The film fails to shed light on relationship between poverty and ill health.
Hazel Grace and Augustus are the young, beautiful cancer-stricken couple from Indianapolis in The Fault in Our Stars, the critically-acclaimed movie that opened in theaters last weekend. Their lives collide in a cancer support group. Augustus is in remission, and Hazel Grace is on oxygen. Their romance, enhanced by their upper middle-class trappings and literary tastes, is sure to leave nary a dry eye. The $48 million in box office sales on opening weekend indicates Americans have their tissue ready.
Instead of leafy suburban Indianapolis, imagine Detroit. Instead of a Make-a-Wish-like trip to Amsterdam to meet a romanticized writer, imagine a blighted park where kids shoot hoops on a warped, rusty backboard. Imagine Hazel Grace and Augustus are poor. Now imagine their families are confined to poverty, in part, because of their cancer. It's a far less appealing backdrop to this generation's "love story." But it's actually much more realistic.
According to a recent report from the Institute of Medicine, the United States is less healthy than nearly all of its peer nations. It's no coincidence that we have the greatest income inequality among similarly developed countries. Income inequality concentrates wealth in the 1% of Americans, and confines a vast swath of the employed —10 million Americans — to poverty. That's more than the populations of New York City, Detroit, and Indianapolis combined.
Income inequality is a possible explanation for such poor health outcomes in the United States, where we spend more per capita on health care than nearly any other country in the world. This is not a new area of interest, however. For nearly two centuries, socioeconomic status has been linked to diseases of all stripes, but not always as a culprit.
Whether socioeconomic status is a cause or consequence of disease has generated debate since the mid-nineteenth century. In the 1840s, Edwin Chadwick, an English social reformer, held that poverty and ill health are connected. In an 1855 report commissioned by the state of Massachusetts, Edward Jarvis showed that paupers had 64 times the cases of insanity as the independent class. This work poured the foundation for research addressing whether poverty causes illness or coats life as an economic residue left by disease. The threat of reliance on the resources of the State loomed large, shaping the fear of immigrants arriving in waves to the U.S. — they will take our jobs, they will get sick, they will cost us — that rings true today.
Studies point to low socioeconomic status as a cause of ill health — not the case for our beloved young couple in this summer's unconventional romance. Whether it is a consequence has been a nuisance to be swatted away statistically in those studies. However, dismissing low socioeconomic status as a consequence of disease does a disservice to complex social and economic realities.
Nearly 56 million Americans, 10 million with full health insurance coverage, will struggle with medical bills this year; the Affordable Care Act will help only some. Health care costs are one of the leading causes of bankruptcy. Of low-income American families filing for bankruptcy, 26% of them do so because they are virtually drowning in a sea of medical bills. According to the National Cancer Institute, the cost of cancer treatment in the U.S. in 2010 was $157 billion. The cost of life-prolonging treatment for Hazel Grace would be almost $50,000 for her first year of treatment, $4,800 for each year she lives, and nearly $90,000 in her last year of life.
Bankruptcy is a buoy, not a lifeline. It affects credit, which in turn affects the ability to secure affordable housing, reliable forms of transportation and even employment. It can wash away any accumulation of wealth, affecting subsequent generations.
Health care costs are an unacceptable contributor to the concentration of poverty in the United States. Diseases like cancer are not wholly democratic — illness occurs along social fault lines such as socioeconomic status and race — but they can fell anyone. As Hazel Grace says, "The world is not a wish-granting factory." But the United States would do well by granting the wish of generations of citizens to lead healthy lives. It's part of the American dream, which for many, is a nightmare.
Dana March is an Assistant Professor in the Department of Epidemiology at Columbia University's Mailman School of Public Health and the Editor-in-Chief of the2x2project.org.
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