Rachel's Democracy & Health News #874, September 28, 2006


[Rachel's introduction: The health of U.S. citizens is abysmally poor, compared to that of other wealthy, industrialized societies. When we look for causes, we often don't examine the real fundamentals --the "social determinants of health." These "social determinants" are, in turn, created or modified by specific public policies. This week and next we depart somewhat from our usual journalistic approach to offer this important new statement on the poor health of U.S. citizens and the public policies that lie behind the shocking numbers. The statement is framed as a challenge to the public health community in the U.S.]

By Dennis Raphael

[Editors' introduction: Dr. Dennis Raphael is a professor in the School of Health Policy and Management, York University, Toronto. In recent years he has edited two volumes on the social determinants of health -- Staying Alive: Critical Perspectives on Health, Illness, and Health Care (2006), and The Social Determinants of Health: Canadian Perspectives (2004). He is the author of Inequality is Bad for Our Hearts; Why Low Income and Social Exclusion are Major Sources of Heart Disease in Canada (2001). If you have a high-speed internet connection, you can see and hear Dr. Raphael delivering an interesting lecture. If you are not familiar with the concept of "social determinants of health," you might read this short article in Wikipedia. In manuscript, this article was originally titled, "Public Policies Drive the Deteriorating Population Health Profile in the USA."]


International interest in the social determinants of health represents yet another cycle of recognition of the importance of structural determinants of health that began in earnest in the 1850's (1, 2).

Yet, recent waves of concern with structural determinants of health appear to have bypassed the mainstream American public health community (3-5). Analysis of how early life, education, employment and working conditions, food security, housing, income and its distribution, and unemployment and employment security (6) shape health and creates health inequalities seem especially timely as the USA presents one of the worse population health profiles among wealthy developed nations and one of the most undeveloped public policy environments in support of health (7, 8).

These public policy issues concern income distribution, employment security and working conditions, and quality of the social infrastructure in support of health. Despite evidence that the USA has become a striking outlier among wealthy developed nations in its population health and public policy profiles, the USA public health community is taking only cautious steps towards addressing the structural antecedents of health and disease (4, 9) . And when the social determinants of health concept is explored the analyses are typically narrow and strangely depoliticized (10-13). Public policy antecedents of health determinants such as family, labor, tax, social assistance, and taxation policy, as examples, are rarely mentioned and when they are, are done in a rather perfunctory manner (14, 15). Resignation that progressive public policy change in support of health in the USA is unlikely is frequently a message conveyed in these analyses (16-19). What roles could the public health community play in this effort and how likely is it that these efforts could succeed?

Social Determinants of Health

The renewed focus on social determinants of health (6, 20-25) grew out of efforts by UK researchers to identify the specific exposures by which members of different socio-economic groups come to experience varying degrees of health and illness (26). It is no accident that the term social determinants of health made its contemporary appearance during the Thatcher era in a UK volume concerned with policy, social organization, and health (27). The concept struck a responsive chord in many wealthy industrialized nations where growing income and wealth inequalities, the weakening of the welfare state, and increasing evidence of social exclusion were causes for concern (28-30).

The social determinants of health concept failed to gain much traction within the USA pubic health community even though the growth in income and wealth inequalities since the 1980's has been greater than any other wealthy developed nation (8). Despite sporadic mention of the concept in various American academic articles (10, 14, 31, 32), the USA public health community gaze is firmly focused on rather narrow issues of identifying racial and ethnic disparities, health care access, and behavioral risk factors rather than structural issues concerned with the distribution of economic and social resources (4, 33). When the social determinants of health are considered, these are strangely de-politicized such that their public policy antecedents are rarely mentioned and certainly not criticized through a consistent political analyses.

The key exceptions to this trend include the work of Smeeding and Rainwater who have labored over the years to raise issues of poverty, income distribution, and service distribution, their public policy antecedents, and their implications for health (8, 34-36). Similarly, the recent volume by Hofrichter brought together much of the sparse literature on the structural determinants of population health in the USA (37). See also Alesina and Glaeser, (38), Rank (39), Kawachi and Kennedy (40), Brooks-Gunn (41) and Auerbach and colleagues (42) and work on income and wealth inequality by numerous non-governmental organizations (43-46).

At the same time the public health community gazes on ethnic and racial disparities, access to health care, and behavioral risk factors, the public policy environment in support of health deteriorates (43, 47-49). Much of this has to do with the neo-liberal and neo-conservative resurgence that began in earnest during the Reagan presidency which coincided -- and was incompatible -- with growing international interest in structural approaches to health promotion (50). Now, 20 years after the Reagan Revolution led to astounding increases in income and wealth inequality, the dismantling of much of the American welfare state, and hardening public attitudes towards governmental provision of services, the public health community is taking cautious steps towards addressing structural determinants of health. How likely are these efforts to be successful?

