Injurious Inequalities


The close relationship between a nation’s physical health and its economic and political health has been a central tenet of statecraft since the rise of the mercantile economy in the 18th century. Especially in England, France, Germany, and Austria during this time, health statistics became an important measure of social cohesion. In the 19th century, politicians, doctors, social reformers, and revolutionary thinkers—from William Farr and Otto von Bismarck to Rudolf Virchow, Edwin Chadwick, Karl Marx, and Frederick Engels—continued to use the physical health of a nation’s citizens as a broad gauge of its social well-being (for classic examples, see Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain and Friedrich Engels’s 1845 The Condition of the Working Class in England). Indeed, the arguments they made combined with the data they collected were central to the establishment of a social security health insurance.

In the 20th century, policymakers looked to poor health statistics as a harbinger of social and political disequilibrium. One notable example was a 1981 article entitled “Health Crisis in the USSR” by the demographer Nick Eberstadt, who made some startling assertions:1 He found that alcoholism, infant mortality, and suicide rates were taking a horrendous toll on Soviet society and concluded that a society plagued by so many markers of poor health was not sustainable. Coming in the midst of the Cold War, even the most hardened spokespeople from both the Right and the Left found it difficult to believe his conclusion that the Soviet Union was on the verge of collapse. In the weeks and months that followed there appeared a flurry of furious responses in the Review’s letters to the editor and other forums, accusing Eberstadt of grossly exaggerating and misinterpreting the data.

On the Right, critics reacted vehemently to the suggestion that the Soviet Union was not the powerful adversary that required huge military budgets. On the Left, the idea that socialism, no matter how corrupted, had led to such human suffering also was not acceptable. Some on the Left even argued that life expectancy in the USSR was going up, not down, and was, by 1975, only slightly below the United States’ average for men.2 The connection between the demographic and health data of 1981 and the dissolution of the Soviet Union a decade later remains a contested point among demographers. Still, Eberstadt’s point is one we should not take lightly.

More recently, 2 interesting studies have appeared that send shivers up this historian’s spine. The first is a little noticed report issued by the Occupational Safety and Health Administration (OSHA) entitled “Adding Inequality to Injury: The Costs of Failing to Protect Workers on the Job.”3 This report cites the ongoing toll of industrial accidents and diseases, noting that even though the overall number of work-related deaths has declined substantially over the past 4 decades, 12 workers still are killed on the job every day of the year. Beyond the gross statistics and estimates of the economic costs, the OSHA report suggests that preventable injuries, diseases, and deaths destabilize entire communities, with African Americans and Hispanics bearing the highest cost. This, in turn, feeds “economic and non-economic losses [that are] difficult to measure.” These diseases and injuries result not only in lost wages, higher costs for workers’ compensation and disability benefits, and lost productivity. They also place huge physical and emotional strains on families forced to find informal means of caring for homebound workers; on caretakers who have to give up work; and on friends and relatives who are asked to care for them. Together, the ripple effect of the uneven distribution of serious illnesses or injuries on already pressed communities is “truly adding inequality to injury.”3(p12)

The second report, “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century,” by the Princeton economists Anne Case and Angus Deaton (a Nobel laureate) and published in the Proceedings of the National Academy of Science, has garnered much more attention.4,5 Their paper shows that between 1999 and 2013, white American males aged 45 to 54 experienced “a marked increase” in mortality, an increase that accounts for at least 96,000 more deaths than what would have been expected if mortality rates had stayed at their 1998 levels. Case and Deaton argue that if these rates had continued to decline over this period at the same pace as they have in other industrialized nations, more than 500,000 more American men in this cohort would still be alive.4(p1)

The fact of increased mortality in this demographic group is troubling enough. What is even more troubling is that these deaths were not due to some epidemic catastrophe like AIDS. Rather, the leading causes of death were suicides, alcohol-related liver disease, poisonings, and drug-related and mental health issues. Accidental or “intent undetermined” poisonings actually took more lives than lung cancer, and the investigators suspect, “suicide appears poised to do so” as well.4(p2) “Increasing midlife distress” related to unemployment and occupational insecurity appeared to account for the overall rise. The “at risk” population were those without a high school degree, those without jobs, individuals with economic and personal stress, as well as those in physical pain, socially isolated, and in poor health, according to self-reports.

Both these studies point to similar societal problems. The consequences of the economic downturn; the decline in opportunities for those without higher education to find meaningful employment; the destruction of the worker’s compensation system; the destruction of the union movement and the respectable wages they guaranteed; the growth of part-time, low-wage jobs; the erosion of pension plans and job security; and the replacement of guaranteed pensions by more risky stock market investments have all fed a health crisis affecting working-class men in the prime of their lives and their communities.

Undoubtedly, both the OSHA and the Case-Deaton reports will face substantial scrutiny and analysis. That said, we should not lose sight of their important message: the economic transformation of our society and our inability to address growing inequality are being measured as greater mortality, morbidity, and general suffering in both individuals and the broader community. Fortunately, our health situation is not nearly as serious as the Soviet Union’s was in 1981. Nevertheless, the suffering of the few may be, demographically speaking, the proverbial “canary in the mine.”


  1. Eberstadt N. The health crisis in the USSR. New York Review of Books. February 19, 1981.
  2. Szymanski A. The health crisis in the USSR: an exchange. New York Review of Books. November 5, 1981. Accessed December 1, 2015.
  3. Michaels D. Adding inequality to injury: the costs of failing to protect workers on the job. Washington, DC: US Department of Labor, Occupational Safety and Health Administration; June 2015. Accessed November 1, 2015.
  4. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS Early Ed. 10.1073/pnas.1518393112.
  5. Cassidy J. Why did the death rate rise among middle-aged white Americans? New Yorker. November 9, 2015 (online only). Accessed December 1, 2015.

Author(s): David Rosner

Read on Wiley Online Library

Volume 94, Issue 1 (pages 47–50)
DOI: 10.1111/1468-0009.12179
Published in 2016

About the Author

David Rosner is the Ronald H. Lauterstein Professor of Sociomedical Sciences and professor of history at Columbia University and codirector of the Center for the History of Public Health at Columbia’s Mailman School of Public Health. He is also an elected member of the National Academy of Medicine. In addition to numerous grants, he has been a Guggenheim Fellow, a recipient of a Robert Wood Johnson Investigator Award, a National Endowment for the Humanities Fellow, and a Josiah Macy Fellow. He and Gerald Markowitz are coauthors on ten books, including Deceit and Denial: The Deadly Politics of Industrial Pollution (University of California Press/Milbank, 2002; 2013) and Lead Wars: The Politics of Science and the Fate of America’s Children (University of California Press/Milbank, 2013). He also testifies for plaintiffs in lawsuits on industrial pollution and occupational disease.

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