A Healthy Protest

I was a bit clumsy.

I was covering a presentation Tuesday about the efforts of several organizations to improve outcomes for South Dakota’s children. You can read about that here.

As I was listening, I started thinking about the role wealth and income equality play in the challenges the state’s children are facing with issues like health and education.

However, when it came time to ask the presenters questions about how inequality may play a role in these challenges, I hadn’t really taken the time to formulate coherent questions. I posed some clumsy inquiries, and they did their best to respond.

My brain likes to take healthy blocks of time off during the day. As I grow older, those blocks seem to get larger. Perhaps you can relate.

A friend later made reference to the questions about inequality and, in his own good-natured way, gave me a hard time about trying to fit everything into my own little worldview.

I must protest that characterization just a little. Since this is my space, I’m granting myself permission to air my grievances. (I’m fairly certain that my friend would be laughing so hard right now that my grievances would go unheard. That means you are stuck with reading them.)

It’s true — I do see wealth and income inequality as playing a role in a lot of societal issues. I’m not just pulling this stuff out of thin air, however. A growing body of research gives weight to these concerns.

A good place to begin learning about the correlations between inequality and all kinds of societal ills is The Spirit Level. (It’s not the New Age tome the title may suggest.)

In just the last week, I’ve read a couple of good journal articles about the state of American health. In short, it’s not good compared to other nations of our stature despite the fact that we spend A LOT more money on health care. They both happened to mention economic inequality.

Let’s look at some excerpts from “The Hurrider I Go the Behinder I Get: The Deteriorating International Ranking of U.S. Health Status” in the most recent issue of the Annual Review of Public Health:

A gap of 3.6 years of life expectancy at birth between the United States and Japan reflects major differences in health. Eradicating coronary heart disease, the leading cause of death in the United States, would likely not enable the United States to transcend the mortality gap (77). Eliminating cancer deaths would add only about three years to life expectancy (75). Reduction of U.S. mortality in 1986 from the nine major chronic diseases would have increased life expectancy by four years (39). One analysis showed that if the United States had had the highest life expectancy achieved by any nation for each of the past 100 years, another 66 million Americans would be alive today (92). The United States currently has a life expectancy that Japan achieved around 1993, suggesting it lags some 15 calendar years behind in achieving the best health outcomes (131, 132). If present trends continue, by 2026 the United States would finally reach the best health that was possible in 2011.

Japan has had the longest life expectancy globally since about 1978 (11) after its unprecedented health surge. Some of the higher overall life expectancy in Japan is generated by the extremely low mortality among elderly Japanese women (71, 128, 129), but Japanese men also do better than those in almost all other nations, ranking third. There has been some concern about registering deaths of very old people in Japan, but the life expectancy figures are calculated from the census to obviate this difficulty (28, 127).

Although life expectancy for the United States as a whole has generally been increasing over the past three decades, there have been declines in parts of the United States: Life expectancy has been diminishing or stagnating in absolute terms for women in almost 20% of U.S. counties. A 2008 study showed absolute declines in 180 out of 2,068 county units (merged from a total 3,141 to account for small numbers and changing boundaries) over the period of 1983 to 1999, whereas for the period 1961 to 1983 there were no such declines (27). For men, 4% of county units did not experience improvements, and there were absolute declines in 11 county units.

Extending the period from 1981 to 2006 showed women in almost 900 counties experiencing no health improvements or absolute declines (62). This study used a new measure, the international frontier of life expectancy, which represents the average of the ten highest county life expectancies for a given year. U.S. county life expectancy was compared with this international frontier time series to calculate how many calendar years each county is behind. During the period 2000–2007 most U.S. counties fell behind the progress seen in the leading countries. When life expectancy in U.S. counties is ranked with comparable local areas of other nations, only a very few are at the level of the international frontier, suggesting that even the healthiest U.S. subpopulations suffer from suboptimal health possible. See Figure 2

———

… In summary, the health rankings of the United States have declined substantially when compared with other nations. In absolute terms, health has improved for the nation as a whole, but the gains have faltered and mortality is actually increasing in a portion of the country, especially for women. Given the preponderance of evidence on so many indicators, despite inaccuracies in individual population health measures, it is clear that the best health status has evaded the residents of the United States …

———

… Public health agencies across the United States, from the federal to the state and local level, almost never provide the health status of other nations or parts of other nations in their organizations’ reports. In the CDC Health United States series documents, any maps presenting data stop at national borders, avoiding international comparisons; for example, similar results for our healthier neighbor, Canada, are never shown. State and local health departments that neighbor Canada do not compare their health indicators with nearby provinces or city regions. One annual publication on America’s health rankings uses an index to grade the performance of U.S. states (135). They devote some space to comparisons of the United States with other nations showing the relative decline in health status, but media reports mostly do not discuss those aspects of the report.

