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July/Aug 2000 issue (#46)
FeaturesThe Progressive Candidates
Bribing for Testimony
"The Enemy of Humanity"
WTO: The Movie
Six Ways to Free the Free Press
Scientists' Global Forecast: Hotter and Drier
Systemic Problems Revealed by Moth Spraying
Organic Farming Feeds A Nation
Chemical Farm News
The RegularsFree Thoughts
Spike The Rabid Media Watch Dog
What matters in improving health? While current debates rage over things such as managed care or the growth of high-tech medicine, one of the greatest impacts on health is being totally ignored. Globalization, or corporate-centered trade, or neo-liberalism are all terms used to describe letting the market decide how to allocate resources. The resulting increases in inequality in the US and elsewhere as a result of the triumph of markets are as much to blame for poor health outcomes as anything.
How do these trends affect health? To answer that question, we first need to define the health of populations. A common way used by the United Nations and the World Health Organization is to compare populations using a mortality measure, such as life expectancy (born today, at today's mortality rates how long can you expect to live), or infant mortality (out of 1000 babies born today, how many will die in their first year of life). Researchers have also found that just asking a large random sample of the population to rank their health from very good to very poor turns out to produce information that compares closely with the mortality figures. People as individuals seem to know how healthy they are, and adding up their individual health estimates pretty closely parallels the population measures of mortality.
What emerges from such scrutiny is that the United States of America, the richest country in human history, stands behind all other rich countries in what I call the Health Olympics, the ranking of countries by life expectancy. Using the latest available United Nations data, from 1997, we were 25th. We weren't always so bad: in 1960, we were 13th, and have been falling since.
Looking at this ranking can tell us a great deal. In 1960, the current gold medallist, Japan, was 23rd. By 1977, it had overtaken all the other countries, and today has a about three and a half year lead over the US. The difference between 76-and-a-half years and 80 years may not sound like a lot, but one way the US could catch up is to eliminate all deaths from our number one killer, heart disease.
Is Japan so healthy because of its health behaviors? More exercise? Less smoking? Apparently not. Japan has the highest number of smokers per capita of any country in the world, except China, which has comparable proportions. Japan places no restrictions on tar or nicotine content, or on tobacco advertising. While smoking is declining in Japan, as in the US, still three times as many Japanese men smoke as American men, yet their lung cancer death rates are one half to one third of ours. How can the healthiest country in the world also smoke the most? What allows them to get away with what most people would consider a very bad habit?
Is it because of a better health care system? To begin with, Japan spends half of what we do on health care. Japanese doctors see an average of 75 patients a day, more than twice as many as US doctors. Those undergoing surgery for appendicitis have a normal appendix removed in 60 percent of cases (the average for the US is 10 percent) suggesting their attempts at precise diagnoses are pretty faulty. Since the US spends 40 percent of all money spent worldwide on health care (one seventh of our total economy), and ranks below all the other rich countries in health, it can't be the health care system.
The research is pretty conclusive on the medicine needed to make a population healthy. Nothing affects the health of populations as much as the amount of social and economic hierarchy observed in that population. The greater the gap between the rich and the poor, the worse the health, as measured by mortality figures, or by self-reported health. Many different investigators, looking at many different populations, over different time periods have carried out these studies, and they all agree. The gap is what matters.
We know, for example, that states in the US where household incomes are the most unequal have 50 percent greater mortality rates than states where the pie is most equitably shared. The same is true for cities. Even if we look at four groupings of cities categorized by income, within each grouping, the cities where everyone shares in the benefits will be healthier than cities where bigger gaps are tolerated. The disparity is such that there is a ten-year gap in life expectancy between cities, and there is a 20-year life-expectancy gap among counties in the US.
We have known for several hundred years that poor people have poor health. In the last few decades we have learned that this is not because the poor have worse health habits than those better off. Yes, they do smoke more, and have higher blood pressures, but as the example of Japan shows, this does not explain their poor health. What is new is our understanding that the degree to which the health of poorer people is worse than the health of the richer people depends on the amount of hierarchy in that society.
