Seattle Post-Intelligencer  [Printer-friendly version]
June 25, 2006


By Stephen Bezruchka

The headlines read that rich Americans aren't as healthy as poor
Brits, despite our spending twice as much money on health care as they
do. Our newborns die at the highest rates of any rich country, even
with our ever-advancing medical technologies. The feds report our
mortality rates have never been lower. The United Kingdom study
director suggests it is the nature of an unequal society in the United
States that affects everybody, while experts over here are puzzled.
What is going on?

Thomas Pynchon wrote in "Gravity's Rainbow" that "if they can get you
asking the wrong question, they don't have to worry about the
answers." Which medical care drug plan to choose is the wrong
question. Instead let's ask, "What makes a society healthy?"

An M.D. can't answer that, nor can most people working in public
health departments. One reason for their ignorance: It is very
difficult to get people to understand something when their salary
depends on their not understanding it. Medical doctors are paid to
treat diseases, so everyone has a disease if we do enough tests.
Public health workers ply a trade, make sure enough kids get their
shots, tell people to say no or wear a condom and check the water for
arsenic. They consider efforts to understand basic conditions that
produce health in society to be outside their job description.

Who can tell us the answer to what makes a population healthy? Few in
this country know, because we don't ask that question. Anyone who does
is marginalized for acting stupid. I was told "Medical care, of
course, that's why we are teaching you to be a good doctor." Our
federal government, in its Institute of Medicine 2003 report "The
Future of the Public's Health in the 21st Century," states on page 59:
"more egalitarian societies (i.e. those with a less steep differential
between the richest and the poorest) have better average health." This
remarkable finding has emerged from research carried out over the last
25 years, and the science is as good as that linking smoking and poor

Why aren't the media broadcasting this news? For the last quarter
century it has become unpatriotic to believe in economic justice.
Instead we give ever more to the rich through tax cuts and subsidies
and demand that the poor accept having less, in the hopes of some
trickling down. Egalitarianism is not a treatment taught in U.S.
medical and public health schools, nor in any school except

What is it about a bigger differential between the richest and poorest
that leads to worse average health? Intuitively, we can see that not
everyone shares the same stress in a bigger-gap society and those
lower down suffer more of the slings and arrows of misfortune rained
down from above. There is less caring and sharing in society when the
gap is in our face.

Other research findings demonstrate that individual behaviors are not
as important for our health as political policies that impact the gap
between the rich and the poor. These behaviors are those we have
learned since about toddlerdom: diet, exercise and not smoking. They
are good ideas but when compared with economic justice, these
individual practices are relatively unimportant. For example, the
healthiest country in the world, Japan, has the highest proportion of
men smoking among all rich countries. Obviously smoking is not good
for your health but compared with the less steep differential, it is
not as important a factor. As a doctor who used to badger people about
this habit, it was very difficult for me to reconcile this finding.
Studies demonstrate the individual behaviors are not that important
for our health.

Health care, even universal health care, has been shown to have little
or no overall impact on a nation's health. The spending on health care
in the United States makes up nearly one half of all monies paid for
health care worldwide. Despite that, we who live in the USA, the
richest country in world history (with half of the globe's
billionaires), die younger than we should. To understand this
conundrum, the first step we must take is to recognize that health and
health care are two very different concepts -- despite sounding so
similar. Health of societies is mostly determined by political and
economic policies while health care can only prevent and treat
individual diseases.

The United States used to be one of the healthiest countries in the
world when egalitarian principles were near the horizon. President
Kennedy told us not to ask what our country can do for us but to ask
what we can do for our country. His request came after a decade of
policies in which the poor made relatively more economic gains than
the rich, something Robin Hood might have admired. For example, in the
United States the general population shared its income growth with
returning World War II veterans and subsidized their re-entry into
society. Back then we were one of the healthiest countries in the
world -- but not for long. The rich and powerful interpreted the
president's remarks to mean, "What can ordinary people do for us?"
During the last 30 years the rich have gotten much richer, and we have
strayed far from egalitarian ideals.

The increasingly steep differential between the richest and poorest is
the reason why we are as healthy as Cuba, the country we have been
strangling for almost 47 years. While our health as a nation has been
improving, other countries are seeing better and faster results.
People in more than 25 countries, including nearly all the rich
nations and a few poor ones as well, live longer and healthier lives
than we do.

There is currently no federal agency, or any other body, whose goal it
is to make us healthier compared with other nations. Our Centers for
Disease Control and Prevention have put forth Healthy People 2000 and
2010 initiatives, with disease and behavior oriented national goals,
but we did not achieve these goals in 2000, and have no chance of
coming close to fulfilling them in the next four years. They do not
address our standing compared with other nations.

This is like giving the Olympic Gold Medal not to the winner, but to
the contestant who said they tried the hardest!

The illiterate of the 21st century will not be those who can't read or
write but those who cannot learn, unlearn and relearn. Much of what I
learned in medical school is not acceptable practice today. Some of
what we think we know today will be folly tomorrow. What the Institute
of Medicine reports will, I think, stand the test of time. If we want
healthy grandchildren, we must seriously consider what the feds have

Economic justice is the medicine we need. In today's situation, this
requires overturning all the recent federal legislation that gives
ever more to the rich. The work of the Hood Robins (who take from the
poor and give to the rich) is bad for our health, as our own Institute
of Medicine acknowledges.

Perhaps we should demand a Health Impact Assessment like other
countries, to track the toll in human lives sacrificed by political
policies that favor the rich over the poor.

This state's Washington Health Foundation is unique in the nation for
trying to make Washington state the healthiest in the country.
According to a composite indicator used to rank the health of states,
we have fallen to 15th place while Minnesota is first and Louisiana is
last. To effect real change and improve health through this country, I
suggest we strive to make Louisiana first in the nation. That state
has among the highest infant death rates, the shortest length of life,
the highest homicide rates, the highest teen birth rates and the
biggest gap between rich and poor. Katrina's aftermath was no
accident. By concentrating on improving health in this country's worst
off state, everyone will do better.

The last 40 years have seen an unbridled giveaway to the minority of
the wealthy and powerful, as politicians distorted Kennedy's words and
did what they could for the rich of America. It is now time for the
majority, who make up the bottom 80 percent of this nation, to ask
what our country can do for us.

Everyone's health, both rich and poor, will benefit from this old-
fashioned idea: economic justice.

Stephen Bezruchka, M.D., MPH, is with the Department of Health
Services, School of Public Health and Community Medicine, at the
University of Washington.