October 01, 2007
Class and Health
Maggie Mahar at the Century Foundation, who writes the Health Beat blog, posted this last week after an important article by Dr. Steven Schroeder on the relationship between class and health appeared in the New England Journal of Medicine. I thought it worth reposting:
When compared to other developed countries, the U.S. ranks near the bottom on most standard measures of health. Many people assume that this is because the U.S. is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. But while it is true that within the U.S. there are enormous disparities by race and ethnic group, even when comparisons are limited to white Americans our performance is “dismal” observes Dr. Steven Schroeder in a lecture published in the New England Journal of Medicine yesterday.
Why? It’s not the lack of universal access to healthcare" says Schroeder, though that’s important. And it’s not just that we don’t exercise enough and eat too much—though that is a major cause. But there is one factor undermining the nation’s health that we just don’t like to talk about in polite society: Class. When it comes to health, class matters.
Schroeder, who is the Distinguished Professor of Health and Health Care at the University of California San Francisco (UCSF) underlines how poorly even white Americans stack up when compared to the citizens of other countries by pointing to maternal mortality as one measure of health. When you look at “all races” you find that in the U.S. 9.9 out of 100,000 women die during childbirth. Focus solely on white women, and the number is still high—7.2 deaths out of 100,000 –especially when compared to Switzerland where only 1.4 women out of 100,000 die while giving birth.
Statistics on infant mortality reveal the same pattern: among “all races” 6.8 American children who were born alive die during infancy; limit the analysis to “whites only” and 5.7 infants die—compared to just 2.7 out of 1,000 in Iceland. .) When researchers compare maternal mortality and infant mortality in white America to rates of death in the 29 other OECD countries, white America ranks close to the bottom third in both categories.
Turn to life expectancy, and you find that white women in the U.S. can expect to live 80.5 years, only slightly longer than American women of all races (who average 80.1 years). Both groups lag far behind Japanese women (who, on average, clock 85.3 years). The gap between “all American men” (who live an average of 74.8 years) and white men in the U.S. (75.3 years) is wider—but not as wide as the gap between white men in the U.S. and men in Iceland (who live an average of 79.7 years).
“How can this be?” asks Schroeder. After all, as everyone knows, the U.S. spends far more on health care than any other nation in the world.
The answer is a stunner: the path “to better health does not generally depend on better health care,” says Schroeder. “Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of premature deaths could be prevented.” [my emphasis]
Schroeder goes on to emphasize the importance of behavior, and talks about smoking and obesity—problems that we have discussed on this blog. Then he turns to the causes of poor health that we tend to ignore: “the nonbehavioral determinants of health.
Here Schroeder points to an overwhelming amount of research (see here, here, and here) which confirms that people living on the lower rungs of the socioeconomic ladder die earlier and suffer from more disabilities than those who are wealthier, better educated, have a better job and live in a better residential neighborhood (the four components that researchers use to define “class”) Moreover, he notes, “the pattern holds true in a stepwise fashion from the bottom of the ladder to the top.”
But isn’t the difference really a function of individual behavior? After all, everyone knows that poorer, less well-educated people are more likely to smoke and eat junk food. Schroeder acknowledges that this is true: “people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities.” In poorer neighborhoods, fresh and organic foods are usually unavailable or exorbitantly expensive; public recreation is often nonexistent, and exercising outdoors can be dangerous.
“Yet, Schroeder points out, even when behavior is held constant, people in lower classes are less healthy and die earlier than others. [my emphasis]. For example, a 1996 study published in the American Journal of Public Health which focuses on white American men –and takes smoking and other risk factors into account-- reveals that men earning less than $10,000 were 1.5 times as likely to die prematurely as were those earning $34,000 or more.
In the U.K., a similar study of British civil servants showed that when smoking and other risk factors were controlled for, those in the lowest employment category were still more than twice as likely to die prematurely of cardiovascular disease as were those in the highest category.
Why? Schroeder points to a combination of “material deprivation” and “psychosocial stress.” Being poor generates terrible anxiety, not just about money, but about safety, your family’s safety, and the fact that catastrophe—in the form of losing your job and losing your home—is always just around the corner.
