There's one view of us as biological creatures that we are determined by our genes, that what we see in our biology is somehow innately us because of who we were born to be. What that misses is that we grow up and develop. We grow up as children, we grow up as adults and continue.
We interact constantly with the world in which we are engaged. That's the way in which our biology actually happens. We carry our history in our bodies. How could we not? Living in America should be a ticket to good health.
We have the highest gross national product in the world. I'm very happy to finally have some of my cars in one location, some of them. We spend $2 trillion per year on medical care. That's nearly half of all the health dollars spent in the world.
But we've seen our statistics. We live shorter, often sicker lives than almost every industrialized nation. We rank 30th in life expectancy.
Especially of economically developed countries, we are at the bottom of the list. A higher percentage of our babies die in their first year of life than in Malta, Slovenia, Cyprus. How can this be?
Is it just because 47 million of us have no health care coverage? Health care can deal with the diseases and illnesses, but a lack of health care is not the cause of illness and disease. It is like saying, since aspirin cures a fever, that the lack of aspirin must be the cause of the fever. So, why are we getting sick in the first place? Is it our American diet?
Individual behaviors? Those behaviors themselves are in part determined by economic status. So our ability to avoid smoking and eat a healthy diet depends in turn on our access to income, education, and what we call the social determinants of health. Written into our bodies is a lifetime of experience, shaped by social conditions, often even more powerful than our genes.
Among twins who lived together until age 18, who basically grew up in the same households, so had at least a relatively similar exposure, if they diverged later in life, if one became professional and the other was working class, they ended up with different health status as adults. This is among identical twins. There are ways in which our society is organized that are bad for our health. And there's no doubt that we could reconfigure ourselves in ways that would...
benefit our health. You're a doctor now? Yes, I'm a doctor now. Dr. Ottaweiler-Troutman knows this is true in Louisville, Kentucky. I'm the director of health for Louisville.
I'm a physician. I have the primary responsibility of overseeing the public health of over 700,000 people in this community. Think about a backup just in case you don't make the end of it. I do push personal responsibility.
I do push self-determination in health. But it has to be seen in the context of the broader issues. social determinants which are the major forces that shape the health outcomes of people and communities. The details are in the data.
This map shows infant mortality rates in the east, very low infant mortality. For Louisville, we've generated data maps to get a clearer picture of what conditions correlate to illness and death across our city. Death rates from lung cancer, a little bit. better outcome in the east.
So the lighter shades mean lower rates of death and illness, and the darker shades mean higher rates. The highest rates of death from diseases of the heart are in the west end. And that even does extend to the east.
Embedded in the data is a somewhat morbid but revealing indicator of population health, excess death. The notion of excess death says that you should be able to predict in any one time frame how many people in a population will die. And if the number that actually die is higher than that, that differential is excess death, premature death, death that should not have happened. It's not as if we won't die. We all will die.
But the question is, at what age, with what degree of suffering, with what degree of preventable illness? And then these are death rates from all types of cancer, and you see the same pattern. In some areas, people die three. Five, even ten years sooner than in others.
Cancer and heart disease are almost twice the rate in some areas as in others. But Louisville has many faces. Its population is spread over 26 neighborhoods or council districts, each with its own social and economic environment, and each with a distinct health profile. And the further east you get, the more affluent the communities become. Furthest east and north is Council District 16, home to Jim Taylor.
Want to go upside down? No. Want to go on your feet? Yeah.
Taylor is a father, grandfather, and a CEO. So the rain passed at least. So is this going to be like when your board chairman came and the girl didn't work? I like to think of myself as a pretty healthy person.
I'm only 12 months away from the 60th year of my existence, and I feel pretty healthy. I can't do the things I did when I was 20 now that I'm almost 60, but I can do most of them in a little moderation. Is James going to be here too? I like James. Like many residents here, Taylor earns well into the six figures.
His income places him in the top 1% of Americans. The wealth of that 1% is greater than that of the bottom 90% combined. We're fortunate that the choices we have... may be greater than people who have less means than we do. I have a neighborhood where I can be outside and know that I'm safe and that I can exercise and walk.
And I know that not every neighborhood in this country or in this city, that's true. Excess death doesn't seem to be a health issue in Council District 16. Here, life expectancy is nearly 80 years. Two years longer than the national average.
