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I recently saw a billboard for an employment service that said, “If you think cigarette smoking is bad for your health, try a dead-end job.” This warning may not just be an advertising quip: public health research now tells us that lower socio-economic status may be more harmful to health than risky personal habits, such as smoking or eating junk food.

In 1967, British epidemiologist Michael Marmot began to study the relationship between poverty and health. He showed that each step up or down the socio-economic ladder correlates with increasing or decreasing health.

Over time, research linking health and wealth became more nuanced. It turns out that “what matters in determining mortality and health in a society is less the overall wealth of that society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society,” according to the editors of the April 20, 1996 issue of the British Medical Journal. In that issue, American epidemiologist George Kaplan and his colleagues showed that the disparity of income in each of the individual U.S. states, rather than the average income per state, predicted the death rate.

“The People’s Epidemiologists,” an article in the March/April 2006 issue of Harvard Magazine, takes the analysis a step further. Fundamental social forces such as “poverty, discrimination, stressful jobs, marketing-driven global food companies, substandard housing, dangerous neighborhoods and so on” actually cause individuals to become ill, according to the studies cited in the article. Nancy Krieger, the epidemiologist featured in the article, has shown that poverty and other social determinants are as formidable as hostile microbes or personal habits when it comes to making us sick. This may seem obvious, but it is a revolutionary idea: the public generally believes that poor lifestyle choices, faulty genes, infectious agents, and poisons are the major factors that give rise to illness.

Krieger is one of many prominent researchers making connections between health and inequality. Michael Marmot recently explained in his book, The Status Syndrome, that the experience of inequality impacts health, making the perception of our place in the social hierarchy an important factor. According to Harvard’s Ichiro Kawachi, the distribution of wealth in the United States has become an “important public health problem.” The claims of Kawachi and his colleagues move public health fi rmly into the political arena, where some people don’t think it belongs. But the links between socio-economic status and health are so compelling that public health researchers are beginning to suggest economic and political remedies.

Richard Wilkinson, an epidemiologist at the University of Nottingham, points out that we are not fated to live in stressful dominance hierarchies that make us sick—we can choose to create more egalitarian societies. In his book, The Impact of Inequality, Wilkinson suggests that employee ownership may provide a path toward greater equality and consequently better health. The University of Washington’s Stephen Bezruchka, another leading researcher on status and health, also reminds us that we can choose. He encourages us to participate in our democracy to effect change. In a 2003 lecture he said that “working together and organizing is our hope.”

It is always true that we have choices, but some conditions embolden us to create the future while others invite powerlessness. When it comes to health care these days, Americans are reluctant to act because we are full of fear. We are afraid: afraid because we have no health care insurance, afraid of losing our health care insurance if we have it, or afraid that the insurance we have will not cover our health care expenses. But in the shadow of those fears is an even greater fear—the fear of poverty— which can either cause or be caused by illness.

In the United States we have all the resources we need to create a new picture: an abundance of talent, ideas, intelligence, and material wealth. We can decide to create a society that not only includes guaranteed health care but also replaces our crushing climate of fear with a creative culture of care. As Wilkinson and Bezruchka suggest, we can choose to work for better health by working for greater equality.