Reports on the income inequality gap and the separate lives of the wealthy and the poor have become depressingly rote. The rich are not like you or me: They can buy their way into exclusive clubs, special social networks, even elitist sex parties. The poorest people in America are now on average not making enough to meet their basic needs—that sounds pretty bad, but can I interest you in a $700 juicer?
In that context, the publication, in the Journal of the American Medical Association (JAMA), of a new study that looks at income and life expectancy after age 40 contains no bombshells. The report, covered widely by the New York Times and pretty much every other outlet on Monday, drills down into how income and longevity correlate. The richest 1 percent of men lives, on average, 15 years longer than the poorest 1 percent; for women that gap is ten years. But the ability of money and the things it buys—access to better medical care, leisure time, healthier food—to stave off death is well known. The big finding from Stanford economist Raj Chetty and his seven co-authors is not that rich people live longer, it's that the life expectancies of Americans in poverty varies wildly depending on where they live.
Here's how the Times summarizes it: "The poor in some cities—big ones like New York and Los Angeles, and also quite a few smaller ones like Birmingham, Ala.—live nearly as long as their middle-class neighbors or have seen rising life expectancy in the 21st century. But in some other parts of the country, adults with the lowest incomes die on average as young as people in much poorer nations like Rwanda, and their life spans are getting shorter."
For the wealthy, it doesn't matter where they live—they seem to have the access to the same sorts of advantages wherever they go. "It is as if the top income percentiles belong to one world of elite, wealthy US adults," wrote Nobel Prize–winning economist Angus Deaton in an article that accompanied the study in JAMA, "whereas the bottom income percentiles each belong to separate worlds of poverty, each unhappy and unhealthy in its own way."
The obvious question, then, is what makes those individual islands of scarcity more or less healthy than other communities? That's beyond the scope of the paper, but it's clear that the answer isn't simply that some places have fewer or worse doctors. "The JAMA paper found that several measures of access to medical care had no clear relationship with longevity among the poor," noted the Times. "But there were correlations with smoking, exercise, and obesity."
The places where the poor lived the longest include New York and San Francisco—rich cities that can afford to provide a lot of services and have proactive public health departments. San Francisco was a pioneer in smoking bans; New York abolished trans fats. Poor people in and around Birmingham had a surprisingly high life expectancy, but there too there has been an investment in health services, according to the Times, and banned smoking in restaurants and other places in 2012.
Any study like this comes with some caveats. One reason poor people in major metropolises have longer life expectancies could be that they have higher proportions of immigrants, who tend to live longer than native-born Americans. Some people have lower incomes because their poor health damaged their earnings power, not the other way round. And the authors adjusted the statistics for race and ethnicity in order to correct for racial differences in life expectancy (for instance, black people generally live less long than whites), something they've been criticized for. "Social marginalization is not reducible to single variables," wrote Steven Woolf and Jason Purnell in a JAMA editorial. "Race/ethnicity is inseparable from the economic consequences and stress associated with segregation, past and present marginalization in the distribution of resources, structural racism, persistent poverty, and violence."
But if we accept the broader findings here, there seems to be almost a trickle-down affect when it comes to long life and health. In poverty-pocked areas in the Midwest and the South, poor people die sooner; in other words, in places that lack the services and infrastructure that wealthy big cities usually provide, people are less healthy.
"Health is about more than healthcare," Woolf and Purnell wrote. Good schools, crime-free neighborhoods, childhoods spared the trauma of family dysfunction, and other factors all contribute to whether someone is happy and healthy as an adult, or whether they're trapped in that old cycle of poverty begetting stress begetting illness begetting more poverty.
Seen from this angle, inequality looks like not just a matter of unfair numbers but a public health problem. New York's example suggests at least the bones of a solution: higher taxes to fund a local government that develops policies to discourage people from eating crappy food and smoking. In many ways, this is a punishingly unfair city, but when it comes to having a healthy populace, it seems like other places could benefit from some New York values.