Most people can quite readily appreciate the fact that if you have more money, you're going to be healthier. But it also turns out that that observation holds not just at the extremes. So, for example, let's say that there's a ladder.
It's not just that the rich differ in some way from the poor in some kind of black-white or yes-no or zero-one kind of way. There's a fine gradation all the way along this ladder, both in wealth and in health. Researchers had wondered about this for decades. But in the 1970s, the pioneering Whitehall studies offered hard data.
Sir Michael Marmot has been lead researcher. I was interested in how social influences affect disease. And so we looked at people's grade in the hierarchy, their employment grade.
Over more than 30 years, Marmot and his team charted the health of 29... thousand British civil servants when we did this in the 1970s the conventional wisdom was that it was the business executive who had a high rate of heart attacks and what we found in white hole was the lower the grade of employment, the higher the risk of heart disease. But not just heart disease. Every major cause of death.
So if you were second from the top, you had worse health than if you were at the top. If you were third from the top, you had worse health than if you were second from the top. All the way from top to bottom.
In Britain, everyone has guaranteed health care. Still, Marmot found that death rates and illness correlated to status, even after he controlled for unhealthy behaviors. A combination of smoking, blood pressure, cholesterol, overweight, sedentary lifestyle, explained no more than about a quarter of the social gradient in mortality.
So heart disease. Among smokers, if a poor person's smoking... He or she has a higher rate of disease than if a wealthy person is smoking.
When a classless country like the United States said, well, we wouldn't find that here because we don't have social classes like they do in Britain. And of course, once people started to look at the United States, they found social gradients in disease of the same order as those we found in Britain. In America, the wealth-health gradient looks like this. Over 70% of affluent Americans report very good to excellent health. Almost twice as many as poor Americans.
No surprise. But in the middle levels, good health decreases significantly. This translates into a reverse slope for chronic disease. Diabetes. Low-income Americans have twice the rate of disease as the affluent.
And for those in the middle, it's still almost twice the rate. A similar pattern holds for stroke, heart disease, eventually contributing to excess death, especially for middle and low-income Americans. The conditions that show up in stark form in the poor health of the poor are showing up in somewhat less stark form in people who we don't think of as poor. The large mass in the middle of society are also being affected. We find these social gradients in health everywhere.
When I first came to Louisville, I was struck by how different the various communities looked. And I began to wonder and then understand that there's a direct connection between the health of populations in Louisville and the social conditions that can be seen as you go from one council district to another. South of Jim Taylor's home is Council District 24. Tondra Young lives here.
Young is 37, a lab supervisor, and she's just gotten engaged. Financially, I'm comfortable. I would like to be rich someday, but right now I'm fine. I'm doing a whole lot better than my mom was. Just bought a new home, and I would describe my family as a middle-class family now.
To get ahead, Tondra went back to college while working full-time. I am going to graduate in the spring. I'm very excited about that. I've traveled a long ways to even get to that point.
Research shows that college graduates live, on average, two and a half years longer than high school graduates. Education offers a way to move up the wealth gradient. It connects to the type of job. It connects to optimism about the future. But getting it depends on whether or not you can afford it.
Tondra's degree has left her $20,000 in debt on top of her mortgage. I think I broke them. In the last five years, the cost of college has increased 35%. Only 15% of adults in Tondra's council district have a college education, compared with over 63% in Jim Taylor's district. Life expectancy here is 75 years, four years less than in Jim Taylor's.
Northwest from Tondra Young's district is Council District 21. This is where Cory Anderson lives with his wife Angelique and their two teenagers. Cory's lived in this part of town all his life. This is my mother.
This is the woman who taught me how to iron my clothes, put my creases in, get the wrinkles out. I give her all the praise and the glory for teaching me how to keep myself nice and neat. When Corey was young, his mom worked full-time, and her job was more than just a paycheck.
She had just purchased the house. Everything is going great for me, you know. I'm doing good, you know, I'm being blessed.
Then all of a sudden, you know, the company moved. It took a major toll on her when she lost that job. You know, she got ill.
You know, her blood pressure went up, and she had to go to the doctor more often. And, you know, it was just something that, you know, really, you know, took a toll on her, you know, mentally and physically. You know, as well as me and my brother. Eventually, Corey's mom did find work, but she had to leave her home.
For most Americans, home ownership is a way to build financial security. I always wanted a house with a big backyard and a fence where my kids can run around and have their own room and a basement. And a husband have a basement with a pool table in it. I want to own the house. I want both of us to own the house.
