The public health literature is pretty clear when it comes to income status and poverty and their profound effects on health, disability, disease and life expectancy. But what about income inequality? Does a rising gap in wealth and resource distribution affect people’s health too?
In a commentary published last week in the American Journal of Public Health, two researchers posit that growing income inequality is a contributing factor to poorer health among American workers. In “Squeezing Blood from a Stone: How Income Inequality Affects the Health of the American Workforce,” authors Jessica Allia R. Williams and Linda Rosenstock write that “because income inequality is inexorably linked to employment, a more complete picture of the effects of inequality on health emerges when analyzed through the lens of the working population.” In particular, the authors write that the characteristics of growing income inequality within the workforce and specifically among low-wage workers — such as less job security, fewer employment benefits and little control over one’s work — do pose adverse risks to workers’ health. They write:
Even though the data available to understand the relation between income inequality and health are limited, we believe there is enough evidence to demonstrate the need for concern beyond issues of fairness, social justice, and health care costs. There is a particular need for concern when the effects of inequality on adults spill over and affect their children. Moreover, changing patterns of work organization and divergent psychosocial working conditions put additional stress on workers whose work organization is changing. Income inequality can be seen as yet another social determinant of health, and when it is addressed much can be done to improve health status beyond access to health care.
The commentary cites research showing that income inequality is growing in the United States: In 2013, the top 5 percent of households accounted for more than 22 percent of all income, whereas the bottom 20 percent accounted for only little more than 3 percent of all income. Compare those statistics to 1980, when the top 5 percent accounted for 16.5 percent of all income and the bottom 20 percent accounted for 4.2 percent of income. Other measures of income inequality include wages, which have stagnated, as well as the wage gap between workers and CEOs. The commentary noted that the ratio of CEO cash compensation to average worker pay was 25 to 1 in 1970; 30 years later and that ratio is now 90 to one.
How work is structured and organized has changed dramatically as well, with many more people working more than 40 hours a week in multiple part-time or full-time jobs or working nonstandard shifts. Many such workplace and employment characteristics have been linked to poorer health, Williams and Rosenstock write. For example, they cited studies showing that poor psychosocial working conditions and long hours have been linked to heart disease and cardiovascular events, while job insecurity and job strain have been associated with increased mortality risk.
To illustrate the effects of income inequality and its associated working conditions, the commentary highlighted the health care workforce, in which there is a substantially large gap between the lowest earners, such as nurses aides, and the highest earners, such as surgeons. As the demand for efficiency increases in the health care industry, many low-wage health care workers are being asked to do more with less, even as they experience some of the nation’s highest work-related injury rates, higher health insurance premiums and pressures to work additional overtime. The workforce is also largely female and from communities of color, so they already face disparities in health care access and disease rates.
The example is a “microcosm” of the larger problem of income inequality and shifting workplace demands, the commentary stated. Williams, a Robert Wood Johnson Foundation Health and Society Scholar at the Harvard Center for Population and Development Studies, and Rosenstock, dean emeritus of the UCLA Fielding School of Public Health, write:
Workers in health care are also likely to work nonstandard shifts, to work overtime, and to face psychosocial hazards such as violence in the workplace that further contribute to poor health. The health care workforce faces a broad array of health problems directly related to work, but, as the vast majority of this workforce earns low wages, they face the increasing pressures of income inequality.
Williams told me that the big difference in studying health and its association with income status as opposed to income inequality is that the former exposes effects at an individual level, while the latter exposes the effects of income differences across a population and whether those differences impact certain groups more than others.
“We wanted to look at how income inequality and changes in work structures both hurt the health of the workforce and reinforce each other,” she said. “If you think about low-paying jobs, the patterns of income match up pretty closely with certain job characteristics. …It’s not just income inequality that matters, it’s also other pressures — these are (workplace) trends that tend to squeeze people from many angles.”
Income inequality is yet another social determinant of health, Williams said, and so understanding its impact may be another key to putting adults and children on a healthier trajectory. She said public health practitioners can help bring this issue to light, especially the nuances of low-wage working conditions that aren’t always considered. For example, Williams said asking a worker if she or he has access to proper safety equipment and training is only one part of the picture. To reveal a more complete picture, also ask the worker whether he or she feels pressure to overlook safety in favor of efficiency. For instance, Williams noted that a health care worker might have access to the type of patient-lifting equipment that prevents worker injuries, but the strains of understaffing create a workplace culture in which safety isn’t a priority.
“Over the past few years, we’ve seen growing attention to the issue of income inequality — people instinctively realize that it’s a problem related to many other issues we face,” Williams said. “Public health (practitioners) can help us in realizing that this is also an issue about health.”
To request a full copy of the income inequality commentary, visit the American Journal of Public Health. Read some of our recent stories on the experiences of low-wage workers and their efforts to organize for better working conditions here, here and here.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.