In Sickness and In Wealth

"Maladaptive" habits help the poor cope with their stressful lives, and the best healers don't blame them.

I recently had the privilege of "shadowing" one of the best docs I know as she made hospital rounds at Grady. Grady is one of those places-like Los Angeles County Hospital, Cook County Hospital in Chicago, and Kings County in Brooklyn where I volunteered as a high school kid-

which are the last refuge of the millions of Americans who are indigent and ill.

In a country with nearly 50 million uninsured-viewed as barbaric by other nations-you are going to have millions needing help. Millions more who are poor enough for Medicaid are technically insured, but their care costs more than the government pays, and their chances for recovery are weighed down by poverty. People like Lisa Bernstein, an assistant professor of medicine at Emory University, are there for them.

We saw devastating illness, and in most cases you could say that bad habits played a major role. A man and a woman had mental changes because their drinking had so damaged their livers that they could not eat much protein without ammonia poisoning their brains. One obese woman had a relentless string of blood clots in her legs, some going to her lungs, and was in terrible pain.

Several had diabetes, partly due to eating habits and overweight. A thin man, a lifelong smoker, was getting oxygen for lungs that were no longer good enough. One sweet 86-year-old lady had nothing to apologize for; she'd fallen and broken her hip, then lain alone in her apartment until she was so dehydrated she nearly died; now she was sitting up with a smile on her face. You could say that her illness was caused by lack of support and poverty.

But then, you could say the same about the others. Personal responsibility is a fine and noble thing when you are educated and rich; but when you are not it can be an almost insurmountable hurdle. As my wife, who does research in poverty-stricken schools, said when we talked about it, the poor are in so much psychological pain it's a miracle if their worst vices are overeating, smoking, and drinking.

I first saw this as a boy in Brooklyn, but I didn't understand it until many years later, when The New York Times asked me to write about a then-new study, which found that men had higher mortality rates in Harlem than in Bangladesh.

All those drugs and guns, you say? Nope. The excess mortality, carefully analyzed, was overwhelmingly from the same things that bring down other Americans: heart disease, cancer, and diabetes. Harlem just had more of them. Whether directly, through lack of care, or through the needed solace of bad habits, the stress of poverty kills.

Or is it inequality? A study of British civil servants showed that clerks and messengers have higher mortality than professionals and that administrators have the least-two thirds or less of the clerks' levels. In the U.S., between 1972 and 1989, there was a near-perfect correlation between income and survival; people making less than $15,000 a year had triple the deaths of those making $70K or more.

Habits, we now know, explain just half the gap. Where you think you are on the status ladder matters in and of itself, in addition to the absolute poverty level. You can ask people to point to their rung on a picture of a ladder and predict how good their health will be. And states like Georgia, with above average income inequality, have above average sickness and mortality.

The June 5 New England Journal of Medicine had a study comparing 22 European nations on inequality and health. Despite big differences between countries in wealth and inequality, every country had a lot more illness and death in the lower ranks.

Three factors helped explain the size of the gap: smoking, excess drinking, and access to medical care. But there was a lot left unexplained. The researchers expected northern European countries, with their large welfare programs, to have lower health inequality, but they didn't.

Spain and Italy, though less generous with welfare, had less inequality in death rates, maybe because of the Mediterranean diet and women's reluctance to smoke. Could it also be that life is slower and less competitive? We don't know. But the psychosocial effects of being and feeling poor must play a role.

Whatever the stresses on those long-suffering Grady people, Dr. Bernstein's gentle touch and voice were a balm to every one of them. Far from blaming the victims, she treated each with the greatest respect, deployed the most sophisticated science, and conveyed real compassion. She had to practically fight City Hall to up the pain meds on one of them; after decades of this work, she can tell drug-seeking from pain.

And for a mentally retarded man who'd been asking for candy for days, she crossed the hall and came back with a candy bar. There's a time for little lectures-I've seen her deliver them in clinic, where the press of events is less. But there is also a time for the milk chocolate of human kindness, and Dr. Bernstein has the wisdom to know when.



  1. Jack Davis says:

    I was wondering if you’ve read Paul Krugman’s Conscience of a Liberal. His chapter on health care is terrific; it covers some of the same ground you cover in Medicine at the Crossroads, in arguing for national health insurance.

    I have to confess when I first read Harlem has a lower life expectancy than Bangladesh, my gut reaction was to blame it on crime.

    jack d

  2. Melvin Konner says:

    That’s everyone’s gut reaction, and violence does count if you just look at young men, but it’s a small part of the overall life expectancy picture. Thanks for the tip about Krugman. I do read his column and while I don’t agree with him about everything, I think we agree about health care. Hillary was wrong in ’93, much closer to being right this year, but still far from the best option: single payer, the solution in almost all civilized countries. Obama misses the main point about insurance, which is that everyone pays, including the lucky ones, so you have a safety net when luck runs out. A system in which young and healthy people can opt out is no system at all, and Obama knows it. This at least is not change we can believe in.

  3. Melvin Konner says:

    Jack, Saudi Arabia may be a special case because of its huge wealth, and also I’m not sure that the large numbers of foreign workers are being properly counted by WHO as people needing health care. But the overall statistics show that (except for New Zealand) the only countries behind us are either in the developing world or the former Communist bloc, and some of those are ahead of us. Say what you want about our diversity, immigration, etc., the countries ahead of us are a varied group, and we are clearly doing something wrong.

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