So if anything happen to me, she ain't got to be put out in the streets. Corey and Angelique both work full-time. Their combined salaries place them right at the national median income, about $48,000.
Half of all American households live at this income level or below. As far as like saving, you know, we don't earn enough to, you know, say we're going to put up $250 and don't touch it. It's going to have to take to work two jobs to really make it. You ain't working two jobs. I didn't say me.
At 37, Corey has already been diagnosed with hypertension, joining one-third of the residents in Council District 21. Average life expectancy here is two years shorter than in Tondra's Council District, six years less than in Jim Taylor's. Troutman sees social conditions change even more markedly as he drives through Louisville City Center across 9th Street. There is almost a cultural demarcation in the city where on one side of this particular Street, 9th Street, there's a tremendous amount of new development going on.
Condos rising up. The downtown business environment is very much alive. And right across the street on 9th Street is where the beginnings of the first set of projects are, public housing projects.
Very little business in this area. Primarily fast foods, small businesses, barbershops, beauty salons, pawnbrokers, nail parlors, check cashing, liquor stores. Payday cash. Cash when it counts. It seems like every place has a 9th Street.
Whether it's 110th Street in Harlem, or South Side of Chicago, or you know, sections of Washington. Of course these differences are not a natural thing. You know, it's not the design of nature that these environments are going to be different. They arise as a result of policies or the absence of policies that create these enormous inequalities in resources.
Is there adequate access to chain supermarkets in this area? The answer is no. As a matter of fact, why aren't there zoning laws to regulate fast food outlets here?
Enterprise zones to build businesses. Better transportation. Why isn't there more mixed income housing?
You know, all these things and others. Our health policy. How social policies can drive health becomes even more apparent in Council District 5, the home of Mary Turner. This is where we usually come down for shoes, school shoes and school clothes.
Up here save a lot. A third of the residents here have never received a high school diploma. Almost 30% live at or below the poverty line, like Mary.
Life expectancy in Mary's Council District is more than three years less than in Corey's district. Nine years less than in Jim Taylor's. Of course we're dying young, versus 80 in the eastern section of the county. You know, because those people are more affluent.
And they have things open to them. Mary is 49 with three children at home. Her husband is disabled.
You have to eat what fits your budget. So when you get these, the family size, and they're $1.99, and you can feed four people with it, you know, versus maybe four with $4. I mean, what's your choice of grain?
you know, especially when you're on a $200 a month budget for food. The food that we buy lasts about two weeks. We spend cash the first part of the month, you know, when we get Social Security and SSI.
And then usually by the last two weeks of the month, things are getting really spare. You know, I've got like three teenagers, so, you know, about the end of the month I start reducing to one meal a day so that I can make sure those kids got everything they need.. 12% of the residents here are unemployed.
More than double the national average. As is Mary, for now. So she volunteers at the neighborhood museum she loves. I do feel like that sometimes things are out of your control because as soon as you try to better yourself, I mean, if I even get a job, you know, then I might lose my medical coverage.
And my medical coverage is necessary, you know, because I had to have my medications in order to work. I had a heart attack several years ago. It was mild, but it was still a heart attack. Thyroid problems, you know, and arthritis, you know, a little bit of everything.
So. We can predict on aggregate, based on where somebody lives, high school graduation rates, and their income, how long they'll live, and when they will die. Now, obviously, there'll be exceptions to that.
But for the most part, we'll be right. And we should not be able to do that. Your life expectancy, how long you will live, should not be dependent on, essentially, the resources you have accessible to you. We know that social class is the most important determinant of health above any other risk factor.
But what does social class mean? Is it housing? Medical care?
Education? Or is it power, confidence, a sense of security? Which one of those is most important?
Hopeless. They're all inextricably intertwined, can't take them apart, so it's really a challenge. But how do we carry social class in our bodies? How does it get under our skin? As you go through the alternative explanations, the one that seemed most impressive to me was this idea of control of destiny.
I don't like that word. What I mean by it is the ability to influence the events that impinge on your life. even if it means not doing anything, but one way or the other, managing those pressures. There are all sorts of ways we've devised for depriving people of a sense of control over their lives, living in a community where it's not safe to go out. Middle-class families having to work two jobs.
