Life & Death on the Social Ladder

1.

Last October I went for a walk in Sighthill Cemetery on the outskirts of Glas-gow. Glasgow is a gloomy Victorian city of silent monuments in green squares and heavy stone buildings with streaks of damp trailing from their windows like tears. It was a time of year when one is very aware of Scotland’s winter darkness closing in. Even at mid-day, in bright sunshine, a reddish haze hung in the air around the weathered, lichen-stained graves.

The oldest burials at Sighthill date from the 1840s, when it was surrounded by open hilly countryside. Today this grassy slope with its obelisks and pillars and swaying trees lies on the edge of one of the city’s main eastbound arterial roads. It is surrounded by derelict industrial sites and overlooks the gray tower blocks, barbed wire, and broken glass of the Sighthill housing project.

Built in the 1960s as an experiment in social housing for the working class, the Sighthill estate is now, like similar projects in New York or Chicago, a ghetto for the socially excluded. On the ground floor of the buildings are the boarded-up premises of shops that closed long ago. Thousands of people live in these buildings, but when I was there the streets were nearly deserted. Paper trash blew here and there; a stray dog rummaged in a pile of garbage in the central courtyard. A heavyset woman in a pink tracksuit, ponytail swinging down her back, pushed a stroller with a tiny child inside. For many of the children growing up here, Sighthill graveyard will be the only countryside they will ever know.

The Industrial Revolution sprang from northern towns like this, but the slow decline of manufacturing in Britain left a long shadow on the region. Most of Britain’s old northern industrial cities, such as Manchester, Sheffield, Leeds, and Liverpool, have high-rise slums like Sighthill, where as many as a third of workers may be unemployed, and two thirds of children leave school without passing their final exams. However, nothing about these places is so alarming as their death rates.

Life expectancy in places like Sighthill can be as much as ten years less than it is in well-to-do neighborhoods in the southern shires, such as Hampshire, Essex, and Hertfordshire. If Britain were divided into two nations, one containing the richer regions and the other the poorer ones, there would be nearly 80,000 more deaths every year in the poorer nation, equivalent to twice the number of deaths from lung cancer. This is what epidemiologists would ordinarily call a plague, and it is killing more people in Britain every year than AIDS ever has. Yet we barely even know it is there.

The difficulty in recognizing this hidden epidemic is partly due to the protean nature of the afflictions of poverty in modern industrialized countries like Britain. Compared to the rich, the poor in Britain are more prone to about eighty different causes of death, including stroke, diabetes, heart disease, cancers of the lung, bowel, and stomach, emphysema, and asthma, as well as infant death, accidents, and mental illnesses such as depression and senile dementia.

I had come to Glasgow to visit Sally Macintyre, a social scientist who has studied health in Scotland for twenty years. She is part of a growing number of people who are concerned about early death among the poor in industrialized countries, where obvious health hazards such as inadequate sanitation, malnutrition, and infectious diseases, which kill millions in the developing world, are relatively unimportant. Unlike such traditional diseases of poverty as malaria and cholera, which can kill in days, Macintyre sees the poverty of the industrialized world as a sort of chronic disease that slowly eats away at the body throughout life.

As we sat in Macintyre’s office, she told me how she thought people age, as though they are obeying the signals of an internal, biological clock that seems to run much faster for the urban poor.

“I used to do research in an obstetric clinic in a poor neighborhood,” she told me, “and I’d see these women who looked about forty to me. The obstetrician would ask them if they had any of their own teeth and they’d say no. These women were really only twenty and they were having their first child, but they had the faces of old people.

“If you go to poor areas of Glasgow, or any big city, what you see is that people look older. At any given chronological age, life is speeded up if you’re poor in all sorts of ways. You leave school earlier, you have children earlier, your children leave home earlier, your organs wear out earlier, and you grow old before your time. In some sense you can read off social class from people’s bodies.”

Macintyre has seen how health is a luxury many people cannot afford. If you come from a place like Sighthill, for example, you are likely to end up going to a bad school, which prepares you mainly for tedious unskilled jobs or unemployment. When you are sick, you are more likely to see a doctor who would probably much rather be working elsewhere. Smoking and television are among the few affordable forms of recreation.

Food, particularly nutritious food, is often more expensive in poor neighborhoods. Sighthill, like many of the industrialized world’s public housing estates, is miles from the city itself. The only shop in walking distance is a huge discount warehouse selling mainly canned and frozen food. Grocers say it isn’t cost-effective to sell fruit and vegetables in poor neighborhoods. In some of Glasgow’s grimmer districts, one of Macintyre’s students told me, the nearest apple is a ten-dollar bus journey away.

