Inequality and Health: Keynote Speech by Stephen Bezruchka, MD
Keynote Speech given at the Washington Physicians for Social Responsibility Benefit, September 19, 2026, edited by John M Repp
Thank you for that introduction and for the honor of being your keynote speaker.
What is the most common sexually transmitted infection? Hint: everyone here has it. LIFE is the most common sexually transmitted infection. Your father’s sperm infected your mother’s ovum to produce a zygote and after about 48 cycles of cell division here you are. How we treat this infection, life, guides my talk.
I measure life by whether you are alive or not. Simplest diagnosis I could make in the ER was that someone was dead. This allows us to calculate mortality rates for populations. Life expectancy, average number of years people live if mortality rates stayed the same, is my measure of health for a nation.
In the 1950s the US had among the lowest mortality rates of all nations. We were one of the healthiest countries in the world. Now some fifty nations, not only all the other rich ones but some, such as Costa Rica, Thailand and the Czech Republic are healthier than America. How did that transition happen?
Our health depends on what our country does for us by political decisions to maximize our health.
We incur many excess deaths a day because we don’t have the average length of life of the other rich nations. The longest lived country is Japan. If we had Japan’s health, then there would one less death every four seconds.
What should the government do so we have Japan’s health?
As we go from the erection to the resurrection about half of your health as an adult has been programmed in the first thousand days after conception. Healthier nations privilege that period in many ways we don’t. Only two countries do not have a federal policy of granting paid pregnant leave to a working mother. You are sitting in one and the other is Papua New Guinea. Go north to Canada and you have close to a year at almost full pay.
Day care in other rich nations is cheap. Many provide a basic income to poorer families.
Education is mostly free in many other rich countries. In Western Europe this includes medical school. Medical students there are given a living allowance. Doctors graduate with no debt which leaves them more likely to engage in primary care –the best part of healthcare. Something a country does for its citizens that we do not. We have to shoulder these huge expenses ourselves, so our country doesn’t have to.
Parenting is difficult here. Growing up in a single-parent home leads to higher child mortality. Poor people make poor parents. We have the most poverty of all rich nations as well as the most child poverty. Poverty is bad for health.
Poverty is a policy choice. Not the result of not working hard enough. What our country has done for us produces a lot of poor people. The meritocracy myth. If you didn’t get rich it is because you were lazy. The American Dream is a nightmare as you have to be asleep to experience it. To achieve the American Dream, be born in Japan.
Early life lasts a lifetime. If your country has not done enough to make your first years healthy, you won’t live that long.
170 years ago, escaped slave and abolitionist Frederick Douglass said, “It is easier to build strong children than repair broken men.” We have a huge healthcare industry repairing broken people. The costs are over 7 trillion dollars, a sixth of our total economy, equal to what the rest of the world spends together. If our healthcare were effective, then we wouldn’t have all the excess deaths. Healthcare can avert about 10% of mortality. That leaves 90% to be explained by other factors. We are the only rich nation without universal access to healthcare. We could certainly afford it but our political choice, what our country does for us, makes it unavailable.
What was different in the U.S. in the 1950s when we were one of the longest lived nations? Then we taxed the rich. The highest marginal tax rate was 91%. If you had a high income and made another dollar, you only got to keep 9 cents. In 1942 President Franklin Delano Roosevelt, FDR, proposed a maximum wage of $25,000 a year. About $500 thousand today. Our country did a lot for us.
What changed? We supported policies of neoliberalism, to make it easy for a few to get very rich while the rest of us shouldered the burden with less. In 1981 President Ronald Reagan said that government is not the solution to your problems, government is the problem. Today we have a government serving the few rich and the rest of us are not doing so well. Donald J Trump’s policies make our health considerably worse and will take years to overcome. So, what else matters?
The phrase “social determinants of health” present the other important elements. Genes matter but only a little. Many more men smoke in Japan than here and yet they are the longest lived country. Yes, smokers are less healthy there than non-smokers there but not to the extent here. Similarly for diet and other health advice we are constantly given. They don’t matter as much as we are led to believe.
Economic inequality has a huge impact on health.
We live in a culture of inequality which began long ago. In today’s culture those with too much command power to dominate and coerce others. Those with little power resent this but can’t express this feeling to our superiors, so resign ourselves, feel humiliated and ashamed – an unhealthy emotion.
Our President commands more power than any other leader in the world which he uses by impulse and is not be hampered by our constitution, or Congress. He invades other nations on a whim and kills others with impunity. We can’t challenge his power which gives him even more power.
From 1975 to 2023 the bottom 90% of us have willingly transferred $79 trillion to the top 1%. When confronted with the harm of our inequality, in comparison to other rich nations, we choose to increase the gap between the richest and the rest of us. We are slitting our own throats and causing our early deaths.
Inequality kills. The gap between rich and the rest of us causes a great deal of stress. Stress can save your life. If the big earthquake came and this building started shaking, we would rush outside to not be killed by the roof collapsing. But chronic stress, being worried about whether ICE will come after you, or how will you pay off your student loans, changes your biology to make it more likely you will have a heart attack, the leading cause of death here.
United States is one of the most stressed nations. The rich want us to be as stressed as possible so they can get richer. They die younger too. Wealthy people here have the health of much less rich people in other nations. Consider it a lose-lose game. All of us live shorter sicker lives.
Why does America have the most philanthropic and charitable organizations of any nation? Unlike in healthier nations, our government won’t provide for us, so we have to shoulder the burden through organizations like WPSR. We are here tonight to raise money for this reason, something not required in healthier countries.
We can use a tested medicine that we gave to Japan at the end of the Second World War that enabled it to become the longest lived nation by 1978. After the War, America occupied Japan. We wrote Japan’s constitution. Article 9 said the country could not go to war or maintain a standing army and had to resolve disputes peacefully. Medicine’s ingredient: Demilitarization. Article 23 made the government responsible for the people’s health. The constitution gave women the vote, and everyone the right to unionize. Second ingredient: Democratization. The country was run by 13 big corporations which we broke up as they would impede the democratic process. Following FDR we imposed a maximum wage. Japan was a rice farming economy with a few landowners and many peasant farmers. The land was transferred from the owners to the peasants. In the ensuing year 94% of the land changed hands. Final ingredient: Decentralization. Those 3 Ds, demilitarization, democratization and decentralization have been the most effective population medicine ever.
Now we know how to treat life. We can take the medicine ourselves or ask Japan to prescribe it to us!
Thank you!