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Forbes Magazine

Why the Rich Live Longer

Thursday May 20, 6:35 pm ET

By Dan Seligman

" There's a stunning new explanation for upscale longevity, and it's

quite contrary to what the world's health bureaucrats have been

telling us.

One of the great mysteries of modern medicine: Why do rich people

live longer than poor people? Why is it that, all around the world,

those with more income, education and high-status jobs score higher

on various measures of health? As stated in a World Health

Organization pamphlet: " People further down the social ladder usually

run at least twice the risk of serious illness and premature death of

those near the top. "

The traditional answer to these questions has been that greater

wealth and social status mean greater access to medical care. But

even ten years ago, when this magazine last delved into the topic

(FORBES, Jan. 31, 1994), the available answers seemed inadequate. If

access was the key, then one would have expected the health gap

between upper and lower classes to shrink or disappear with the

advent of programs like Britain's National Health Service and

America's Medicare and Medicaid, not to mention employer-sponsored

health insurance. In fact, the gap widened in both Britain and

America as these programs took effect. The 1994 article cited a study

of British civil servants--all with equal access to medical care and

other social services, and all working in similar physical

environments--showing that even within this homogeneous group the

higher-status employees were healthier: " Each civil service rank

outlived the one immediately below. " How could this be?

Today the standard answer--or, at least, the answer you are

guaranteed to get from the WHO and other large health bureaucracies--

is that inequality itself is the killer. The argument is that low

status translates into insecurity, stress and anxiety, all of which

increases susceptibility to disease. This psychosocial case is

lengthily elaborated in Social Determinants of Health, a 1999

publication collectively created by 22 medical specialists and

endorsed by the WHO. " Is it plausible, " the book asks at one

point, " that the organization of work, degree of social isolation and

sense of control over life could affect the likelihood of developing

and dying from chronic diseases such as diabetes and cardiovascular

disease? " The authors' answer is a resounding yes. Pushing their case

to the outer limits, the authors supply data indicating that in the

world of African wild baboons, those who are socially dominant tend

to be most healthy (as mainly evidenced in their higher levels of

good cholesterol).

This revised standard answer has some plausibility, but also some

serious weaknesses. One of its problems is that we lack serious

comparative data on tension and anxiety levels in low- and high-

status jobs. It is far from clear that barbers, elevator operators

and lower-level civil servants suffer more tension than do surgeons,

executive vice presidents and higher-level civil servants. Another

problem is that psychosocial explanations don't tell us why the

health gap would widen when employers and governments provide more

health care. Nor do they explain one well-known source of the health

gap: the notoriously high rate of smoking in the low-status

population.

An explanation not presenting these problems has recently been

proposed in several papers by two scholars long associated with IQ

studies: Gottfredson, a sociologist based at the University of

Delaware, and psychologist Ian Deary of the University of Edinburgh.

Their solution to the age-old mystery of health and status is at once

utterly original and supremely obvious. The rich live longer, they

write, mainly because the rich are smarter. The argument rests on

several different propositions, all well documented. The crucial

points are that (a) social status correlates strongly and positively

with IQ and other measures of intelligence;( intelligence

correlates strongly with " health literacy, " the ability to understand

and follow a prescription for disease prevention and treatment; and

© intelligence is also correlated with forward planning--which

means avoidance of health risks (including smoking) as they are

identified.

The first leg of that argument has been established for many decades.

In modern developed countries IQ correlates about 0.5 with measures

of income and social status--a figure telling us that IQ is not

everything but also making plain that it powerfully influences where

people end up in life. The mean IQ of Americans in the Census

Bureau's " professional and technical " category is 111. The mean for

unskilled laborers is 89. An American whose IQ is in the range

between 76 and 90 (i.e., well below average) is eight times as likely

to be living in poverty as someone whose IQ is over 125.

Second leg: Intelligent people tend to be the most knowledgeable

about health-related issues. Health literacy matters more than it

used to. In the past big gains in health and longevity were

associated with improvements in public sanitation, immunization and

other initiatives not requiring decisions by ordinary citizens. But

today the major threats to health are chronic diseases--which,

inescapably, require patients to participate in the treatment, which

means in turn that they need to understand what's going on. Memorable

sentence in the Gottfredson-Deary paper in the February 2004 issue of

Current Directions in Psychological Science: " For better or worse,

people are substantially their own primary health care providers. "

The authors invite you to conceptualize the role of " patient " as

having a job, and argue that, as with real jobs in the workplace,

intelligent people will learn what's needed more rapidly, will

understand what's important and what isn't and will do best at coping

with unforeseen emergencies.

It is clear that a lot of patients out there are doing their jobs

very badly. Deary was coauthor of a 2003 study in which childhood IQs

in Scotland were related to adult health outcomes. A central finding:

Mortality rates were 17% higher for each 15-point falloff in IQ. One

reason for the failure of broad-based access to reduce the health gap

is that low-IQ patients use their access inefficiently. A Gottfredson

paper in the January 2004 issue of the Journal of Personality &

Social Psychology cites a 1993 study indicating that more than half

of the 1.8 billion prescriptions issued annually in the U.S. are

taken incorrectly. The same study reported that 10% of all

hospitalizations resulted from patients' inability to manage their

drug therapy. A 1998 study reported that almost 30% of patients were

taking medications in ways that seriously threatened their health.

Noncompliance with doctors' orders is demonstrably rampant in low-

income clinics, reaching 60% in one cited s tudy. Noncompliance is

often taken to signify a lack of patient motivation, but it often

clearly reflects a simple failure to understand directions.

A new Test of Functional Health Literacy of Adults can evaluate the

problem in a mere 22 minutes. It measures comprehension of the labels

on prescription vials, of appointment slips, of what the patient is

expected to do before diagnostic tests, etc. The results turn out to

be somewhat horrifying. In a sample of 2,659 clinic patients in two

urban hospitals, 42% did not understand the instructions for taking

medicine on an empty stomach, and 26% did not understand when the

next appointment was scheduled. The problem is maximized for patients

with chronic illnesses. Asthma, diabetes and hypertension all require

patients to make a lot of decisions daily as well as in emergencies,

but many patients are simply not up to it. A study cited in the

Gottfredson-Deary paper mentions that a high proportion of insulin-

dependent diabetics did not know how to tell when their blood sugar

was too high or too low or how to get it back to normal.

And then there is the third leg of the IQargument: the lifestyle

question. Smoking, obesity and sedentary living are more prevalent

among low-status citizens. A 2001 study by the Centers for Disease

Control & Prevention found that college graduates are three times as

likely to live healthily as those who never got beyond high school.

Not clear is what the government can do about this.

The data on IQ, social status and health present some huge conundrums

for policymakers. For years Americans debated what to do for, and

about, poor people unable to pay for health care. Ultimately they

decided it simply had to be paid for. But now, with money ordinarily

not a barrier to medical care, we are discovering another

obstacle: " regimen complexity. " As this fact of life sinks in, the

system will be under pressure to find ways to deliver high-quality

care to the low-status population much more simply, understandably--

and economically. Not an easy task. "