Seattle Post-Intelligencer, June 25, 2006
OP-ED: ECONOMIC EQUALITY IS BEST MEDICINE
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 health.
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 kindergarten.
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 said.
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.