We are beginning to understand the biology of this phenomenon. Studies on other primates (our baboon brothers for example) where hierarchies can be examined, show that low ranking males have higher levels of blood cortisol, the chronic stress hormone. When acutely stressed, these animals are not able to mount as effective a fight-or-flight response as high-ranking males, so they are less likely to fend off attackers. Furthermore, the acute stress hormones are not disposed of as quickly, so they stay around and do harm. Studies on captive macaque monkeys show that these mechanisms appear to lead to coronary heart disease. Under controlled conditions, when hierarchy is manipulated, heart disease can regress if a low ranking animal rises up the ladder. There are now studies in humans showing that similar mechanisms can explain vastly different heart disease death rates among populations with different income distributions. The links between hierarchy and population health are at least as good as the links between smoking and lung cancer. (The scientific studies can be reviewed at: http://depts.washington.edu/eqhlth/).
In order to explain the decline of the US in the Health Olympics, we must look at changes in income and wealth distribution. In the post-World War II reconstruction, there was an attempt to share the spoils of the war with everyone. The GI bill, guaranteed housing loans, and other market interventions lessened inequality. Now, these social protections are being dismantled at the behest of business in order to restore profit rates that began to fall in the late 1960s.
Globalization is accelerating the generation of world-wide inequality. As businesses in rich countries seek to lower costs, production of labor-intensive goods moves to poor countries where labor is plentiful. This lowers the demand for labor in rich countries, and wages become relatively depressed so poor people have to struggle with all members of the family working, sometimes in several jobs.
One result is that the income and wealth gaps rise within rich countries, so that in the US, for example, the richest 1 percent of the population now controls over 40 percent of the wealth. This is in marked contrast to the 1960s, when the biggest growth in income, for example, went to the bottom 20 percent of families. Internationally, the gap between the richest and poorest fifth of countries has grown from 3-to-1 in 1820 to 30-to-1 in 1960 to 60-to-1 in 1990, to 74-to-1 in 1997. For most of the world's people, about two to three billion, it is a lose-lose situation.
The countries or populations that are most integrated into the global economy have worse health than those that do not accept markets for the poor. The United States has become economically as polarized as ever in history, and our lowered standing in the health Olympics mirrors this. We also have the smallest middle class among all rich countries (defined as from 75 percent of median income to 150 percent of median income). Japan, which has the smallest gap between the rich and poor, has survived because it remains partially protected from globalization, and because of the social cohesion in its society, as shown during their recent economic crisis where CEOs and managers took pay cuts rather than lay off workers.
Populations that have resisted the forces of globalization have much better health than might otherwise be expected. Kerala state in India, for example, is among India's poorest, yet with health indicators rivaling the US and much better than any other state in India. Kerala has shunned transnational corporations and does not allow sweatshops. It has worked to equitably share its resources by implementing land reform. Women have great power there, and literacy is almost universal, with primary rather than specialist education the focus. Shops selling basic commodities at fair prices are located close to villages. People matter there.
If health is a goal in the US, we must begin with a compass that reads our standing in the Health Olympics, rather than the minute-to-minute changes in the Dow Jones or Nasdaq. The President should be asked to review this standing in the State-of-the-Union address. Newspapers need to display health measures of their city's populations in comparison to other cities or states. Vigorous debate must take place on how we can become more healthy. Structural medicine will be necessary. Certainly, universal coverage would allow the 40 million poorest Americans who are uninsured to have better access. But even if that were to become a reality, our standing in the Health Olympics would not change unless economic inequality also shrinks.
Stephen Bezruchka, MD, MPH is an emergency physician at Virginia Mason and Group Health hospitals in Seattle, and teaches in the School of Public Health and Community Medicine at the University of Washington.