Middle-class families not being able to spend time with their kids. Being relatively poor. Having job insecurity. All of those things will decrease control over people's lives. And all of those things are likely to increase risk of illness.
And there are good biological reasons why that might be the case. When we feel threatened or don't have control in our lives, one critical biological reaction kicks in. The stress response. When the brain perceives a threat, it signals the adrenal glands to release potent stress hormones, among them cortisol.
They flood your bloodstream with glucose, increase your heart rate, raise blood pressure. They put your body on alert. Cortisol improves memory, enhances immune function, it helps you reestablish energy supplies.
Mother Nature put all of this stuff in there to help us survive. Stress helps to motivate us. In our society today, everybody experiences stress. In fact, the person who has no stress is the person who's dead.
A normal stress response spikes up when needed, then turns off. But what happens when pressures are relentless and you lack the power and resources to control them? When the stress response stays turned on for months or years?
These systems begin to work overtime. We produce too much cortisol. Chronically, cortisol can impair immune function.
It can actually inhibit memory and even cause areas of the brain to shrink. When you get... prolonged activation of these stress pathways, they in turn affect heart rate variability, the ability to handle insulin and glucose, and those in turn we think increase risk of diabetes and heart disease.
Because of the stresses, the wear and tear on the body's systems is reflected ultimately in higher rates of disease and accelerated aging. University Hospital, Louisville's major teaching hospital. you'd expect to see the wear and tear of stress in the bodies of patients. But as a large hierarchical workplace, much like any other, University Hospital reveals more.
Stress is everywhere. There are days that the pager that I carry goes off nonstop and gives me a horrible headache, and I just think that the next time I hear a page or a beep, I'm going to throw it up against the wall. Corey Anderson, floor technician, is stressed.
So is Tondra Young, supervisor of a clinical lab. And Jim Taylor, CEO of the hospital, is stressed. But neither chronic stress nor its health effects are equally distributed on a hierarchy.
All right, that's a chase and a flee. So that one's dominated over the one that ran away. Consider this hierarchy of macaque monkeys. Primatologist Carol Shively has been studying macaques for almost 30 years.
Same thing happened. He can play that game all day long with her because he's dominant. It's a very mild sort of harassment.
A dominant animal has complete control over his life. He can go where he wants in the pen, do what he wants. That animal has all the control that it needs to create an optimal environment for itself.
In contrast, subordinate animals alternate animals have almost no control over what happens to them. They have to be watching all the time, and in fact with that high level of vigilance comes increases in heart rate. Dogs with less power and control are are in a state of chronic stress. The evidence is in their stress hormone levels.
They have higher levels of cortisol circulating in their blood. It's the same chemical that is released in human beings in response to stress. And when it is sustained at high level, starts having negative effects on cellular function and tissues. Shively can actually look into the hearts of macaques to see the damage from chronic stress.
This is a cross-section of the artery of a dominant monkey. The hole in the center is large, and that means that there's lots of room for blood to flow through. Now, this is the artery. of a subordinate animal.
So what's happened here is that a subordinate monkey has developed a much larger atherosclerotic plaque than a dominant animal who lived for the same amount of time, ate the same amount of diet, and... so on and so forth. And that is simply due to the stress of social subordination. Now, if this monkey keeps developing atherosclerosis at this increased rate relative to this monkey, this one is going to end up with an artery that is completely compromised and have a myocardial infarction.
In other words, a heart attack. Monkeys are one thing. Humans are another.
Do we see a similar pattern? That's what psychologist Sheldon Cohen wanted to know. He used the same stress measure Shively used, levels of cortisol.
Who's next? We have people chew on little cotton swabs until they get wet, can take it and analyze it for cortisol. He compared their levels with their socioeconomic status.
And to tell you the truth, I'm always somewhat surprised when I see these data. It turns out the more education you have, the less cortisol you release during the day. The more income you have, the less cortisol you release during the day.
Then Cohen wanted to test the effect of stress on our bodies. His focus? Our immune system.
Basically, we brought healthy people in, we exposed them to a virus. We actually do this by putting a drop in their nostrils that has cold virus in it. Cohen's finding? Those with less chronic stress caught fewer colds than those with more stress.
While a cold virus may seem minor, it could signal more serious health problems. The cold study is a paradigm we can use that allows us to see how effectively the immune system is operating. which has implications for not only colds and other infectious diseases, autoimmune diseases, and some kinds of cancers.