During the Industrial Revolution, when Frederick Engels visited London and the great cities that awoke around the mines and textile mills in northern England, he was struck by the harshness of the workers’ lives. For most of them, the day began before sunrise with a long walk to a factory or a dark pit in the ground where the dank air was filled with particles of cotton or coal or metal filings that slowly poisoned the lungs and heart. Workers would return home late in the evening to crowded back-to-back tenements without air or light or plumbing. Disease seeped through the damp and rotting walls and half of all children died. A child born to a working-class family lived, on average, to the age of fifteen. A child born into a rich family survived, on average, more than twice as long.

In 1911, the Registrar General divided the British people into five social classes according to their occupations (or, for women, the occupations of their husbands). For example, doctors, lawyers, and other professionals were assigned to social class I, and unskilled laborers, such as cleaners and farm workers, were assigned to social class V. After the introduction of the National Health Service in 1948, which provided free health care to the entire population, it was expected that health inequalities among different social classes would gradually disappear.

British life expectancy has been increasing throughout the century by about two years every decade. Under the National Health Service, it continued to improve at about the same rate, or even a little more slowly. The enormous increases in life expectancy during this century are believed to have resulted less from such medical advances as vaccines and antibiotics than from basic public health measures including improved housing and nutrition, sanitation, cleaner water, and the social imperative to bathe, which emerged after World War I. This is not to say that safer childbirth and the free distribution of antibiotics and vaccines under the National Health Service after World War II were not important, but rather that other measures have been even more important.

However, while the National Health Service improved health overall in Britain, it failed to eliminate health inequalities. Just as the poor had been more prone to infectious diseases in Victorian slums, they were now more prone to such chronic diseases as stroke, heart disease, and many cancers. These chronic diseases have been this century’s real emerging plagues, and today they are the leading cause of death in Western countries.

In the 1970s, a British government committee found that while death rates for children in all social classes were going down, adult death rates showed a disturbing rise in inequality.¹ For example, among adult men in higher social classes, such as doctors, lawyers, and managers, death rates declined between 1950 and 1970 by around 20 percent, but among bus conductors, cleaners, postmen, and other semiskilled or unskilled workers, death rates remained roughly constant. Since 1970, death rates have continued to decline much more quickly for men in higher social classes, so that in 1991 death rates in the poorest 10 percent of electoral wards in Britain were four times higher than they were in the richest 10 percent.

Something similar has been happening in the United States. Today male life expectancy in such generally poor urban areas as the Bronx or Washington, D.C., is ten to fifteen years lower than it is in richer districts such as Fairfax, Virginia, or Douglas, Colorado. A thirty-year-old black man living in Harlem is likely to die younger than a thirty-year-old male Bangladeshi, and he will most likely die of stroke, heart disease, cancer, or diabetes, not, as one might assume, from homicide or the complications of drug addiction.

Year by year, everyone in Western countries, except perhaps the very poor, can expect to live a little bit longer than he or she could the previous year. The underlying causes of these gains in life expectancy are much debated, but whatever they are, not everyone seems to be benefiting equally. During the 1960s, a group of epidemiologists in London made a disturbing discovery. Apparently these stark health differences are not just a problem for the poor. The life expectancy of most people seems to be exquisitely tuned by social status, even the life expectancy of middle-class people who don’t live in slums. Wherever you stand on the social ladder, your risk of early death is higher than it is for your social betters. In other words, the high rate of early death among the poor seems closely linked to the fact that they occupy the bottom of a very tall social ladder. All of us stand somewhere on this ladder, and the nearer we are to the bottom, the sicker we are likely to be and the younger we are likely to die.

2.

Around dawn on weekday mornings, in the district of central London known as Whitehall, with its early morning tourists in their colorful leisure gear gazing at Big Ben and the royal guards in their sentry boxes and the statues of mounted heroes, a busy stream of dark-suited office workers heads for the white stone buildings that house the departments of government. These men (and some women) in the civil service are the nation’s neurons, making the government bureaucracies run.

