21 May, 2018

A famous saying goes: It is better to be rich and healthy than poor and sick. A side-saying broadens this simple fact by clarifying that you would better be rich if you are sick. There have been numerous studies on the association of socioeconomic status with health and disease, and there is no need to enlarge on that. However, a new study from the United States, where money really talks, has found alarming data that must be discussed by the citizens and their administration [1]. The study analyzed data on a cohort of 51–61-year-old people at baseline, who were followed long-term. The participants of the Health and Retirement Study gave detailed information on their wealth (housing, businesses, individual retirement accounts, cash and savings accounts, investment holdings, loans, debts, etc.), and accordingly were grouped into wealthy or poor. Furthermore, they were divided into subgroups that considered changes in wealth during the study period, i.e. those who maintained or increased their wealth, those who lost wealth, and those who experienced ‘wealth shock’, defined as loss of at least 75% of their wealth during a period of 2 years. All-cause mortality data were obtained as well, which allowed examination of associations between mortality risk and economic status. The sample size was 8714 participants with a mean follow-up of 17.7 years, totaling 80,683 person-years; 26.2% experienced a negative wealth shock and 6.9% had long-term asset poverty. A total of 2823 participants died during follow-up. In the positive-wealth-without-shock reference group, the crude mortality rate was 30.6 deaths per 1000 person-years. By contrast, the crude mortality rates were 64.9 per 1000 person-years for those who experienced a negative wealth shock and 73.4 per 1000 person-years for those who had asset poverty.

Comment

Low socioeconomic status is usually perceived as a risk factor for various diseases, because people who belong to this subset may not eat healthily and keep ideal lifestyle recommendations, and perhaps have either no awareness or appropriate medical insurance in regard to best preventive medical care. Declining financial resources can result in reduced spending on health-related goods and services. Delaying needed medical care and incomplete adherence to prescribed medication can have long-term health consequences. Furthermore, wealth shock is certainly related to stress and various emotional and psychological disorders, which may increase the risk for organic diseases, mainly cardiovascular.

Many previous studies have pointed at similar associations in line with those of Pool and colleagues. A large US sample of 530,000 people showed that there was a higher mortality in those with lower incomes; it urged the need for public health attention to this population segment [2]. Another study from the US concluded that, overall, there was a strong inverse association between wealth and poor health status and between wealth and mortality [3]. The results for men and women were similar. Less wealthy women had between 24 and 90% higher risk of death compared with the wealthiest quintile. Interestingly, self-rated health correlated with wealth and mortality, namely those with low self-rated health were poorer and tended to have higher mortality.

An obvious rationale to the above associations in the US could be the way the health system operates. One would argue that, in countries with a more socialized health-care system, the situation is not the same. However, when UK data were compared to US data, this assumption did not hold, as low wealth was associated with death and disability in both countries [4]. The unfortunate, perhaps alarming, conclusion was that access to health care may not attenuate wealth-associated disparities in older adults.

The 2008 collapse of the world financial markets led to many individual wealth shocks. The related significant adverse health outcomes were well documented and initiated better health-care programs for those with low incomes. However, such global financial crises may occur again as a result of strategic and political movements among the world’s most powerful countries. If this happens, we should expect serious health consequences, in line with the data presented above.

Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel 

References

1. Pool LR, Burgard SA, Needham BL, et al. Association of a negative wealth shock with all-cause mortality in middle-aged and older adults in the United States. JAMA 2018;319:1341-50
   http://www.ncbi.nlm.nih.gov/pubmed/29614178
2. Sorlie PD, Backlund E, Keller JB. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health 1995;85:949-56
   http://www.ncbi.nlm.nih.gov/pubmed/7604919
3. Hajat A, Kaufman JS, Rose KM, Siddiqi A, Thomas JC. Long-term effects of wealth on mortality and self-rated health status. Am J Epidemiol 2011;173:192-200
   http://www.ncbi.nlm.nih.gov/pubmed/21059808 
4. Makaroun LK, Brown RT, Diaz-Ramirez LG, et al. Wealth-associated disparities in death and disability in the United States and England. JAMA Intern Med 2017;177:1745-53
   http://www.ncbi.nlm.nih.gov/pubmed/29059279