So, higher status, less stress. Less stress, better immune function. Still like this place compared to where you were?
Being CEO is a high-demand job, but Taylor usually has the power, resources, and control to manage that pressure. Tondra Young has a high demand job, but less power and control. Sometimes it can get a little stressful because, you know, I have 50-something employees running around on three different shifts, three different buildings. Sometimes it can be tough for me because, you know, everybody's not going to like the decisions that I've made for the department, but I'm making the best decision for the department and for patient care.
It's coming along. Okay, it's looking good in here. The control that I have on doing my job is limited.
Corey Anderson's job requires him to respond to a lot of demands from above. Yes, mission is completed for the first floor. Mission one, what's my next project? In one scenario, Corey is first told to clean patient rooms. But I got pulled to help out with trash, so I started on the trash.
And when I pulled the trash, I got a page to tell me to go back to the rooms. I was bounced around. You want these scrubbed eyes? Like Corey, one in every five American men works in a high-demand, low-control job.
They're more like... to experience high blood pressure at work. And their blood pressure doesn't fall as much as men with more control, even when they sleep.
It's not only about work. It's about where you are in the hierarchy and how that relates to the circumstances in which you live, grow up, as well as work. So this is basically what I call my neighborhood.
I don't venture no farther, you know, because I just, I'm not comfortable with, you know, venturing back there or back over that way. A lot of things, you know, do occur back in... back and my wife she knew a cab driver who was uh who was murdered back there in the back two cab drivers one got shot in the head the other one got shot and they dropped him off in his yard remember corey right over here on kingston i thought he got strangled well yeah they strangled him and then they shot um another young boy The accumulation of stressors or the accumulation of resources to manage them. So much is determined by class. I am well paid for what I do.
I'm fortunate enough to be able to have the choice of where we live. And more than half the mornings when I come to work, I have to stop for the deer to go by. And that kind of thing is just what happens in this neighborhood. This is the second biggest that you get this. We have the time to exercise because the lives we live don't require us to try to find a bus that we have to ride for two hours to get to our job.
And on the other end, we don't have. You know, huge demands on us when we're not working. Jackie and I talked a lot about healthy choices of eating. Well, that doesn't come for free.
We have the ability to get to places where one can make. those choices. We have the time to prepare the meal that we had the money to buy. So a certain economic status brings you control over other parts of your life.
The kinds of places you can live, the kinds of vacations you can take, or if you can take a vacation. We went by bus all the way from here to Miami. We got on this party bus. Once we got on that bus, brother, it was over for me. Throw your hands up.
That's how she was. I was like, hallelujah. No kids.
No kids. It was just a break, a piece of something that we needed because we never get to go nowhere. You know, we always here with the kids.
babysitting someone else's kids. Vacation to me is going to the park, sitting on the river and watching the river flow by. You know, that's my vacation. Little short things, you know, it's not, there's no family vacations.
It doesn't happen. My children, I think they're living with a whole lot of stress, a whole lot, you know. And they really, you know, are kind of at a loss to do anything about it, you know.
I mean, they're young. I mean, what can they do? They don't like being by themselves on the streets, you know.
They don't like to walk by themselves. They want somebody with them. That's the reason why you see them going two and three, you know. I mean, it happens a lot around here.
Contrary to some stereotypes, most of the poor in America are white. Mary grew up poor. Her children join the 21% of all American children who live in poverty.
The unremitting stress of childhood poverty can have lifelong health consequences. Just the burden of day after day not knowing whether there's going to be food on the table or not knowing whether you're going to have a roof over your head is actually toxic to the brain. And the reason for that is because when the stress hormone levels go up, and if it stays up for days and weeks, on end.
Those hormone levels literally interfere with the development of brain circuitry. They interfere with the development of the connections in the brain. So we begin to see in children who experience toxic stress long-term impacts.
of what's basically been chemically damaging to their brains. The concept here is the pile-up of risk, the cumulative burden of having things that are increasing your chances of having problems, as opposed to the cumulative protection of having things in your life that increase the likelihood that you're going to have better outcomes. Economic security may offer some of those cumulative health benefits. In another cold virus study, Cohen used a familiar proxy for that security, home ownership.
We ask people if their parents own their own home. Does whether their parents own their home when they were a kid predict whether you get a cold when you're an adult? We now take them as an adult, we expose them to a virus. It turns out it's a great predictor.