In the 1960s, a group of epidemiologists from the University of London set out to study the heart-attack rate among the civil servants of Whitehall. The scientists chose to study civil servants because they were an orderly population; like white mice or fruit flies, they seemed similar to each other in so many respects. They were all white-collar workers, mostly Anglo-Saxon, and all middle class. To Whitehall visitors such as myself it isn’t easy to distinguish a chief administrator from a filing clerk. They don’t wear bowler hats anymore, but many of them have the same dark suits and haircuts and the same courteous, inscrutable bureaucratic manner.

In the late 1960s the scientists managed to persuade about 18,000 men in the civil service in Whitehall then between the ages of forty and sixty-four to participate in the study. They began by looking at obvious risk factors for heart disease such as diet, exercise, and smoking. They weighed and measured the civil servants, compared their blood pressure readings and cholesterol levels, and interviewed them about different aspects of their lifestyles, including their exercise, smoking, eating, and drinking habits.

In 1976, a young epidemiologist named Michael Marmot joined the Whitehall study of civil servants. At first he wasn’t sure what aspect of the civil servants’ health he wanted to measure, but he was interested in the connection between social factors and disease. He was assigned to measure heart-attack rates among workers in different civil service ranks, and soon found that those in the lowest employment grades were four times more likely to die of a heart attack than chief administrators and others at the top of the hierarchy. Lower-grade civil servants were also more likely to come down with other afflictions such as strokes and certain cancers and stomach diseases.

Perhaps the most surprising finding of the Whitehall study at the time was that everyone in the hierarchy seemed to be vulnerable to the effects of social status, not just those at the bottom. Even a small increment in social status could be reflected in statistics on life and death. For example, “administrators,” those in the civil service who design policies and set the strategies for executing them, were half as likely to have a fatal heart attack as the “executives” who ran the various departments and carried out the policies dictated to them by the administrators. For the clerks, who worked for the executives, the risk of a fatal heart attack was three times as high as it was for administrators.

The risk of dying of a heart attack increased steadily, right down the chain of command. For the remaining support staff, such as assistant clerks and data processors, the risk was four times as high as for the administrators. These were middle-class people, and yet all of them seemed to be part of some mortal gradient. In his book Unhealthy Societies, the British economist Richard Wilkinson writes that if a virus or something toxic in the water were killing as many civil servants as the professional hierarchy itself seemed to be, the Whitehall buildings would be evacuated and closed down.

Marmot is around fifty, small as a jockey, with black hair and a physician’s small scrubbed hands. His uniform is the gray suit, blue shirt, and conservative tie affected by educated professional men of his class. Marmot’s father came from a poor Ukrainian Jewish immigrant family in London. He left school at fourteen and went to work in the clothing trade in the East End. When Marmot was a small child, his father’s fortunes began to improve and the family moved often, following a typical social migratory pattern for Jews at the time. From the slums of Whitechapel they moved to Victoria Park in Bethnal Green, then on to Stamford Hill, and then Edgware. At the time, many upwardly mobile Jewish families followed this arc around northeast London. “I suppose,” he told me, “the next step would have been Hampstead garden suburb, but then my father decided to move us all to Australia.”

Marmot went to medical school in Sydney in the 1960s, and it was then that he began exploring the relationship between society and disease. Early on he became impatient with his medical training. “When I was studying medicine,” he said, “I used to walk around the wards in hospital and see all these people with heart disease and chronic bronchitis and liver problems and so on and think, we’re putting Band-Aids on these people. There’s got to be a better way than to wait until people come here with all these problems and then patch them up and send them home or let them die.”

For every patient he treated or watched die, there were always ten more in the waiting room, and many others out in the world progressively becoming ill. Dealing with one patient at a time seemed to him terribly inadequate, like trying to patch up soldiers one by one in a war that is being lost. As he worked on those wards, Marmot’s ambition gradually began to take shape. He wanted to find out why people got sick in the first place. Curing individuals wasn’t enough. He wanted to cure entire societies.

Marmot found that a civil servant’s income was not the only thing that seemed to predict how healthy he was. The size of his house and whether or not he had a car also seemed to predict his likelihood of death or serious illness. “Why should having a three-bedroom house be worse for your health than having a four-bedroom house?” Marmot wondered at the time.

It is well known that people who smoke more and have high cholesterol and high blood pressure are more likely to have heart attacks. Indeed, at least some of Marmot’s top civil servants seemed healthier. More of them were taller and slimmer, fewer of them smoked, and more of them exercised than those in lower grades. What was odd was that class differences in death rates remained even among civil servants without blood pressure or cholesterol problems, and even among nonsmokers and joggers. Less than half of the excess risk of a fatal heart attack in lower-grade civil servants was explained by higher cholesterol, blood pressure, smoking, or other conventional risk factors for heart disease. Simply being senior assistant statistician, rather than chief statistician, increased one’s risk of having a fatal heart attack nearly twofold, even if one led an apparently salubrious life.

