When it comes to the health of the poor, place matters

In the United States, poverty hurts. We have long known there is a correlation between wealth and health. Richer people live longer lives. This is especially true in Philadelphia, where life expectancy at birth can vary by as much as 20 years between rich and poor neighborhoods.

A comprehensive study just published in the Journal of American Medical Association confirms these findings with a few twists—the difference in life expectancy for poor people varies by where they live. In some places, being poor doesn't affect your health as much as in other places. The authors found that life expectancy at age 40 — how long you should expect to live after your 40th birthday — for the top 1% of earners is 14 years longer than for people in the bottom 1%. They also noted that while rich people are living longer, in the time between 2001 and 2014 poor people have not gained any extra years of life.

These nationwide figures are not surprising. The interesting finding is that there is significant geographical variation. In some communities, the life expectancy gap between rich and poor is narrowing while in other places poor people are actually losing years of life. Why?

The usual suspects accounting for differences in longevity are health insurance coverage, access to and quality of medical care, environmental factors, and unemployment. These are all known to impact the diseases you get and your ability to get the care that will make you well. Interestingly, this study found that these factors didn't matter as much as the real standout: health behavior. Or, what was specifically measured: avoiding obesity, not smoking and regular exercise.

Of course, we know that people who take better care of themselves are less likely to get sick and more likely to make it into old age. A key finding of this study is that in some communities poor people have healthier habits and thus live longer. At the top of the list are cities like New York and Santa Barbara, California. Gary, Indiana and Las Vegas, Nevada ranked at the bottom.

So what does New York have that Las Vegas lacks? This study doesn't really answer the question but there are hints. The cities where poor people have better health behaviors tend to have higher immigrant populations, more college-educated and wealthy people, and higher government expenditures. Speculating, we could say that the ideal city for low-income folks spends more on government services, has a dynamic immigrant community, academic institutions that produce highly educated people and industries that hire them, as well as amenities and a quality of life that attracts wealthy residents.

It's hard to say why these factors should have an indirect impact on the health behaviors of poor people that leads to a longer life expectancy. We know that being around people who don't smoke, exercise more, seem fit, etc. is likely to influence your own choices. On the other hand, bad habits can be just as contagious. Perhaps, it's these unseen and subtle connections influencing decisions that ultimately improves one's health habits.

Successful cities seem to have a secret sauce, an environment that immunizes low-income people against the ravages of poverty. Whatever it is, for the poor, place matters.

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