Within most nations, social class, occupational status, and income are analyzed as key issues that interact with public policy approaches to resource distribution and service provision to shape health inequalities and population health (28, 51, 52). Social stratification interacts with public policy to produce differential exposures to societal resources that shape health (53, 54). In the USA however, issues of social class, occupational position, and income take a back seat to analysis of "racial and ethnic disparities" in health (4). Indeed, discussion of resource distribution including income and general social provision as determinants of health is clearly undeveloped in the USA. Analysis of social stratification and social class as health determinants is even less so (42, 55-57).The reasons for this and the impact this focus has on public health researchers and workers' activities in the service of health are discussed below.

The USA Population Health Profile

The social determinants of health and their public policy antecedents are especially relevant to the USA as its health profile is especially poor in relation to other wealthy industrialized nations. For the following indicators of population health of a nation, a rank of 1 is best, with increasing rank indicating poorer relative performance as compared to the wealthy industrialized nations of the Organization for Economic Cooperation and Development (OECD).

Life Expectancy

In 2002, life expectancy for American males was 74.4 years, and for women, 79.8 years providing a relative rank of 22nd of 30 wealthy developed nations for men; and 25th of 30 for women (7). The average life expectancy increase in the USA of 7.2 years from 1960 to 2002 was well below the OECD average of 9.2 years giving the USA a rank of 22nd of 30 nations.

Infant Mortality Rate

In 2002, the USA's 2002 rate of 6.8/1000 gives it a rank of 25th of the 29 wealthy industrialized nations for which these data are available (7).

Low Birthweight Rate

In 2003 the USA's low birthweight rate was 7.9 per 100 newborns giving it a ranking of 25th of 28 wealthy industrialized nations for which these data were available (7).

Childhood Death by Injury Rate

During the period 1991-1995, 14.1 American children per 100,000 died from injuries giving the USA a ranking of 23rd of 26 wealthy industrialized nations (58).

Child Maltreatment Deaths

During the 1990's the incidence of childhood death by maltreatment per 100,000 children in the USA was 2.2 per 100,000 (59). This gave the USA an overall rank of 26th of 27 wealthy industrialized nations. A ranking that takes into account "undetermined intent" raises the USA's rate to 2.4 per 100,000 and a relative ranking of 25th of 27.

Teenage Pregnancy Rate

The USA's rate during the 1990's of 51.1 births to 1000 women below 20 years of age gives it a rank of 28th of 28 wealthy industrialized nations. These rates are exceptionally high -- 21 points higher than the nearest nation, the UK.

To summarize, the USA shows a very poor population health profile on a variety of health indicators. It does poorly on male and female life expectancy, infant mortality rank, low birthweight rate, deaths from child injury and child maltreatment.

Poverty as a Health Determinant: USA Rates in International Perspective

Poverty is increasingly seen as the greatest threat to human development and a nation's quality of life (60, 61). The experience of poverty also results in -- as well as contributes to -- social exclusion, a process identified by the European Union and the World Health Organization as the primary threat to the smooth functioning of developed societies (62, 63). Where does the USA stand on this indicator?

Overall National Poverty Rates and Poverty Gaps

Using the internationally agreed-upon convention of poverty as the percentage of individuals with disposable income less than 50% of the median income of the population, the USA's overall poverty rate for the mid 1990's was 16.6% (7). By 2000 it had increased to 17.0% which was well above the OECD average of 10.2%. The USA's relative rank in this important rating was 26th of 27 wealthy industrialized nations. In terms of the gap between the average incomes of those living in poverty and the median income of the population, the USA's gap of 34.3% is above the OECD average of 27.7%, providing a rank of 23rd of 27.

Child Poverty -- Relative and Absolute Rates

During the late 1990s, the USA's relative child poverty rate of 22.4% gave it a ranking of 22nd of 23 wealthy industrialized nations (64). These rates can be compared with those seen for the Nordic nations (Denmark, 5.1%; Finland, 4.3%; Norway, 3.9%; and Sweden, 2.6%), Belgium (4.4%); and Luxembourg (4.5%).

Absolute child poverty rates are generated by applying the USA poverty standard to other nations adjusting for national currencies and national purchasing power. The USA poverty standard is set very low and is usually seen as an indicator of very limited resources associated with serious material and social deprivation (64). The USA's rate of 13.9% places it 11th of 19 nations for whom these data were available. The Nordic nations also have very low absolute poverty rates (Sweden, 5.3%; Norway, 3%; Denmark, 5.1%; Finland, 6.9%), Belgium (7.5%), and Luxembourg (1.2%) thereby maintaining their low rankings on both kinds of poverty indicators.