Studies of other groups of men in Framingham, Massachusetts, Finland, and the West of Scotland have found similar social patterns of disease. Smoking, diet, and other conventional health risks certainly matter, but social standing seems to matter too, and for some people it matters even more than all the other risks put together. Lower social status also seems to make ordinary risks worse. If a clerk and a manager both smoked twenty cigarettes a day, the clerk was more likely to die of lung cancer.

A growing number of researchers, including George Davey Smith of Bristol University, who worked with Marmot on the Whitehall study, and Sally Macintyre, believe that both health and social position are products of one’s life history. For them, heart disease may begin at birth or even before.

For example, many of today’s middle-class heart-attack victims were children during the 1930s and 1940s. There was considerable inequality then, even in Britain’s new welfare state. Richer children would have been better educated, and they would have eventually obtained better jobs. At the same time, they would have been better nourished, and their own parents would have been stronger and healthier. Stronger, healthier mothers have larger, healthier babies, and there is mounting evidence that heart attacks, strokes, and other chronic diseases are more likely to afflict adults who were small or underweight at birth.

Deprivation in the womb, childhood, and young adulthood may mark us for life. Davey Smith studied a sample of British men and found that those whose fathers had worked as laborers or drivers or at other unskilled jobs were more prone to heart disease and stroke in later life than men whose fathers had been skilled workers, such as professionals and managers. Transient periods of poverty seem to have lasting harmful effects on health, independent of smoking, diet, exercise, and so on. Because social mobility in Britain is limited, people from rich families still much more readily rise to the top of the civil service than people from poorer families. Many lower-ranking civil servants would have therefore experienced more and longer periods of deprivation in early life than their bosses. The residents of Sighthill and other very poor regions would have experienced even greater periods of deprivation, and their health as adults would therefore be that much worse.

Marmot accepts that deprivation in early life is likely to be very important for adult health. However, he also believes that the ways of being poor have changed. In the past poverty meant leaky roofs, exposed sewage, poor nutrition, and risky workplaces, and the diseases of poverty included tuberculosis, cholera, and scarlet fever. Today poverty means not being able to entertain friends, buy children new clothes, eat out, or have holidays. For Marmot, being poor today means feeling powerless and excluded from society.

Marmot suspects that the very poor, and his lower-grade civil servants as well, may all be suffering from different degrees of the same thing, a feeling of relative deprivation. Relative deprivation does not kill people the way open sewers and overcrowded slums do, but it does cause a certain amount of social stress, which may be harmful in other ways.

For most of us, stress is a broad term, often used to describe any kind of emotional problem. But physiologists know a great deal about what stress is. Animals under stress produce particular hormones and react in stereotyped ways. Doctors have long recognized a relationship between heart attacks and stress, and some have even ascribed the modern rise in heart disease to the “stress of modern existence,” traffic jams, deadlines, business trips, and so on, for which our evolution has left us unprepared.

Marmot used a standard psychological questionnaire to determine the types of stress experienced by different civil servants. Psychologists including Robert Karasek distinguish between stress caused by high demands on one’s capacities, such as tight deadlines and overwork, and stress caused by a low sense of “control” over one’s life. The kind of pressure an executive feels when he has too many appointments in his diary, or must make decisions affecting an entire organization, is very different from the kind of stress a clerk feels when he thinks that he is stuck in a routine, under someone else’s often arbitrary authority, and that his life has reached a dead end. Marmot found that feelings of low control over one’s life were associated with lower civil service rank, greater risk of heart attack, and higher blood levels of a substance called fibrinogen, which is associated both with stress and with heart attacks.

A sense of control can be an internal, personal feeling, as well as a characteristic of one’s job. Marmot explained it to me this way: “I often ride my bike to visit the Chief Medical Officer for Whitehall in one of the government buildings. One day I was late for a meeting and I said to the chap guarding the front door, ‘Can I leave my bicycle in your garage?’ He said, ‘No, it’s absolutely impossible. You can’t do that.’ And I said, ‘I have a meeting with the chief medical officer in four minutes’ time, and I can’t park my bike on the street in Whitehall because the special branch of the secret service will think it’s a terrorist bomb. I’m stuck.’ And then the guard said, ‘Oh all right,’ and then he took me into the garage and he said, ‘you can leave your bike anywhere you like.’

