“We need a whole new scientific agenda on poverty and mortality,” said David Brady, a professor of public policy at the University of California Riverside, whose recent co-authored study aims to jump-start that agenda by asking just how many Americans die from poverty each year.
It’s well established that poverty is bad for your health. But as a public health issue, the US knows less about the direct link between poverty and death than we know about, say, the link between smoking and death. Current estimates suggest smoking kills 480,000 Americans per year. Obesity kills 280,000, and drug overdoses claimed 106,000 American lives in 2021. Together, risk factors and their mortality estimates help motivate public health campaigns and government-funded efforts to save lives. But how many Americans does poverty actually kill? The question has received little attention compared to other mortality risks, and meanwhile, poverty remains prevalent across the country.
Brady — alongside sociologist Hui Zheng at Ohio State University and Ulrich Kohler, a professor of empirical social research at the University of Potsdam — published their study in April in the Journal of the American Medical Association. Their results find poverty is America’s fourth-leading risk factor for death, behind only heart disease, cancer, and smoking. A single year of poverty, defined relatively in the study as having less than 50 percent of the US median household income, is associated with 183,000 American deaths per year. Being in “cumulative poverty,” or 10 years or more of uninterrupted poverty, is associated with 295,000 annual deaths.
Amelia Karraker, a health scientist administrator at the National Institute on Aging, explains that research has shown a variety of pathways that connect poverty and mortality. These range from neighborhood amenities and nutrition down to the impacts of stress on the body: “Being poor is really stressful, which we know from NIH-supported research has implications for what’s actually happening in the body at the cellular level, which ultimately impacts health and mortality,” she said.
Crucially, that doesn’t mean you’ll find “poverty” written as the cause on anyone’s death certificate. Risk factors are only correlations that imply an association but not necessarily causation (although new research found that cash transfers to women in low- and middle-income countries cut mortality rates by 20 percent). But proving an association is a necessary step toward deciphering whether poverty might be more than an association. For example, there is an association between the number of Nicolas Cage movies released and the number of people who drown in swimming pools that year. No one is arguing that we should dissuade Cage from releasing films in order to combat drowning. But there is also an association between cigarette smoking and lung cancer. Here, we do believe one causes the other, so we do try and dissuade people from smoking to combat lung cancer deaths.
Arguing that poverty is more like the latter elevates the debate from a statistics squabble to one of literal life and death. “We just let all these people die from poverty each year,” Brady said. “What motivated me to think about it in comparison to homicide or other causes of death in America is that people would have to agree that poverty is important if it’s actually associated with anywhere near this quantity of death.”
Without a number attached to the relationship, presenting poverty as a serious public health risk falls a little flat. “Poverty and mortality are tightly correlated” isn’t exactly as galvanizing a message as “poverty kills nearly 200,000 Americans a year.” But the key question is what it means to “die from poverty.” As a social determinant of health, the government already recognizes a direct line between economic conditions and health outcomes. Physicians are now going a step further, establishing a movement known as anti-poverty medicine that aims not only to identify poverty as a health risk but develop treatments. Attaching a death toll contributes a new data point — perhaps even a rallying point — to illuminate the ties between poverty and death, and just maybe, it will motivate a more urgent anti-poverty agenda on the grounds that it could save lives.
Poverty is more than just another mortality risk
Measured in relative terms, poverty in the US is significantly worse than in similarly wealthy countries. Meanwhile, US citizens face a higher mortality rate at almost every age than residents of peer countries, and that disparity is growing. Even according to the US Census Bureau’s supplemental poverty measure (an approach that tries to blend relative methods with absolute ones, while accounting for government programs like SNAP benefits and tax credits), nearly 26 million Americans remained in poverty in 2021.
Brady, Zheng, and Kohler analyzed data from 1997–2019, drawing from the Panel Study of Income Dynamics and the Cross-National Equivalent File. Since the data ends before the Covid-19 pandemic began, and poverty likely compounded the pandemic’s death toll, they believe their findings are conservative. In 2019, being in poverty was 10 times more of a mortality risk than murder, 4.7 times more than firearms, and 2.6 times as deadly as drug overdoses. And poor people die younger than others. Their mortality rates begin diverging from the rest around age 40, reaching a peak disparity near 70, and converging back with the rest around 90.
