SOCIOECONOMIC STATUS, STRESS, AND DISEASE
The following passages are extracts from Robert Sapolsky’s book: Why Zebras Don’t Get Ulcers
If you want to see an example of chronic stress, study poverty. Being poor involves lots of physical stressors. Manual labor and a greater risk of work-related accidents. Maybe even two or three exhausting jobs, complete with chronic sleep deprivation. Maybe walking to work, walking to the laundromat, walking back from the market with the heavy bag of groceries, instead of driving an air-conditioned car. Maybe too little money to afford a new mattress that might help that aching back, or some more hot water in the shower for that arthritic throb; and, of course, maybe some hunger thrown in as well…. The list goes on and on.
Naturally, being poor brings disproportionate amounts of psychological stressors as well. Lack of control, lack of predictability: numbing work on an assembly line, an occupational career spent taking orders or going from one temporary stint to the next. The first one laid off when economic times are bad—and studies show that the deleterious effects of unemployment on health begin not at the time the person is laid off, but when the mere threat of it first occurs. Wondering if the money will stretch to the end of the month. Wondering if the rickety car will get you to tomorrow’s job interview on time. How’sthis for an implication of lack of control: one study of the working poor showed that they were less likely to comply with their doctors’ orders to take antihypertensive diuretics (drugs that lower blood pressure by making you urinate) because they weren’t allowed to go to the bathroom at work as often as they needed to when taking the drugs.
As a next factor, being poor means that you often can’t cope with stressors very efficiently. Because you have no
resources in reserve, you can never plan for the future, and can only respond to the present crisis. And when you do, your solutions in the present come with a whopping great price later on—metaphorically, or maybe not so
metaphorically, you’re always paying the rent with money from a loan shark. Everything has to be reactive, in the moment. Which increases the odds that you’ll be in even worse shape to deal with the next stressor— growing strong from adversity is mostly a luxury for those who are better off.
Along with all of that stress and reduced means of coping, poverty brings with it a marked lack of outlets. Feeling a little stressed with life and considering a relaxing vacation, buying an exercycle, or taking some classical guitar lessons to get a little peace of mind? Probably not. Or how about quitting that stressful job and taking some time off at home to figure out what you’re doing with your life? Not when there’s an extended family counting on your paycheck and no money in the bank. Feeling like at least jogging regularly to get some exercise and let off some steam? Statistically, a poor person is far more likely to live in a crime-riddled neighborhood, and jogging may wind up being a hair-raising stressor.
Finally, along with long hours of work and kids to take care of comes a serious lack of social support—if everyone you know is working two or three jobs, you and your loved ones, despite the best of intentions, aren’t going to be having much time to sit around being supportive. Thus, poverty generally equals more stressors—and though the studies are mixed as to whether or not the poor have more major catastrophic stressors, they have plenty more chronic daily stressors.
The health risk of poverty turns out to be a huge effect, the biggest risk factor there is in all of behavioral medicine— in other words, if you have a bunch of people of the same gender, age, and ethnicity and you want to make some predictions about who is going to live how long, the single most useful fact to know is each person’s SES. If you want to increase the odds of living a long and healthy life, don’t be poor. Poverty is associated with increased risks of cardiovascular disease, respiratory disease, ulcers, rheumatoid disorders, psychiatric diseases, and a number of types of cancer, just to name a few.* It is associated with higher rates of people judging themselves to be of poor health, of infant mortality, and of mortality due to all causes. Moreover, lower SES predicts lower birth weight, after controlling for body size—and we know from chapter 6 the lifelong effects of low birth weight. In other words, be born poor but hit the lottery when you’re three weeks old, spend the rest of your life double-dating with Donald Trump, and you’re still going to have a statistical increase in
some realms of disease risk for the rest of your life.
Findings such as these go back centuries. For example, one study of men in England and Wales demonstrated a steep SES gradient in mortality in every decade of the twentieth century. This has a critical implication that has been pointed out by Robert Evans of the University of British Columbia: the diseases that people were dying of most frequently a century ago are dramatically different from the most common ones now. Different causes of death, but same SES gradient, same relationship between SES and health. Which tells you that the gradient arises less from disease than from social class. Thus, writes Evans, the “roots [of the SES health gradient] lie beyond the reach of medical therapy.”
In the United States, poor people (with or without health insurance) don’t have the same access to medical care as do the wealthy. This includes fewer preventive check-ups with doctors, a longer lag time for testing when something bothersome has been noted, and less adequate care when something has actually been discovered, especially if the medical care involves an expensive, fancy technique. As one example of this, a 1967 study showed that the poorer you are judged to be (based on the neighborhood you live in, your home, your appearance), the less likely paramedics are to try to revive you on the way to the hospital. In more recent studies, for the same severity of a stroke, SES influenced your likelihood of receiving physical, occupational, or speech therapy, and how long you waited until undergoing surgery to repair the damaged blood vessel that caused the stroke.
In a place like England, the SES gradient has gotten worse over this century, despite the imposition of universal health care allowing everyone equal health care access.
