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Inexorably Linked

The correlation between economic status and health, by James W. Squires, M.D.

Poverty is strongly correlated with poor health. This relationship is now coming into sharper focus as the limitations of our health care system become more evident. Furthermore, the connection between poverty and poor health is caused by more than a lack of health insurance and barriers to health care. It is simplistic to think that health care makes us healthy, despite the complex science and technology behind the modern medicine we so revere.

The risk of dying before the age of 65 is more than three times greater for those at the lower end of the socioeconomic ladder than for those at the top. Those on the middle rungs of the ladder – middle-income Americans – are twice as likely to die prematurely than those at the top. About a quarter of these excess deaths (those before age 65) are among the poorest eight percent of the population.1

Foundations of every size are now increasingly concerned about these facts, with a special emphasis on the link between a lack of education (failure to graduate from high school) and poverty, a combination that almost invariably leads to poor health for a number of reasons. They include the inability to purchase healthy food, diminished opportunities for physical activity, barriers to obtaining affordable housing in safe neighborhoods, and the physical impact of the stress associated with poverty.2

These factors are determined by low income, not by personal behaviors.

We face growing income disparities in the United States. Minimum income growth and unemployment further aggravates the situation. More and more people are discovering that it could happen to them – with increasing layoffs, off-shoring of jobs, and the closing of manufacturing facilities due to a global economy. Yet still, the misconception exists that “poor people need to work harder and think smarter.” No amount of hard work and wise choices can avert these larger forces. And so many of us are discovering that we are a pink slip away from a similar fate.

Poverty is an issue we must all care about and address, whatever our political views might be. Without a well-educated, healthy workforce, we will be unable to fuel the American economy and compete on a global stage. As our population continues to age, we must provide our young people with a chance at college and good jobs in the places where they grew up. Every dropout is another economically unstable individual who faces a tenuous future. As a liveable wage eludes more people, our economic engine will continue to sputter on a state and national level. In the end, we all suffer from poverty, no matter what tax bracket in which we find ourselves.

As New Hampshire’s largest health foundation, the Endowment for Health works to improve the health of its people – especially the vulnerable and underserved. We do this through supporting work that reduces barriers to health and health care access – including geographic, economic and social-cultural barriers. These are areas we, as a health foundation, can influence. However, solutions to the larger problem will take collaboration with government, business and other nonprofits. This collaboration is essential in order to increase the opportunities we provide people to make a livable wage and to get an affordable education. Nothing could be more closely linked with health.

Here in New Hampshire, we are one state, but ten counties. Several of our more northern and rural counties face the greatest challenges – educationally, economically, and medically. However, the southern counties of New Hampshire have higher levels of education and income. How can we create opportunities for all of our citizens?

The Endowment for Health believes a more systemic view is called for. Perhaps we should spend less money on warehousing people in our corrections system and instead seek to provide more quality mental health and substance abuse treatment services. Should we spend millions to pursue capital punishment or could we use some of those resources to bolster our schools? 

Re-thinking our funding priorities is of critical importance as it can make a real and lasting difference to vulnerable and underserved populations. Perhaps a single parent on welfare can one day get help to further his or her education instead of facing a lifetime of low-paying jobs. That would be a tangible measure of progress toward solving the real problem.

We must not lose sight of the big picture. The very things that would reduce poverty would also increase the health of our citizens. So we must continue to focus on education, economic development, job creation, affordable housing in safe neighborhoods, quality childcare, and access to nutrition, physical activity and stress management resources. Without acknowledging these inexorable links, we cannot make real and lasting change to the system.


1. Based on 9-year mortality data from the National Longitudinal Mortality Survey.
2.  Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S., John D. and Catherine T. MacArthur Foundation


James W. Squires, M.D., is a surgeon and founder of the Matthew Thornton Health Plan in 1971. He served two terms in the New Hampshire Senate from 1996 to 2000. In January 2001, he became the first president of the Endowment for Health.