The study used a Cox model, a type of statistical analysis commonly used in medical research to isolate the effects of a given variable (often particular drugs, but in this case, poverty) on how long patients survive. But no matter how you analyze it, singling out annual deaths across an entire country from a fuzzy cause like poverty is a statistical nightmare. It’s difficult to imagine how one could untangle all the confounding factors — like the reverse effect of how poor health also affects income — to deliver a plausible number.
One of the few previous efforts came from a group of epidemiologists in 2011, who estimated poverty’s death toll at 133,000 per year. And while few prior studies aimed to directly estimate deaths attributable to social factors, there is a decades-long history of wrangling statistical complexities to frame poverty as an actual cause of death. Brady cited a famous 1995 paper by sociologists Bruce Link and Jo Phelan, making the case that over and above mere risk factors, social conditions like poverty should be seen as “fundamental causes of disease” that put you at risk of more proximate risks, like heart disease.
Link and Phelan’s paper argued that if you break down a fundamental cause of disease into its more tractable causes of death, like breaking the mortality risks of poverty down into a cocktail of heart disease, lung cancer, and drug overdoses, fundamental causes like poverty get ousted from the picture. Treating individual risk factors alone leaves the underlying social condition intact, and it will continue putting people at risk of other risk factors.
Rather than tracing all the different pathways that lead from poverty to mortality and focusing public health-inspired anti-poverty efforts on each one separately, Link and Phelan urged an approach that stays with poverty. “If we wish to alter the effects of these potent determinants of disease, we must do so by directly intervening in ways that change the social conditions themselves,” they write. Nearly three decades later, clinicians are putting these ideas into practice.
Physicians are now prescribing anti-poverty as medicine
While the use of social determinants of health as a framework is gaining significant traction among physicians, companies, and even the WHO, Lucy Marcil, a pediatrician and associate director for economic mobility in the Center for the Urban Child and Healthy Family at Boston Medical Center, feels they don’t go far enough. She helped coin the idea of anti-poverty medicine in 2021. She explained that “anti-poverty medicine is one step further upstream to the root cause. Social determinants of health are important, but getting someone access to a food pantry doesn’t really address why they’re hungry in the first place.”
“I started this work about a decade ago,” Marcil told Vox. “At the time, there was a lot of confusion when I would say that I try to get more people tax credits because it helps their health. Now it’s pretty well established at most major academic medical centers that trying to alleviate economic inequities is an important part of trying to promote health.”
Putting a number on poverty’s death count could help build the case for anti-poverty programs embedded within systems of clinical care (like free tax preparation offered in health care systems that already have the community’s trust, an initiative Marcil pioneered). “If I’m able to say to a funder or to a health system, ‘Look, it’s been published in a reputable journal that there are X number of deaths in our country every year due to poverty,’ I have a much stronger case for why they should pay for [anti-poverty] programs,” she said.
But physicians can only go so far upstream of poverty. Even before the study positioned long-term poverty as a greater mortality risk than obesity or dementia, public health scholars had been arguing that anti-poverty efforts should play a central role in a national agenda for public health.
A national anti-poverty agenda for public health
Public health campaigns against poverty face a strange and difficult landscape. One thing Americans seem to dislike more than poverty is welfare. Although 82 percent of Americans reported dissatisfaction with efforts to reduce poverty and homelessness in a 2021 Gallup poll, only 40 percent in a 2019 Pew Research Center survey felt the government should provide more aid to those in need.
Even after President Joe Biden’s temporary expansion to the child tax credit (CTC) nearly cut child poverty in half and showed no signs of fostering welfare dependence among recipients, critics were unmoved. The policy expired at the end of 2021, 3.7 million American children fell back into poverty, and we’ve yet to see the program return. Meanwhile, as the Atlantic’s Derek Thompson writes, “a typical American baby is about 1.8 times more likely to die in her first year than the average infant from a group of similarly rich countries,” and child poverty is a major risk factor in all manners of infant mortality.