Recent Analyses from the Luxembourg Income Study (LIS)

How does the very high level of poverty in the USA come about? An analysis of LIS data by Smeeding provides insights into this process among 11 wealthy developed nations (36). These nations represent four Anglo-Saxon nations, Canada, Ireland, United Kingdom, and the USA; four central European nations, Austria, Belgium, Germany, and the Netherlands; one Southern European nation, Italy; and two Nordic nations, Finland and Sweden.

These analyses highlight how public policy determines poverty rates. Poverty rates are based on the international convention of a poverty cut-off of less than 50% of median adjusted disposable income for individuals.

The USA's overall poverty rate of 17% places it as the highest of these 11 nations. For USA children living in single parent households the poverty rate is a striking 41.4%, almost four times the rate for Swedish children living in this situation and almost six times the rate for Finnish children. The situation for USA elders does not fare much better. The USA's elder poverty rate of 28.4% is the second highest among these nations exceeded only by the strikingly high rate of 48.3% seen in Ireland. Similarly, the USA's poverty rate for childless adults is at 18.8%, exceeding every nation.

Have USA rates changed over time? Smeeding compares overall poverty rates for each nation over a 23 year period from the base year of 1987 to 2000. In 1987, the relative poverty rate for the USA was 17.8%. For 2000 he provides two rates. The 2000 relative rate applies the same calculation to 2000 as applied in 1987: the poverty line as less than 50% of the median disposable income for all residents. For the USA, the relative poverty rate in 2000 was 17% showing little change form 1987.

The anchored rate refers to the percentage of Americans in 2000 living below the poverty line as it was calculated in 1987 and adjusted for increases in the cost of living since that time. In the USA, this figure is 13.8%. There has been therefore some improvement in the actual income of those at the bottom, but in relative terms poverty rates in USA are virtually unchanged from 1987 to 2000.

Poverty rates are shaped by government spending programs.

Market income refers to income derived from gainful employment or investments and other private sources. Relying upon the market as the source of income provides rather high overall poverty rates across all nations. The USA's poverty rate based on market income is lower than most nations. Social insurance and taxes -- referring to transfers such as child benefits and children's allowances and changes in distribution resulting from taxation -- reduces the USA's poverty rate to 19.3%. The USA's poverty rate associated with the provision of a few more varied benefits -- called social assistance -- further reduces the poverty rate to 17.0%.

What is the calculated effect on poverty rates of these government programs? In the USA, social insurance programs reduce the poverty rate by 16.5% and all programs reduce it by 26.4% which is the smallest amount among these nations. In contrast, the overall reduction rate is 60.9% for the nations included in this analysis. Indeed, Sweden reduces its poverty rate by 77.4% by such actions. Belgium, Germany, Austria, and Finland also reduce their overall poverty rate by at least 70% through government action.

The USA expends a miserly 2.3% of Gross Domestic Product (GDP) on non-elderly citizens. In contrast, Finland and Sweden spend over 10% of GDP on citizen benefits. The importance of government expenditures in reducing poverty is illustrated by an analysis that reveals that non-elderly cash and near-cash (e.g., housing subsidies, active labor market subsidies, etc.) predict 61% of the variation among these nations' non-elderly poverty rates. Nations that spend more money on these benefits have lower poverty rates. Nations that spend less have higher poverty rates.

Smeeding also shows that the percentage of low-paid workers is strongly related to the percentage of non-elderly citizens within a nation living in poverty (36). The USA has 25% of its workers identified as earning less than 65% of the median wage and a poverty rate of 17.8%. In contrast only 5% of Finnish and Swedish workers earn low wages and their poverty rates are 4.5% and 6% respectively. These variations in numbers of low paid workers accounts for a strikingly high 85% of the variation among nations in the number of people living in poverty. In essence, the single best predictor of the number of people living in poverty in a nation is the number of people earning low wages. This begs the question of why so many USA workers are low-paid, an issue discussed in following sections.

Nations that transfer less resources to citizens are more likely to have higher levels of poverty -- and as other evidence shows -- poorer population health profiles (65-67). Nations that tolerate greater proportions of low-paid workers have higher poverty rates and the associated population health consequences. The next sections explore the nature of these differences in governmental support of citizens through transfers and programs.

USA Public Policy in Perspective

Health inequalities and population health profiles associated with these inequalities result from systematic variations in approaches to public policy (68, 69). Commonly termed the welfare state, this basket of public policies serves to promote human, social and economic development, reduce citizen uncertainty, and foster health and well-being. This political economy of health is well developed in Europe, much less so in North America (70, 71). It is especially undeveloped in the USA.