Within the world of medicine, while some attention has been given to racial disparities in health and health care, the importance of class, and “the wide differences in health between the haves and the have-nots are largely ignored,” Schroeder observes in a 2004 NEJM article that he co-authored with Stephen L. Isaacs J.D. Clearly, he stresses addressing racism should be a priority: “to bring about a fair and just society, every effort should be made to eliminate prejudice and discrimination.” And often, he admits, it is hard to “disentangle” race and poverty. But he argues “concentrating mainly on race as a way of eliminating these problems of premature death, illness and disability among the poor downplays the importance of socioeconomic status on health.”
“The focus on reducing racial inequality is understandable since this disparity, the result of a long history of racism and discrimination, is patently unfair,” Schroeder continues. “Because of the nation's history and heritage, Americans are acutely conscious of race. In contrast, class disparities draw little attention, perhaps because they are seen as an inevitable consequence of market forces or the fact that life is unfair. As a nation, we are uncomfortable with the concept of class. Americans like to believe that they live in a society with such potential for upward mobility that every citizen's socioeconomic status is fluid. The concept of class smacks of Marxism and economic warfare.” [my emphasis]
Here let me add, as an aside, that I have asked a physician who is an expert on racial discrimination and health care to send me a post for this blog. I hope to publish her comment soon.
But today, I’m focusing on the socio-economic factors which influence the health of Americans of all races because in some areas class trumps race. For example, while African-Americans have higher rates of death from heart attack than do whites at all levels of income--and the poorest Americans, whatever their race, have substantially higher rates of heart attack than those who are better off --the difference in the rates of premature death from heart attack between poorer and richer people is far greater than the difference in the rates of premature death between blacks and whites.
But how does class explain why the U.S.lags so far behind other developed countries when we look at markers like maternal mortality and life expectancy? After all, the U.S. is not the only country where class matters. Here, Schroeder points to an uncomfortable fact: “nations differ greatly in their degree of social inequality.” [my emphasis] And in the U.S., in recent decades, the gap between the haves and the have nots has widened, to a point that we have become a divided nation.
Wages at the top of the ladder have spiraled while wages in the lower rungs have flattened or even fallen. Meanwhile tax policies have favor the rich, particularly in the 1980s, under President Reagan, and in recent years, under the current administration. Even in the late 1990s, during President Clinton’s last term, the wealth of a prosperous economy did not trickle down: between 1997 and 2001 the top 10 percent of U.S. earners received 49 percent of the growth in real wages and salaries; and the top 1 percent reaped 24 percent of the total while the bottom half of workers received less than 13 percent.
Granted, inequality was growing in most of the rest of the world over the same span, “but the United States led among the richer nations; and unlike most others that offset market inequality though government intervention, the United States has not done so,” observes William K. Tabb, author of Economic Governance in the Age of Globalization.
This may say something about our priorities as a nation. “One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism,” Schroeder notes. “Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer.”
Yet, he suggests, we could do better, first by recognizing how social policies involving education, taxation, transportation and housing have important health consequences and by analyzing the impact of these policies on health.
Moreover, when it comes to health policy, he observes, we need to focus on the social and environmental factors which affect the health of the less fortunate people in our society.. Instead, in a nation where health care has become big business, we pour the bulk of our health care dollars into “the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies,” Schroeders notes, “and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health [when compared to other countries.] “
Perhaps our health care policy reflects our values. “It is arguable that the status quo is an accurate expression of the national political will,” says Schroeder “a relentless search for better health among the middle and upper classes. [my emphasis]. This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health "cures" and "scares" are featured in the popular media. The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic.”
And yet, and yet . . . Schroeder sees reason for “cautious optimism.” Although we trail behind other countries, we are healthier than we once were. We have reduced smoking ratse, homicide rates and motor-vehicle accidents. Vaccines and cardiovascular drugs have improved medical care. But progress in other areas will require “political action,” Schroeder declares, “starting with relentless measurement of and focus on actual health status and the actions that could improve it. Inaction means acceptance of
America's poor health status.”
If we got serious about improving public health we could improve productivity, boost the economy, rein in health care spending and “most important, improve people’s lives” Schroeder argues. Here, he calls on physicians and other healthcare professionals to become “champions” for public health. In the end though, it is not only health professionals, Schroeder suggests, but all Americans who should see improving the health of the nation as a matter of patriotism. “Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. Why don't we try to become number one in health? “