Health is a Socio-Economic Problem

8/9/2019 Health is a Socio-Economic Problem

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Health is a Socio-Economic Problem

Note: This is an update of an earlier and timely article.The recent debates on health plans have omitted a vital aspect of the discussion - recent reportshave shown that a large inequality in the distributions of wealth and income are more significantfactors than either absolute poverty or low income in determining the health of deprivedpopulations. Despite these published reports, the United States government and the medicalprofession neglect the data and refuse to propose programs that will modify the socio-economicsystem in a manner that improves the health of all of its citizens. The neglect creates a seriousproblem; citizens' security and health are threatened and therefore the security and health of thenation are also threatened.

Let's start with brief descriptions of research that support the theses that social status anddistribution of income determine the quality of health.

The Research

CAUSE OF DEATH: INEQUALITY. Dollar & Sense, May, 2001, Alejandro ReussMen with less than 12 years of education are more than twice as likely to die of chronic diseases

(e.g., heart disease), more than three times as likely to die as a result of injury, and nearly twiceas likely to die of communicable diseases, compared to those with 13 or more years of education.Women with family incomes below $10,000 are more than three times as likely to die of heartdisease and nearly three times as likely to die of diabetes, compared to those with family incomesabove $25,000. African Americans are more likely than whites to die of heart disease; stroke;lung, colon, prostate, and breast cancer, as well as all cancers combined; liver disease; diabetes;AIDS; accidental injury; and homicide. In all, the lower you are in a social hierarchy, the worseyour health and the shorter your life are likely to be.

Numerous studies suggest that more unequal income distribution in a country, state, or citylowers the life expectancies for persons at all income levels. One study published in the AmericanJournal of Public Health, for example, shows that U.S. metropolitan areas with low per capitaincomes and low levels of income inequality have lower mortality rates than areas with high

median incomes and high levels of income inequality. Meanwhile, for a given per capita incomemortality rates always decline as inequality declines.

Kawachi, I. and B.P. Kennedy, 1997, Socioeconomic Determinants of Health: Health and SocialCohesion: Why Care About Income Inequality?, British Medical Journal, 314: 1037-1040Growing evidence suggests that the distribution of incomein addition to the absolute standard ofliving enjoyed by the pooris a key determinant of population health. A large gap between richpeople and poor people leads to higher mortality through the breakdown of social cohesion. Therecent surge in income inequality in many countries has been accompanied by a marked increasein the residential concentration of poverty and affluence. Residential segregation diminishes theopportunities for social cohesion. Income inequality has spillover effects on society at large,including increased rates of crime and violence, impeded productivity and economic growth, andthe impaired functioning of representative democracy. The extent of inequality in society is often a

consequence of explicit policies and public choice. Reducing income inequality offers theprospect of greater social cohesiveness and better population health.

In wartime Britain, narrowing of income differentials was accompanied by a greater sense ofsolidarity and social cohesion as well as dramatic improvements in life expectancy. In contrast, inthe originally closeknit town of Roseto, rapid economic change in the 1960s opened the gapbetween rich people and poor people. The resulting breakdown of community cohesion wasfollowed by a sharp increase in deaths from coronary disease

Health disparities and the law: wrongs in search of a right.


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American Journal of Law & Medicine, Summer-Fall, 2003, Mary A. BobinskilnThe perhaps unexpected influence of socioeconomic factors can be seen when comparing thedata on life expectancy in the United States with that found in other countries. The life expectancyfor women in the United States is lower than it is in eighteen other countries; in life expectancy formen, the United States ranks twenty-fifth.

Socioeconomic status, as measured either by income or level of education, is strongly correlatedwith health status.Healthy People 2010:In general, population groups that suffer the worst health status also are those that have thehighest poverty rates and the least education. Disparities in income and education levels areassociated with differences in the occurrence of illness and death, including heart disease,diabetes, obesity, elevated blood level, and low birth weight. Higher incomes permit increasedaccess to medical care, enable people to afford better housing and live in safer neighborhoods,and increase the opportunity to engage in health-promoting behaviors.

A note on the effect of unemployment on mortality. Gerdtham UG, Johannesson M., Departmentof Community Medicine, Malmo University Hospital, Lund University, Malmo, [email protected] significantly increases the risk of being dead at the end of follow-up by nearly

50% (from 5.36 to 7.83%). In an analysis of cause-specific mortality, we find that unemploymentsignificantly increases the risk of suicides and the risk of dying from "other diseases" (all diseasesexcept cancer and cardiovascular), but has no significant effect on cancer mortality,cardiovascular mortality or deaths due to "other external causes" (motor vehicle accidents,accidents and homicides).

University of Chicago, Nov, 16-22, Sir Michael Marmot, The Social Determinants of Health andDisease HealthOne of the dominant features affecting the health situation of all industrialized countries is thesocial gradient in health and disease. Analysts who approach this topic commonly think of it as aproblem of poor health for the disadvantaged and good health for those who are not in thedisadvantaged category. This is an inadequate way to pose the problem. The Whitehall Study ofcivil servants showed that, amongst people who are not poor, there is a social gradient in

mortality that runs from the bottom to the top in each society. People in each socio-economiccategory have worse health than those above them in the hierarchy. Data from the United Statesconfirmed this pattern. In seeking to understand causes for the social gradient it is worth makingtwo observations. First, it applies in non-human primates and other social animals: the lower thestatus the higher the disease risk and the shorter the life-span. Second, it applies to manysocieties and different time periods.

The research and analysis that demonstrate the significance of effect of disparity in income onhealth emphasizes the unwillingness of social, medical and economic disciplines to validate theresearch. During the last century, advances in health were more due to advances in the socio-economic system, and much less to medical advances.