And it's a graded predictor. That is, the more years their parents own their home, the less likely they are to get a cold when we expose them to a virus. All of it really comes down to whether you're building a strong or a weak foundation in early childhood.
When you pile up risk factors, it ends up being translated into a weaker foundation, a brain that's been subjected to more disruption, an immune system that's been more threatened. And poor or not, if you're not white, the prognosis can be worse. You live around here?
No, where do you live? I live in Jefferson Town. In Jefferson?
You traveled a long way to get here. I'm clear that... On the social gradient, that line that we talked about earlier, that I'm on the top of that line.
Kenneth? How old are you, Kenneth? 11. I'm highly educated.
I have a medical degree. I have several other degrees. I make good money. I live in a good neighborhood.
But I know that according to the research, if you're an African-American, no matter what your social status, your socioeconomic status, your health outcomes are going to be worse than your white counterpart. African Americans die earlier and have higher rates than whites of many chronic diseases across the social gradient. Why should there be an elevated risk of disease in African Americans of higher social class?
Bad genetics. Not true. When you look at other countries where the discrimination is not as prevalent, you don't find those kinds of rates. So something's happening. As a physician, I've been following around the store.
When I go in to buy something, I've been looked at as scant. So I've seen a woman grab her purse when I come into the elevator, and for goodness sakes, you know, I am Dr. Trautman. You know, this shouldn't happen to me, but it does. The whole idea of vigilance and the burden that it takes to be constantly on guard over time really does change biological markers and make people vulnerable to getting sick.
Racial discrimination can be an added stressor, linked with high blood pressure, increased rates of infant death, coronary artery disease. Troutman knows what this can lead to. He authored a cornerstone study with former Surgeon General David Satcher on excess death among African Americans. It was a national study, and we found over 83,000 excess deaths per year in the African-American community alone. 83,000 excess deaths each year.
That's the equivalent of a major airliner filled with black passengers falling out of the sky every single day, every year. If these inequalities in health, this gradient in health, was a fixed property of society and never changed, then you'd say we're stuck. But that's not the case. The magnitude of the inequalities in health changes over time.
It can get rapidly worse, and if it can get rapidly worse, it ought to be possible to make it rapidly better. Reducing health inequality is not impossible. As a society, we've done it before. A century ago, the average American lived only about 48 years.
As living conditions and medical care improved, we began living longer. Those improvements reached more Americans through social reforms, like universal education, better sanitation, the eight-hour workday, even a controversial tax on personal income. This social security measure...
The 1930s. An array of new social programs prevented an economic crisis from becoming an even worse health crisis....and through increased services for the protection of children and the prevention of ill health. Returning World War II veterans got the GI Bill.
It offered homes and education, and eventually the kind of wealth that sets health on an upward trajectory. Still, most African Americans were excluded. The 1950s. The middle class was growing, income inequality was declining. Prosperity and medical advances extended our lives even longer.
But the vast majority of improvements in health in our society over the last century have had very little to do with medical innovation. What really counts, it's other kinds of things we can do, and those other kinds of things tend to be non-medical things. like thinking about the distribution of wealth in our society, or providing public health infrastructure, or better education for people, better housing, all of those things which aren't medical phenomena. It is all of those that are really material for public health. Black and white together!
In the 1960s, civil rights laws, anti-poverty programs, Medicare and Medicaid, all brought the benefits of prosperity to those who hadn't yet shared in it. During the 1960s to early 70s, the black-white gap in income narrowed, and the black-white gap on multiple indicators of health also narrowed. What this says, very eloquently, is that economic policy is health policy. And when we improve economic circumstances and narrow the economic gap, we improve the health. So we can potentially intervene or potentially see a world in which while we do not eliminate hierarchy, we constrain the way in which hierarchy affects human beings.
So it's not just that the people at the top can afford those things and get them, and those at the bottom that do not. If we provide them to all, we still have some hierarchy, but now we've kind of reduced the disparities. But since the 1980s, we've gone in the opposite direction.
Look at me, I used to work for these people. Now I got to stand in line and get a box of cheese. We're waiting for the Reagan trickle down and it's not trickling. In the midst of a recession, governments slashed social programs, deregulated industry, reduced taxes for the wealthy. with consequences that remain with us today.
Where's the people? This is like dead. In a country that prides itself on equality of opportunity, it is becoming anything but that as the gap between the super-rich and the middle class widens. dramatic fashion. Warren Buffett, the world's richest man.