“This is what this man thinks of as control. He has the lowliest job in the place, and that puts him at high risk of a heart attack. But he thinks he has control over me and my bike. The question is whether that attitude of perceived control is protecting him.” What Marmot didn’t say was that by referring to his appointment with the man’s boss, and with his knowing talk about the special branch, he was asserting a degree of status and control himself.

3.

All animals have fears, but human beings more than any other can create stress just by thinking and heighten their worries into neuroses. Perfectly safe in our houses, well fed and free from immediate danger, we can still bathe ourselves in stress hormones. The Stanford endocrinologist Robert Sapolsky has written that while these hormones are useful in emergencies, in the long term they can lead to a kind of emotional suicide. Stress hormones divert blood to the brain and muscles at the expense of other tissues, permitting us to think and run quickly. They also make the blood “stickier,” or more likely to form clots, as though anticipating a wound. This is harmless if it occurs occasionally, for a few minutes or hours, but months or years of unrelieved stress, Sapolsky concluded, may eventually degrade the immune system, make tumors grow faster, cause brain damage and dementia, harden the arteries, and give rise to spontaneous blood clots that can cause heart attacks and strokes.

Is the industrialized world in the grip of an epidemic of chronic stress? This year people in America and Britain will live longer, on average, then they ever have. However, the rich and powerful, as if there were not already enough to envy them for, will live even longer than everyone else. Is this because many of us are poisoning ourselves with stress hormones? One insistent and provocative voice in this debate belongs to the economist Richard Wilkinson. Wilkinson believes that the greatest cause of social stress, and the greatest threat to public health in industrialized countries, is economic inequality. The best way to save civil servants, and presumably the rest of us, according to Wilkinson, is to reduce the vast differences in wealth in capitalist countries, which exaggerate social class divisions, and cause in Wilkinson’s view, stress, heart attacks, and widening health inequalities.

Wilkinson’s book, Unhealthy Societies: The Afflictions of Inequality, published in 1996, has aroused considerable controversy in public health circles. Many researchers, including Marmot, admire Wilkinson’s ideas, although not everyone does. In the first part of Wilkinson’s book, he discusses a number of studies that seem to show that people live longer in countries where income differences between the poorest and richest classes are lower. In Japan, for example, which has had relatively high levels of employment, and in the late 1980s had the lowest level of income inequality among workers of any country reporting to the World Bank, life expectancy is the highest in the world. At the same time Sweden, which had the second highest life expectancy in the world, had the second lowest level of income inequality. People in Japan and Sweden live, on average, two or three years longer than people do in the US and Britain, where income differences are wider. Wilkinson’s colleagues in the US have also shown that states such as New York or Louisiana, where income differences between rich and poor are widest, have higher early death rates than states such as Utah or Minnesota, where income inequalities are smaller. The death rate is about 30 percent higher in Louisiana than in Utah. At the same time, the poorest half of the population of Utah receives 23 percent of all household income, whereas the poorest half of Louisiana receives less than 18 percent of total income, the lowest share of any state in the nation.

Some epidemiologists are skeptical of Wilkinson’s analysis. Ken Judge, Professor of Social Policy at the University of Kent and Canterbury, has claimed that there are some mathematical mistakes in Wilkinson’s research, which if corrected would seriously undermine his conclusions. Judge also reviewed a number of other studies purporting to show relationships between income inequality and mortality and argued that most were flawed in some way. For example, many used inconsistent measures of income inequality.

Professor Judge then made his own estimate of the relationship between income inequality and mortality and found that it was very weak, if present at all. He gathered statistics on income inequality and population health from fifteen OECD countries and found that health differences were almost entirely explained by overall national wealth, total health and welfare spending, and the percentage of women in the labor force, an indication of women’s status that tends to correlate with population health. Income inequality was found to have very little effect on the health of entire populations.²

Moreover, even if people who lived in more egalitarian societies did have higher life expectancy, this would not necessarily tell us very much. So many factors affect the average life expectancy of a nation or a state, including genetics, health services, diet, smoking habits, and environmental hazards. To single out income inequality is to take a bold step indeed. For example, even if countries or regions with high levels of income inequality were shown to have higher early death rates, this would not prove that income inequality was the cause of these early death rates. One might also find that places with a greater number of electric dishwashers per capita have lower early death rates than places with fewer dishwashers. Dishwashers tend to be found in the more well-to-do neighborhoods, so this would not be an unexpected finding. However, it would not follow that the donation of dishwashers to every household in Harlem or Glasgow would have much effect on death rates. In the same way, there is as yet little evidence that reducing income inequality would have much effect either.