The 20th Century Advances in Health

The medical profession credits the decrease in mortality and the conquering of manycommunicable diseases to the discoveries and uses of vaccines and antibiotics. Historical trendson mortality and disease clearly indicate that the infant and adult mortality rate steadily declineddue to the economic benefits of the industrial revolution, which included improved scientificknowledge, increased incomes, improved health care and nutrition. At the same time governmentregulation and social factors enabled cleaner water and safer environments. Although theintroduction of vaccines and antibiotics have had a role in controlling communicable diseases,these diseases were already on a decline before modern controlled methods.

Conclusion: Social and economic factors have been large determinants in the increase in


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longevity and the decline of communicable diseases. Attention to these same socio-economicfactors can advance individual health in the 21st century similar to the advances made the 20thcentury. Some statistics:

Historical data indicates that social and economic progress, and not medical intervention, hasbeen the more significant factor in advancement of American public health. Why aren'tgovernment and private institutions giving more attention to the benefits of the social factors?Research by competent and well-recognized investigators highlight the effects of the socio-economic system on the health of the populace. Why aren't these investigations being widelydistributed, and why aren't they being used to clarify directions to improve public health? Thereason: Pure neglect.

The NeglectThe U.S. government defines the security and health of the American nation as the security andhealth of the economic system and its industries. It is taken for granted that if the economicsystem is growing then the citizens will be healthier. This narrow thinking works against the lowereconomic classes of society. Some thoughts:

Those who control the economic and political reins of society don't experience the inequalities inthe system and don't suffer economically, socially and psychologically from the discrepancies.The system leaders have no direct interest in changing the system.Those who suffer from the inequalities don't have the power, the finances, the organization andthe political muscle to make their case heard.The system is guided by investment leading to profit, rather than investment leading to public

health. Investment demands proof that reducing inequalities will provide profits.A propaganda machine publicizes economic inequality as beneficial for investment and growth.The drug and medical industries benefit financially from the supposition that they provide theunique solutions to health problems. Large research grants enable them to develop products.Afterwards, they convince the public that the investment in the developments must be recoupedfrom the pricing of products. The drug and medical institutions discourage solutions other thantheir own for resolving health problems.The health inequality is treated as a system cost that is less than the financial burden to cure it.Government and industrial leaders are ignorant of the data that describes the effects of social andeconomic inequality upon the public health.


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What can be done to improve the health of a populace?The principal method to improve the health of a population is to respond to the neglect thatcauses ill-health.

If social and economic inequalities cause inequalities in health, then it's obvious that reducing theformer will reduce the latter. This means attacking the wage and benefit scales from both sides;increasing wages and benefits for the less fortunate and reducing the wages and benefits for themore fortunate. Why should the person who labors at irregular hours to clean a floor be muchless rewarded than the person who walks the floor and labors easily during regular hours?Income can be more fairly distributed with total wages and benefits in the system remaining thesame. The health will increase for those presently at the low end of the scale and will stay thesame for those at the high end of the scale.Those who claim that substantial income differentials are necessary for a growing society shouldbe forced to prove their argument. Many nations, especially those in the European Union, whichhave less economic inequalities, have powerful economies, even with less resources then thenations that have large inequalities.The United States government has successfully regulated behavior (tobacco laws, intravenoususers, and pollution), and this type of regulation has greatly improved the health of its citizens.The government has also regulated the economic system (minimum wage laws, anti-trust laws,communication and exchange commissions, and banking laws) and this regulation has served to

improve the health of its citizens. The government can do more for public health by applyingpressure that narrows income distribution.Historical trends in improved health, reduced infant mortality, and reduction in communicablediseases clearly show that the social factors of education and sanitation, environmental factors ofcleaner water and air and the economic factor of increased prosperity for all have been major inthese improvements. It seems conclusive that attention to social and economic factors can besignificant in improving public health. More research into the effects of these factors upon healthcan be instrumental in improving health.The drug and medical industry have overrated their performances. Statistics show that drugshave not been the major reason for the decline in many diseases. The medical industry has notgreatly reduced pneumonia, cancer, diabetes and the annual return of influenza. Diseaseresistance to drugs have been noticed. As one example, gonorrhea has been declared resistantto known drugs. An examination of the drug culture and its benefits should be made.

Although treated with skepticism, the Health Maintenance Organizations (HMO), who want tolower costs, are eager to improve the health of all citizens. HMOs have a part to play in the healthdebate.If it is true that the social and economic inequalities are more significant than the absolute socialand economic level, then programs that realign populations, such as low income housing in highincome areas, might be counterproductive.Indeed, not all studies have shown that poor people have worse health if they live in a poor arearather than in a rich one. This lack of unanimity may be the result of the sense of relativedeprivation running counter to the effects of the wider environment: a poor person living in anaffluent area may have a better environment but may also feel relatively poorer.(Kawachi, I. andB.P. Kennedy, 1997, Socioeconomic Determinants of Health: Health and Social Cohesion: WhyCare About Income Inequality?, British Medical Journal, 314: 1037-1040)

Deprived groups don't want to be parted from their environment. Living in the same impoverishedmanner, but close to groups that emphasize the inequality might be more punishing than livingwith others at the same low economic leve. Improving the impoverished environment is morerewarding than shuffling people to other neighborhoods so they can observe how they shouldlive. Many programs for alleviating the burdens of the less fortunate have proved ineffective andhave only served as token gestures to pacify those desiring system improvements. Only directattacks on social and economic inequalities can be effective.

The jury is in: The social-economic system that has great inequalities and doesn't properly rewardall of its people is detrimental to the health of a major part of its population. The mechanism for


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resolving the problem is obvious - narrow the distribution of wealth in the system.

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Health is a Socio-Economic Problem