Marmot considered a system where gradations in SES status are so clear that occupational rank practically comes stamped on people’s foreheads—the British civil service system, which ranges from unskilled blue-collar workers to high-powered executives. Compare the highest and lowest rungs and there’s a fourfold difference in rates of cardiac disease mortality. Remember, this is in a system where everyone has roughly equal health care access, is paid a living wage, and, very important in the context of the effects of unpredictability, is highly likely to continue to be able to earn that living wage.
Being poor is statistically likely to come with another risk factor-being poorly educated. Thus, maybe poor people don’t understand, don’t know about the risk factors they are being exposed to, or the health-promoting factors they are lacking—even if it is within their power to do something, they aren’t informed.
The intertwining of poverty and poor education probably explains the high rates of poor people who, despite their poverty, could still be eating somewhat more healthfully, using seat belts or crash helmets, and so on, but don’t. And it probably helps to explain why poor people are less likely to comply with some treatment regime prescribed for them that they can actually afford—they are less likely to have understood the instructions or to
think that following them is important. Moreover, a high degree of education generalizes to better problem-solving skills across the board. Statistically, being better educated predicts that your community of friends and relatives is better educated as well, with those attendant advantages.
A central concept of this book is that stress is heavily rooted in psychology once you are dealing with organisms who aren’t being chased by predators, and who have adequate shelter and sufficient calories to sustain good health.
It’s not about being poor. It’s about feeling poor, which is to say, it’s about feeling poorer than others around you. Once you’ve done that, look at what health measures have to do with one’s subjective SES. Amazingly, it is at least as good a predictor of these health measures as is one’s actual SES, and, in some cases, it is even better. Cardiovascular measures, metabolism measures, glucocorticoid levels, obesity in kids. Feeling poor in our socioeconomic world predicts poor health.
What Wilkinson and others have shown is that poverty is not only a predictor of poor health but, independent of absolute income, so is poverty amid plenty—the more income inequality there is in a society, the worse the health and mortality rates.
This is obviously the case in traditional settings where all people know about is the immediate community of their village—look at how many chickens he has, I’m such a loser. But thanks to urbanization, mobility, and the media that makes for a global village, something absolutely unprecedented can now occur—we can now be made to feel poor, or poorly about ourselves, by people we don’t even know.
But Wilkinson makes an extraordinary point—in societies that have more income equality, both the poor and the wealthy are healthier than their counterparts in a less equal society with the same average income. There is something more profound happening here.
Measures like those tell you that on the levels of states, provinces, cities, and neighborhoods, low social capital tends to mean poor health, poor self-reported health, and high mortality rates.*
Findings such as these make perfect sense to Wilkinson. In his writing, he emphasizes that trust requires reciprocity, and reciprocity requires equality. In contrast, hierarchy is about domination, not symmetry and equality. By definition, you can’t have a society with both dramatic income inequality and lots of social capital. These findings would also have made sense to the late Aaron Antonovsky, who was one of the first to study the SES/health gradient. He stressed how damaging it is to health and psyche to be an invisible member of society. To recognize the extent to which the poor exist without feedback, just consider the varied ways that most of us have developed for looking through homeless people as we walk past them.
And Kawachi’s work shows that the strongest route from income inequality (after controlling for absolute income) to poor health is via the social capital measures.
How does lots of social capital turn into better health throughout a community? Less social isolation. More rapid
diffusion of health information. Potentially, social constraints on publicly unhealthy behaviors. Less psychological stress. Better organized groups demanding better public services (and, related to that, another great measure of social capital is how many people in a community bother to vote).
So it sounds like a solution to life’s ills, including some stress-related ills, is to get into a community with lots of social capital. However, as will be touched on in the next chapter, this isn’t always a great thing. Sometimes, communities get tremendous amounts of social capital by having all of their members goose-step to the same thoughts and beliefs and behaviors, and don’t cotton much to anyone different.
Research by Kawachi and others shows another feature of income inequality that translates into more physical and psychological stress: the more economically unequal a society, the more crime—assault, robbery, and, particularly, homicide—and the more gun ownership. Critically, income inequality is consistently a better predictor of crime than poverty per se.
Our American credo is that people are willing to tolerate a society with miserably low levels of social capital, so long as there can be massive income inequality … with the hope that they will soon be sitting at the top of this steep pyramid.
What does this dichotomy between our animal cousins and us signify? The primate relationship is nuanced and filled with qualifiers; the human relationship is a sledgehammer that obliterates every societal difference. Are we humans actually less complicated and sophisticated than nonhuman primates? Not even the most chauvinistic primatologists holding out for their beasts would vote for that conclusion. I think it suggests something else. Agriculture is a fairly recent human invention, and in many ways it was one of the great stupid moves of all time. Hunter-gatherers have thousands of wild sources of food to subsist on. Agriculture changed all that, generating an overwhelming reliance on a few dozen domesticated food sources, making you extremely vulnerable to the next famine, the next locust infestation, the next potato blight. Agriculture allowed for the stockpiling of surplus resources and thus, inevitably the unequal stockpiling of them—stratification of society and the invention of classes. Thus, it allowed for the invention of poverty. I think that the punch line of the primate-human difference is that when humans invented poverty, they came up with a way of subjugating the low-ranking like nothing ever before seen in the primate world.