Giving the poor in Harlem or Glasgow more money probably would improve health. However, that is not what Wilkinson is arguing. For Wilkinson, relative, not absolute, deprivation is what matters. According to this approach, taking money away from people on Fifth Avenue would improve the health of Harlem residents just as much as raising Harlem incomes. Yet the direct connection between such hypotheses about relative deprivation and the bodily conditions that cause death seems highly abstract.

According to the English sociologist W.G. Runciman, relative deprivation applies to people who see themselves as deprived not in relation to the richest class, but to the class directly above them. ³ For example, when Runciman asked a sample of British people who they thought was doing noticeably better than they were, his respondents tended to cite not the outrageously rich, such as film stars, tycoons, and aristocrats, but rather people very close to themselves. “People with no children,” said a woman with four of them. “Army officers retiring since I did,” said a retired army officer. “People on night work,” said a brazier in the engineering industry who could only work during the day. “University research people who went into research instead of teaching,” said a schoolteacher’s wife. Wilkinson doesn’t explain how he thinks people experience relative deprivation, but he implies that Sighthill residents are somehow made a little sicker every time stocks belonging to people hundreds of miles away in Knightsbridge go up, making Britain a little more unequal.

About halfway through Unhealthy Societies, Wilkinson’s approach changes. He describes particular societies that have changed either economically or socially during this century, and describes how the health of their populations has changed too. In these sections, where Wilkinson is being more anecdotal and historical, rather than attempting to be scientific, he is more convincing. Here he shows, in examples from Britain during the war and from a small Italian immigrant town in Pennsylvania, how health and society might be related.

Britain was at its most egalitarian during the two world wars. Even though hundreds of thousands of soldiers died in battle, even though bombs wrecked much of London and killed 30,000 civilians, even though medical services were diverted to the troops and living standards fell, even with rationing and lack of fuel and all the other burdens of war, average national life expectancy increased by more than six years during both of the decades that included the two world wars, nearly twice as fast as during any other decade. Life expectancy has never risen so quickly in Britain, for all groups, poor and rich alike.

Government policies to improve nutrition and, toward the very end of World War II, the use of antibiotics certainly had a part in these health gains; but Wilkinson believes that the true reason lies in the fact that Britain became a more egalitarian country during the wars. The world wars were high points in British civic life. There was full employment, and although high taxes meant the incomes of the richer half of the population fell, the incomes of the poorer half increased. Inequality did not disappear, but something changed. There was an ethos of cooperation and common striving. For a time, most of the nation was of one mind.

In Unhealthy Societies, Wilkinson also discusses Roseto, Pennsylvania, a small town in the foothills of the Pocono Mountains settled by immigrants from southern Italy in the 1880s. They brought with them a peasant culture of simplicity and neighborliness and a rich, fattening cuisine. During the 1950s, local doctors discovered that Roseto residents died of heart attacks at half the national rate. Dietitians, cardiologists, and other medical experts descended on the town. They followed the locals to the supermarket and took notes as housewives prepared meatballs, marinara sauce, lasagna, and other rich traditional dishes.

The mystery deepened when the researchers found that Rosetans smoked heavily and consumed vast amounts of lard, used, for example, in their sausages and tomato sauce. Italian immigrants from other nearby Pennsylvania villages were as likely to have heart attacks as anyone else in America.

The sociologist Stewart Wolf of Lehigh University believed the secret of Roseto’s health lay in the quality of social life there. Roseto was a close community. In most houses, several generations lived together and protected each other against misfortunes such as illness or unemployment. There was no crime and the welfare rolls were empty. Social life was centered around the church, and the local priest knew everyone by name. “You go down the street and everyone says ‘Hello, Hello!’ You feel like you’re the mayor,” a woman whose family had lived in the town for generations told two Chicago Tribune journalists. Young people joined singing groups and brass bands and eventually married one another. As adults they joined the American Legion and the Holy Name Society and formed grassroots Italian social clubs where men spent the evenings gossiping and playing cards. At church picnics, factory owners mingled with their workers.

