a decimal between zero and one. For example, if everyone in a population has exactly the same amount of money, there is no inequality. The “Gini coefficient” is zero. If one person in the population has all the money, the “Gini coefficient” is one. Wikipedia has an understandable explanation of this valuable and important tool. For convenience it is often multiplied by one hundred to yield a two-digit “Gini index.”

The Gini index is most often used to characterize the economy of a country. The Scandinavian countries have the smallest economic disparities with Gini indices around 24. To put that in perspective, my well-to-do Danish pathologist friend and his wife ran their own private lab in the evening to be able to afford a car. On the other hand, they knew that their mentally disabled daughter would receive the best possible residential care from the government when they were gone.

The average for all the countries of the European Union is 31. The United States’ Gini index was at its lowest between 1968 and 1978 at about 39 and has been climbing steadily. The most recent estimates place it at about 47, similar to China, Mexico and Argentina.

The Gini coefficient, or index, is an important tool because, it turns out, our health seems to depend not only on how much we have, but also on how much those around us have. The only estimate I’ve seen of the overall impact of the Gini index of population wealth as a determinant of individual life expectancy puts it at 2.5 percent. That estimate is on Dr. David Kindig’s group’s University of Wisconsin website, County Health Rankings: Mobilizing Toward Community Health. Two and a half percent may not sound like a big impact, but realize that that rather strange factor is in competition with our heredity and all the environmental toxicology and microbiology, violent crime and speeding trucks around us. Maybe 2.5 percent is not so small an effect after all.

No one knows how economic inequality shortens life, but it does. Clearly it is more dangerous to be poor in a rich country than to be poor in a poor country. Sir Michael Marmot who pioneered research on health disparities makes this point by noting that black men in New York City have shorter life expectancies than men in Bangladesh.

But what has this to do with rural America? The reason for this growth in disparity is that almost all of the growth in America’s economy in recent years has been in the high-income sectors, and these are generally in urban populations. Diane McLaughlin, writing in Rural America points out that between 1979 and 1999, the Gini coefficient for central cities grew from .41 to .47 while the rural Gini coefficient only grew from .40 to .43. At first that sounds good, but what that really means is that the rich urbanites got really rich while the poor urban and city people stayed poor.

There is much we don’t understand about the health impact of inequality. How close, geographically speaking, must the gradient be to be significant? Does the wealth gradient have to be within everyday life to have an impact? Does seeing wealth via television next to your hard life have some negative impact? Is the impact all within the person, or is it mediated through hospitals, clinics and political processes? We just don’t know.

Rural America has always had jarring contrasts between wealth and poverty. The sumptuous Greenbrier in West Virginia lies near the heart of Appalachia. Bar Harbor is within a few miles of the poorest county in Maine. The workers there occasionally refer to themselves, among themselves, as the serfs. People working in the wealthy Rocky Mountain ski resorts, the folk who haul the trash and make the beds, commute up to 60 miles from affordable housing.

It has been stated that Americans seek to level opportunity whereas Europeans are more inclined to level income. To the extent higher education relates to opportunity though, we are even pricing opportunity out of reach. Poor people of average ability can no longer go to college.

I believe it is bad economic policy to let the gap between our rich and our poor become as wide as those of Mexico and China. I know it is bad health policy.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Summer 2010 Issue