At the federal level, another reason to quantify poverty’s death toll could be to add mortality estimates to the cost-benefit analyses that groups like the Congressional Budget Office (CBO) use to score policies and their impacts. Telling Americans that the expanded CTC almost single-handedly reduced child poverty by half hasn’t yet proved compelling enough to make the changes permanent. If the CBO were to include in their cost estimates that the expanded CTC would save a certain number of American lives per year, or conversely, that letting it expire would cost a certain number of American deaths, maybe the policy discourse would move more urgently.
Finding strategies to help support policy implementation is crucial because, ultimately, treating poverty as a public health issue will require a stronger welfare state that benefits low-income Americans. “No country in the history of capitalist democracies has ever accomplished sustainably low poverty without an above-average welfare state,” Brady said. “And so until you get serious about expanding the welfare state in all its forms, you’re not serious about reducing poverty.”
Relative to similarly rich countries, the US has high poverty rates, high mortality rates, and a confusing welfare state. It has the second largest welfare state in the world if you include things like subsidies for employer-based health insurance, tax-favored retirement accounts, and homeowner subsidies. These mostly benefit those who are already well-off.
Instead, if you judge the American safety net based on the share of GDP spent on programs that benefit low-income citizens, it falls well below the average among other rich nations.
In other words, poverty is a policy choice, and the US has yet to choose otherwise. As the sociologist Matthew Desmond put it in his recent call for poverty abolitionism, “Ending poverty in America will require both short- and long-term solutions: strategies that stem the bleeding now, alongside more enduring interventions that target the disease and don’t just treat the symptoms.”
For starters, the US could revive the expanded CTC and make it permanent, or even combine it with the earned income tax credit into a universal child allowance that would cut child poverty by 64 percent, and reduce deep child poverty by 70 percent (child poverty is one of the largest contributing factors to overall poverty in America). “The biggest movers in the welfare state are pensions and health care, so invest in those as anti-poverty policy,” Brady recommends. Universal pensions and extending “catastrophic coverage” health care to all are a few options. The US could also directly provide homes for the more than 1 million Americans who experience homelessness in the course of a year.
If it wanted to go big, it could implement a guaranteed income pegged to the poverty line that would eliminate poverty outright, like the 2021 proposal from scholars at the New School’s Institute on Race and Political Economy. They estimate such a plan would cost $876 billion per year (that’s on par with the annual cost of Medicare, which sat around $900 billion in 2021). Meanwhile, one 2018 estimate places the annual cost of childhood poverty alone at $1.03 trillion per year.
“A federal policy with a universal cash transfer could be relatively adequate on its own if there weren’t barriers to receiving it,” Marcil said. But she’s seen firsthand how the implementation of social policy often means jumping through administrative hoops and abominably complex paperwork, with the result that the aid often fails to reach the most vulnerable populations. In her clinic, they help patients who have just given birth apply for Massachusetts’ paid parental leave program.
Otherwise, Marcil estimates only one-third of those eligible successfully navigate the bureaucratic gauntlet to claim the benefits. Most of those who get left out are low-income Americans on Medicaid who identify as Black or Hispanic. “In my experience,” Marcil said, “most social policies are written in ways that make it challenging for those who have been historically marginalized to access them.”
While big-picture death toll estimates may help bolster the overall motivation for anti-poverty medicine, Marcil argues that data on specific interventions is also crucial to justify the expenditure against the array of alternatives. “Because then you can go to a policymaker and say, ‘Look, someone got paid leave, and they were less likely to show up in the emergency room than this other family who didn’t get paid leave,’” she said. “So it would save Medicaid money to help poor people get access to paid parental leave.”
Objections to a new agenda on poverty and mortality will range from moral (unconditional aid undermines the American work ethic) to budgetary (how do you choose between giving nurses a raise or funding an on-site food pantry for food-insecure patients?). But as Brady’s new paper helps establish, the scope of the problem is vast, as is the cost — in terms of American lives — of continuing to treat symptoms of poverty while skimping on treatment for the fundamental cause.