Although there were significant income differences among the people of the town, there was hardly any display of wealth. Practically everyone dressed in the same simple clothes and lived in similar square, clapboard houses with front porches, screen doors, and small gardens. They even ate the same foods on specific days of the week: spaghetti and meatballs on Sundays, spinach soup on Mondays, and so on. By the early Sixties, when Wolf began his study, some of the young people in the town were beginning to find all this conformity a bit oppressive.

In the 1970s, life changed in Roseto as a new, more American generation of Rosetans came of age. Families dispersed as young people moved away. The well-to-do people of Roseto, in keeping with growing national pros-perity, started building newer, bigger houses on the outskirts of town. They bought Cadillacs and hired interior decorators, walled off their gardens, and no longer invited their relatives to move in. By 1985 the heart-attack rate in Roseto had risen, reaching the same level as in the surrounding towns. During this time, diet and smoking habits had, if anything, improved in Roseto, along with national trends. The heart-attack rate in America overall was falling but, for some reason, it failed to do so in Roseto, even though, like everyone else in America, Rosetans were living longer on average than before.

The only thing that had changed, according to Wolf, who spent nearly fifty years studying the town, was the degree of cohesion in social life. Roseto became a lonelier place. There were fewer picnics, the brass bands performed less frequently, membership in social clubs and other organizations dropped off. People who lost their jobs now went on welfare. As one unemployed man told Wolf, “Things have changed. People don’t care anymore.”

Wilkinson, drawing on Stewart Wolf’s research, believes that, as in Roseto, great changes took place in British society during the 1980s and 1990s. The health gap between rich and poor in Britain has widened most dramatically during the last twenty years, a period of Thatcherite prosperity. During the 1980s, differences in income between workers and professionals soared. Executive pay rose by 50 percent in real terms but workers’ salaries did not rise at all. The income taxes of the rich fell, while regressive taxes on everything from fuel to soap rose, so that in real terms the poor saw their incomes fall by 10 percent. Great swathes of poverty were created, particularly where old industries such as mines, steelworks, and shipbuilding shut down.

Rising income inequality went hand in hand with profound institutional changes. Union power withered under Thatcher’s leadership. Whatever can be said about the economic effects of unions, they create a sense of brotherhood and solidarity. Their decline left many workers, if not unemployed, feeling adrift.

British people often talk about how much the country has changed. Rising rates of divorce, illiteracy, and delinquency and the poignant accounts of unemployed manufacturing workers have all created the unmistakable impression that the bonds of Britain’s social order are fraying.

An attitude of fellowship or a sense of common purpose may matter more for population health than economic equality. There were rich people in 1960s Roseto, and there was inequality in Britain during the war; as George Orwell observed, “soldiers died on the field of battle, while fat women drove around in Rolls Royces nursing Pekingeses.” However, there may be something health-giving about societies that strive together, where individuals are sustained by strong social or family ties and shared ambitions. The Harvard political scientist Robert Putnam has described the unmistakable decline in the cohesiveness of civil society and the increase in atomization in America during the past thirty years. He sees it in ever-lower voter turnout and decreasing membership in church groups, parent-teacher associations, the Boy Scouts, the Red Cross, and even bowling clubs. ⁴

Americans seem to miss this sense of community. One of the comforts of watching television shows like Friends, Seinfeld, and Cheers may be that they portray what it was like to know our neighbors better. Advertising agencies know the power of images of large, extended families around a fire, on the beach, or at a wedding.

There is something suggestive about Wilkinson’s ideas. We live in an age of rising income inequality and increasing health inequalities; many of us are also aware of a sense of lost community. Whether any one of these things is the cause of the other is not clear. Wilkinson may have allowed his scientific ideas to get carried away by his political ones, but even if his statistics are arguable, and even if much of the evidence for the notion that egalitarian societies are healthier is anecdotal, it seems to me unwise to dismiss it.

Throughout history, epidemics have tended to emerge during periods of social change. Rene Dubos, one of the world’s greatest experts on tuberculosis, having spent a lifetime studying the effects of crowding and poor sanitation on the spread of disease, finally concluded that these factors were secondary to the effects of social disruption.⁵ While old plagues such as tuberculosis, measles, and cholera have all but disappeared in rich countries, modern afflictions like heart disease, lung disease, diabetes, and cancers have taken their places and although they are not infectious in the usual sense, they may be spreading through socially divided societies as though they were, preying on their weakest members.