Societal Commitments to Citizens and Governmental Spending

Public commitment to supporting citizens is seen in percentage of Gross Domestic Product (GDP) transferred to citizens through programs, services, or cash benefits. Nations may choose to transfer relatively small amounts, allowing the marketplace to serve as the primary arbiter of how economic resources are distributed (72). Or a nation may choose to intervene to control the marketplace and make decisions concerning these allocations of resources (73). Nations that transfer a greater proportion of resources are more likely to show better population health profiles, and relatively less health inequalities (67). These health and inequality differences emerge through a series of mechanisms that involve degree of poverty and the material and social deprivation that are associated with such levels (65).

An especially important indicator is extent of government transfers. Transfers refer to governments taking fiscal resources that are generated by the economy and distributing them to the population as services, monetary supports, or investments in social infrastructure. Such infrastructure includes education, employment training, social assistance or welfare payments, family supports, pensions, health and social services, and other benefits (7).

Among the developed nations of the OECD, the average public expenditures in 2001 was 21% of Gross Domestic Product (GDP) (74). There is rather large variation among countries with Denmark (spending 29.2% of GDP) and Sweden (spending 28.9% of GDP) being the highest public spenders. The USA ranks 26th of 30 wealthy industrialized nations and spends just 14.8% of GDP on public expenditures. The only nations that allocate a smaller percentage of GDP to public expenditure are Ireland (13.8%); Turkey (13.2%); Mexico (11.8%); and Korea (6.1%).

The USA is the highest spender on total expenditure on health care. However, it is in the mid-range on public spending for health care as much of its spending on health care is from private sources. It is in the other areas of benefits and supports to citizens that the USA reveals itself as a very frugal public spender. The USA ranks near the bottom of nations in allocations to old-age related spending, primarily pensions with a rank of 26th of 30 wealthy industrialized nations. The USA also ranks among the lowest spenders on incapacity or disability-related issues for a rank of 25th of 29 wealthy industrialized nations. And the USA ranks very poorly on family benefits achieving a rank of 28th of 29 of these wealthy industrialized nations.

Another way to slice up the expenditure pie is to consider spending on income support to the working age population and social services as well as health and pensions. Income support involves family benefits, wage subsidies, and child support paid by governments to help keep low-income individuals and families out of poverty. Social services include counseling, employment supports, and other community services. Not surprisingly, the USA ranks relatively low on income supports to the working-aged population and social services. The USA spends just 7.9% of GDP in income supports to the working age population (rank 28th of 30) and 6.7% on social services (rank 20th of 30).

Active Labor Policy

Active labor policy refers to the extent that governments support training and other policies that foster employment and reduce unemployment. The USA allocates 0.53% of GDP to such policies. This provides it with a ranking of 20th of 22 wealthy industrialized nations for which data was available.

Public Policy and Citizen: Implications for Day-to-Day Life

How do these differing commitments to supporting citizens translate into differing conditions of day-to-day life? Only a few sets of issues can be examined here: resources available to the unemployed, level of social assistance benefits, level of minimum wages, and levels of pension benefits.

Unemployment Benefits over a Five Year Period for an Average Production Worker

For most Americans, benefits that would be available over a five year period would be unemployment insurance which would expire after a year of benefits. A family with liquid assets would then need to liquidate these prior to receiving social assistance benefits. For these non- destitute families, unemployment insurance provides only 6% replacement income over this period. This ranks the USA 27th of 28 wealthy industrialized nations in its generosity of benefit. If families did qualify for social assistance, the benefit percentage would be 30%, providing a ranking of 26th of 28 nations (7).

Social Assistance or Welfare

The OECD identifies as social assistance and welfare support as "benefits of last resort." On average, USA social assistance benefits for a married couple with two children provide 22% of median average income. This places these benefits as 28% less than the <50% of median income-indicator of poverty. As compared to the other nations for which these data are provided, the USA ranks 20th of 23 nations in providing these benefits of last resort (7).

Minimum Wages

Percentage of low-paid workers is the best predictor of percentage of citizens living in poverty. How does the USA compare to other nations in having minimum wages that keep people out of poverty? For an American two-child family with one full-time minimum wage earner, the wages received places the family at 34% of the median household income, well below the commonly accepted poverty cut-off of 50% of median poverty level (7). For a two-parent family with two children working full-time at minimum wages, the level of median income achieved is 46% of the poverty level. The USA's ranking for single parent working family is 12th of 15 wealthy industrialized nations. For the two-parent working family, the USA rank is 14th of 15.


The Social Security System provides benefits to individuals upon retirement. The OECD provides data on the value of pension benefits provided by each nation as a function of the gross earnings of an average production worker (7). For a worker earning 50% of an average production worker, the USA's pension provides a rate of 61% of these earnings. For an American earning the average production worker's income, the rate is 51%. The rates for average-waged workers are very low by international comparison giving the USA a rank of 25th of 30 wealthy industrialized nations. For very low-paid workers, the USA achieves an even lower rank of 28th of 30.

[To be continued next week.]


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