The nation faces daunting economic conditions, brought on in recent years by the recession and fiscal crisis but set against long-term economic trends that date to the 1970s. Each decade has brought a greater separation in the income of chief executives and workers.  A large number of Americans are now unemployed, and wages have stagnated.  Median household income in the United States has been declining since 1999.  The result is not only a higher poverty rate–at 15%, the highest poverty rate in the US since 1993–but also a swelling middle classin which millions of new households are facing challenges in making ends meet.

The effects go beyond the size of paychecks or retirement savings.  The effects reach into the daily lives of Americans and their ability to meet basic human needs such as food security and housing, and their ability to ensure that their children receive a good education and health care. In recent years, a larger number of Americans have encountered challenges in putting food on the dinner table and keeping their homes. The conditions of life in America are undergoing profound changes, but there are few efforts to monitor their full dimension, their impact on the average household, or the experiences of vulnerable populations such as children, seniors, minorities, and the poor.   The Project on Societal Distress, an initiative of the Virginia Commonwealth University Center on Human Needs funded by the W.K. Kellogg Foundation, was launched in 2007 to monitor the wellbeing of basic living conditions, education, and health in the United States.

This posting inaugurates a new blog to foster discussion and dialogue about the challenges Americans face in meeting basic needs–the prevalence, the causes, the implications, and the solutions.  We encourage feedback and critiques of the data we report in the Project on Societal Distress, such as the strengths and limitations of the data we display, the surveys from which they are drawn, and the metrics used for defining such concepts as food security, poverty, education, or health.  This project is nonpartisanand invites commentary from all viewpoints to help ensure that the discussion on this blog is balanced and vibrant.

This discussion comes at a turbulent time in America, when the economy and lifestyles are undergoing difficult upheavals.  It’s not just that the average American’s income is declining, it’s also that the gap between the rich and the poor–the haves and have nots–is widening.  One of the most striking patterns since the late 1960s is widening income inequality.  Between 1997 and 2007, real wages (adjusted for inflation) at the 10th percentile decreased by 1.0% while real wages increased by 28.7% for those at the 90th percentile.  

Income inequality is only part of the story, because it is only one facet of social inequality in America. Huge gaps exist in opportunities for education, stable housing, access to healthy foods, and support services for those in need.  For example, in 2010, the proportion of Hispanics adults with less than 7 years of elementary school education was 22 times the rate for whites. In 2009, two out of five households in poverty reported food insecurity.

The health of Americans, and even their life expectancy, will probably be affected by these trends. </span  The impact will be greatest on today’s children, whose exposure to current socioeconomic conditions could affect the diseases they develop as adults. Researchers have documented that education, income, food access, housing conditions, and other social determinants of health exert powerful influences on health status.  Social determinants probably exert a greater influence on morbidity and mortality than does the health care system itself. 

The difficult conditions in which many Americans live are the silent killer of millions.  Research conducted by the Virginia Commonwealth University Center on Human Needs demonstrated that 25% of all deaths in Virginia would not have occurred if the entire state experienced the mortality rate of its five most affluent counties and cities. Americans tend to think that health problems are best solved by new advances and discoveries in science and health care, but our earlier research demonstrated that giving US adults the health of college-educated adults would save seven lives for every life saved by biomedical advances.

If all this is true, the worsening living conditions in America could portend worsening problems with the health of Americans and their children.  Declines in income and increases in food insecurity and precarious housing may eventually translate into higher rates of disease, greater demands on the health care system, and higher costs of medical care–this at a time when the spiraling costs of health care are already fomenting a national crisis. Policymakers concerned about medical spending–in government and in the boardrooms of corporations and health plans–do not always make the connection between health spending and socioeconomic issues like jobs, education reform, child care, neighborhood economic development, and urban design   In fact, the current budget crisis is tempting many fiscal conservatives to reduce spending on education, job training, unemployment assistance, and safety net programs to help offset mounting entitlement costs for Medicare and Medicaid. 

But it is a fallacy to “cut costs” in ways that ultimately increase spending.  Helping Americans to get an education and good jobs could be the best way to control the spiraling costs of health care.  In a recent study published in Health Affairs, Milstein and colleagues used simulation modeling to demonstrate that expanding insurance coverage and improving the quality of health care would save lives over the next 25 years, but that addressing behavioral and environmental determinants of health would save even more lives and would provide the only means to truly bend the cost curve and lower health care spending.  We discuss this further in an October 2011 commentary in Health Affairs.

Connecting the dots between living conditions and health is important not only at the national level–in the White House and on Capitol Hill–but also in the statehouse and in local communities.  To paraphrase Tip O’Neill, health status is all local.  A growing number of communities are recognizing that the health of their citizens is determined less by the doctors or hospitals they visit than by the living conditions to which they return after the appointment. The “Health in All Policies” movement recognizes that health is determined by policies that affect access to fresh produce, the built environment and opportunities for safe outdoor physical activity, bicycle and pedestrian paths, advertising for tobacco and alcohol products, and so on. 

It’s also important for leaders to see the health consequences of education and job policies. In a project funded by the Robert Wood Johnson Foundation, we have developed the County Health Calculator, an interactive web-based tool that enables users to manipulate a slider bar to examine how health in any county, state, or the nation would be affected if more residents attended college or earned a basic income.  Soon we will be releasing reports for eight communities–Albuquerque, Baltimore, Boston, Chicago, New Orleans, Oakland, San Joaquin Valley, and the South Delta of Mississippi–which will show how health disparities across neighborhoods or census tracts are linked to behavioral, socioeconomic, and environmental factors within the community.

The logic is strong, and the evidence is mounting, that action taken to improve education and basic living conditions for Americans is important not only to enhance the quality of life but also to improve the health of Americans and of the economy. But fiscal pressures to cut spending are strong.  Policymakers face the challenge of rising above political concerns and harsh budget realities to make choices that will save lives, reduce disease rates and the costs of health care, improve the wellbeing of families and the productivity of workers, and thereby enhance the competitiveness of American businesses.  Whether today’s leaders can act on this logic is doubtful.  In the meantime, the Project on Societal Distress will continue to monitor the difficulties Americans face in meeting basic needs.

Check back in with us periodically for commentary from a range of policy experts, researchers, and others interested in the living conditions of Americans and to read the responses of readers to these important topics.  We look forward to covering issues from literacy to minority health to preventive care.

Steven H. Woolf, MD, MPH

Director, VCU Center on Human Needs

Virginia Commonwealth University