Here are a few figures on the Forbes 400. Other people save their Playboy magazines. I saved the Forbes 400 magazine. 20 years ago, the total wealth of the list was then $220 billion.
Now it's $1.54 trillion, exactly a seven for one increase. Tax law changes have benefited this group, including me. in a huge way. Wealth inequality reached a record low in 1976. Since then, it has soared.
Today, we are far and away the most unequal of the world's rich democracies. During that same period, the average American went exactly nowhere on the economic front. He's been on a treadmill while the super-rich have been on a spaceship. The poor are getting poorer and the middle class is getting squeezed. With what we know in terms of health, that suggests that we will have even more health problems in our society in the future.
That's because here, health depends largely on our individual assets and resources. In America... It's the strongest relationship you'll find anywhere, that wealth pretty much equals health. And that's true for me, as it is true for, you know, the poorest person in the quote-unquote inner city, and people living in the suburbs.
The wealth-health gradient is not as steep in most other industrialized nations. Many use their resources to ensure that more of their citizens have the freedom to lead flourishing, healthy lives. All guarantee universal health care coverage, mandate at least four weeks of paid vacation. France's minimum wage has been twice as much as ours.
Ireland provides free college education. Sweden's family policies reduce child poverty to a mere 4.2%, compared to our 21%. It's tragic, actually, that we are the richest country in the world and that we are far behind many other countries in terms of how we use our resources to make life better for families with young children and thereby invest in our future. Those countries have found ways to break the tight linkage between income and wealth and health.
And they invest in better education systems, housing support, child care, access to recreation. They subsidize through tax policy mechanisms that break that strong relationship. Those countries where wealth is more equitably distributed are healthier. Here in the U.S., many communities are taking health matters into their own hands.
I'm glad you're here. I'm really, I'm excited that you're here because this is the mosaic of people, partnerships, organizations, agents. that we need to come together to make this a reality. One, two, three. In Louisville, the city's new Health Equity Center trains citizens to take political action and design policies that address the health of the people.
health needs of their community. It's not enough to talk about individual behavior and feel that if we could just get people to exercise more and eat more fruits and vegetables, everything would be all right. That is not the case. The bigger issues are the social conditions that drive the ultimate health status of populations. We sold nine of them on Saturday.
Oh, did you? Oh, I knew you were going to sell them. In Seattle, Washington, community activists target unhealthy housing and the asthma that keeps many people from going to school.
from leading productive lives. So the air inside the home is actually healthier than the air outside. Part of good public health is empowering communities, and I don't think we should shy away from that.
And empowering communities means creating those conditions where people become empowered and make the changes they need to control their lives. Power is a public health issue. And here's my grandpa. He died of diabetes. Diabetes and the complications of diabetes.
In Arizona, Native Americans are farming again. With better food and new economic resources, they're beginning to take control of their destinies and diabetes. Of course, the proof is in the pudding.
The proof is in the next steps, what we can organize, what we can implement, and how we're able to move this community ahead. It's about human rights. It's about addressing the social determinants of health in order to make a difference. It's about fairness. It's about health, equity, and social justice.
We've got to create a movement where people understand we're talking about leading more flourishing lives. We need to do certain things because they're the right things to do. But it's also an issue of individual self-interest. If I live in a just society, I'll benefit. Yeah, but look right here.
I got a tuba right here. It's trying to come up right here. An economist would tell you it's inefficient to have people who could otherwise be contributing during their productive years to the overall benefit of society. Caught up in hospitals that create a net dependence on society, so they're drawing resources down from society, rather than producing resources that benefit the society as a whole.
And the cost of that lost productivity to business. due to chronic illness is staggering. It's now estimated at over $1 trillion a year.
Worse, one study predicts that today's generation of young Americans may be the first in a century to live shorter lives than their parents. And I would hope that we would all be able to gravitate towards an egalitarian society where health is seen as a basic human right. Somebody told me this table had the fastest kids in all of Louisville. Is that true?
But even if you're not willing to go that far, you better be involved in this because the self-interest would dictate that you're at risk too. We can wait for things to happen and try to repair them in this mode of damage control. Or we can invest early, try to set good trajectories for families and children and communities. We can do those things, or we can engage in damage control.
Alright, see ya. Bye bye. We have a choice.