Punishing the poor, killing the poor: punitive political responses to economic decline deepen health inequalities in the United States

Elias Nosrati, Michael Ash, Michael Marmot, Martin McKee and Lawrence P King

Nosrati authors

Health inequalities are on the rise in the United States: the gap in life expectancy between those at the top and the bottom of the income spectrum has increased rapidly since the dawn of the century, to the point where the lives of the poor are cut short by up to a decade and a half compared with those of the wealthy. Moreover, while the rich tend to live longer everywhere, life expectancy among the poor varies significantly by geographical region.

In our article recently published in the IJE, we show that these patterns of health are the product of powerful political and economic forces. Over the past few decades, neoliberal politics, the decline of unions and economic globalisation have resulted in rapid industrial restructuring and economic dislocation in the US. Organised labour has been eroded in the industrial heartland, and manufacturing operations have been shifted to the non-unionised south and to foreign countries.

american-flag-2054414Partially in response to the turbulence wrought by deindustrialisation, the penal system, rather than the welfare state, has served as a principal mechanism of regulating the increasingly marginalised working class. Since the mid 1970s, American jail and prison incarceration rates have reached a peak of almost eight inmates per 1000 residents, with an absolute number of more than 2.2 million people behind bars, which amounts to a sevenfold increase in four decades. Populations in areas of concentrated disadvantage that have undergone rapid economic decline have been shown to experience incarceration rates more than forty times higher than privileged White communities and three times higher than communities with similar crime rates. Most notably, for working-age African American men without a high school diploma, the life-course risk of imprisonment exceeds 60%.

Our analyses show that these macro-level developments in American society have potentially devastating consequences for population health: they disproportionately affect the poor and thus actively contribute to the deepening of health inequalities. Job destruction and prison incarceration rates at the state level are significantly associated with declines in the life expectancy of those in America’s lowest income quartile and could indeed account for much (if not the entire) increase in the health gap between the rich and the poor since 2001.

Our findings are relevant to major debates about inequality in the 21st century. They show that economic globalisation and deindustrialisation generate consequential health disadvantages among society’s most vulnerable. Current approaches to industrial policy must therefore be redefined if the threat of a widening health gap is to be taken seriously. Our findings also indicate that an appropriate political response to the ravages of economic decline would be to create social safety nets for working-class communities, rather than rolling out a penal apparatus which, in its current modus operandi, effectively does little but criminalise poverty.

Read more:

Nosrati E, Ash M, Marmot M, McKee M, King LP. The association between income and life expectancy revisited: deindustrialization, incarceration and the widening health gap. International Journal of Epidemiology, dyx243, https://doi.org/10.1093/ije/dyx243.


Elias Nosrati is a Cambridge Trust International Scholar at the University of Cambridge. His research focuses on the political economy of public health and the interface between social and medical sciences.

Michael Ash (@michaelaoash) is Professor of Economics at the University of Massachusetts, Amherst. His research focuses on labour economics, environmental change and health disparities.

Sir Michael Marmot (@MichaelMarmot) is Professor of Epidemiology and Public Health and Director of the Institute of Health Equity at University College London, where he studies the social determinants of health.

Martin McKee (@martinmckee) is Professor of European Public Health at the London School of Hygiene and Tropical Medicine. His main research foci are health determinants, health system performance and the relationship between health and the economy.

Lawrence P King is Professor of Economics at the University of Massachusetts, Amherst. His work focuses on the comparative study of socioeconomic transitions and the political economy of public health.

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