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Medicine and Public Policy |

Poverty and Ill Health: Physicians Can, and Should, Make a Difference

Michael McCally, MD, PhD; Andrew Haines, MD; Oliver Fein, MD; Whitney Addington, MD; Robert S. Lawrence, MD; and Christine K. Cassel, MD
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From Mount Sinai School of Medicine and Cornell University Medical College, New York, New York; Royal Free and University College Schools of Medicine, London, United Kingdom; Rush School of Medicine, Chicago, Illinois; and Johns Hopkins School of Public Health, Baltimore, Maryland. Requests for Reprints: Michael McCally, MD, PhD, Department of Community and Preventive Medicine, Box 1043, Mount Sinai School of Medicine, New York, NY 10029; e-mail, mm6@doc.mssm.edu. Current Author Addresses: Dr. McCally: Department of Community and Preventive Medicine, Box 1043, Mount Sinai School of Medicine, New York, NY 10029.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(9):726-733. doi:10.7326/0003-4819-129-9-199811010-00009
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A growing body of research confirms the existence of a powerful connection between socioeconomic status and health.This research has implications for both clinical practice and public policy and deserves to be more widely understood by physicians. Absolute poverty, which implies a lack of resources deemed necessary for survival, is self-evidently associated with poor health, particularly in less developed countries. Over the past two decades, economic decline or stagnation has reduced the incomes of 1.6 billion people. Strong evidence now indicates that relative poverty, which is defined in relation to the average resources available in a society, is also a major determinant of health in industrialized countries. For example, persons in U.S. states with income distributions that are more equitable have longer life expectancies than persons in less egalitarian states.

There are numerous possible approaches to improving the health of poor populations.The most essential task is to ensure the satisfaction of basic human needs: shelter, clean air, safe drinking water, and adequate nutrition. Other approaches include reducing barriers to the adoption of healthier modes of living and improving access to appropriate and effective health and social services. Physicians as clinicians, educators, research scientists, and advocates for policy change can contribute to all of these approaches. Physicians and other health professionals should understand poverty and its effects on health and should endeavor to influence policymakers nationally and internationally to reduce the burden of ill health that is a consequence of poverty.


poverty ; income


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Figure 1.
Comparison of standardized mortality ratios for men 15 to 64 years of age by social class over five decades in England and Wales.[18]

Figures have been adjusted to the classification of occupations used in 1951. Information on men 20 to 64 years of age in Great Britain was obtained from Black and colleagues .

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Figure 2.
Income and age-adjusted mortality rates among 300 000 white men in the United States.[23]

Data obtained from Smith and colleagues .

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Figure 3.
Age-adjusted mortality in the United States in 1990 and the Robin Hood index of income inequality.[27]

Circles represent the states of the United States. Data were not available for New Mexico, Rhode Island, and Virginia. Adapted from Kennedy and colleagues with permission.

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Figure 4.
Life expectancy at birth and gross national product (GNP) in 1970 and 1995 in rich and poor countries in 1990 U.

S. dollars. Triangles represent life expectancy in 1970; diamonds represent life expectancy in 1995. Data obtained from World Development Indicators, World Bank, 1995.

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