We have found no surveys of the U.S. public’s understanding of how their health compares with that of other nations. There are few surveys of health disparities within the United States (15). One survey of U.S. medical students in 2002 found that nearly one-third of respondents thought that the United States was the longest lived nation in the world or had the lowest infant mortality (1). Doctors in practice are not likely to be better informed, although there have been a few reports in leading medical journals of the poor U.S. health status compared with other nations (54, 118, 124). Those who speak with a range of audiences of public health workers around the nation find a large fraction of these groups are similarly unaware of the U.S. ranking in health. There are very few reports in the popular media (8) …

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… An explanation of the relative health decline may come from a population health approach that highlights the importance of structural, economic, and political factors that govern the level of inequality tolerated in society. Early life may be when these factors matter most. The United States demonstrates among the worst inequalities in outcomes for children of all rich nations (134). Income and economic inequality are important factors in a wide range of social and health outcomes (144, 145). One meta-analysis suggests that one-third of all deaths in the United States can be linked to inequality (58). Chronic stress beginning in pregnancy may be a biological mechanism through which these factors begin to operate (117, 141). The United States does not provide paid maternity leave nor paid prenatal leave, which may be important factors in affecting health outcomes (14, 38, 41, 42, 88, 97, 140). Reported stress in the United States is among the highest of all nations (55). Chronic stress may be the twenty-first-century tobacco. Addressing these issues is a major challenge and requires a level of understanding that does not exist in today’s corporatized medical environment. European policies addressing social and economic safety nets may help present some direction for improving health in the United States (138) …

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In Summary:

1. Around 1950, the United States had among the best health outcomes measured by mortality indicators, but 60 years later, it ranked behind the other rich countries and a number of poorer ones.

2. The differences in mortality outcomes between the United States and the healthiest nations today represent substantial inequalities in health.

3. Reasons for this relative decline are likely due to structural changes related to societal determinants of population health stemming from high economic inequality and lack of attention to early life issues.

4. Public awareness of deteriorating health rankings in the United States is limited, so the next steps to improving health require major communication strategies.

It really is worth reading the whole article. I highly recommend it.

Oh, and you did notice the mentions of economic inequality as a contributing factor to the decline in health status, right? 🙂

The issue of inequality was also discussed at length recently in “Erosion of Our Moral Compass, Social Trust, and the Fiscal Strength of the United States: Income Inequality, Tax Policy, and Well-Being” by Michael P. O’Donnell, the editor in chief of the American Journal of Health Promotion:

Why does inequality have such a strong impact? Inequality seems to have a devastating and cascading effect on health and other factors for at least five reasons.

First, poverty, independent of inequality, causes many health problems. These problems leave poor people with lower resilience to recover from the additional risks caused by inequality. For example, medical conditions that are higher for people with low income include obesity,22 asthma,23 diabetes,24 hypertension,25 human immunodeficiency virus infection,26 and coronary heart disease and stroke,27 as well as preterm birth28 and adolescent pregnancy.29 Smoking rates are higher among people with lower incomes and less education,30 as are death by homicide31 and premature death by any cause. Rates of disease and death are higher for these groups partly because of poor health habits, but also because of lack of access to clean and safe housing32 and clean air33 and poor access to regular medical care,34 nutritious foods, and formal education.35

Second, inequality causes people to judge themselves negatively relative to other people, a phenomenon called social evaluative threat, which in turn has been shown to trigger release of cortisol and proinflammatory cytokines.36 Cortisol impedes immune functions, increases the risk of heart disease, and threatens other physiological systems. Chronic inflammation has been linked to increased rates of autoimmune disorders including rheumatoid arthritis, lupus, and polymyalgia rheumatica; asthma; the inflammatory bowel diseases ulcerative colitis and Crohn’s disease; cardiovascular disease; bacterial endocarditis; cancer; urinary infections; and cystitis, and may increase the risk of a squamous cell bladder cancer.37 An indirect impact of social evaluative threat is that defending one’s honor becomes more important, and can lead to physical injuries caused by fighting and the additional stress caused by hostile interactions.

Third, the importance of maintaining status increases the social pressure to divert limited financial resources from food, rent, utilities, medical care, and other necessities of basic living that will preserve good health to buying nice clothes, cars, toys for kids, or entertainment to raise status, or to drugs, alcohol, or cigarettes to help cope with the stress. This temptation to divert resources from basic needs to entertainment and luxuries is much lower in poor nations in which incomes are low for all people because these discretionary luxuries are rare, not promoted through ubiquitous advertising, and rarely purchased by peers. As such, the standard of living a typical family in a poor nation that has low levels of income inequality might be similar to the standard living of a poor person in the United States (which has high income inequality) in an absolute sense, but the person living in the poor nation does not suffer the negative consequences of income inequality because that person’s standard of living is the same as everyone else he or she encounters.

Fourth, a pregnant woman experiencing the elevated stress caused by inequality generates cortisol and other stress related hormones and toxins. This combination can cause lasting damage to her fetus, increasing the likelihood of low birth weight, premature birth, or other congenital defects. This is in addition to the damage to the fetus caused by malnutrition. This makes it very difficult for this woman’s child to ever catch up.

Fifth, early childhood development is impacted directly by poverty. For example, Goodman et al38 found that the most important factors affecting child development are birth weight, mother suffering from postnatal depression, being read to every day at age 3, and having a regular bedtime at age 3, and that all of those factors are related to socioeconomic status (SES). Recovering from these setbacks compounds the challenges of a child born into poverty. For example, one of the findings of the 1970 British Cohort Study was that children in high-SES families maintained or improved their cognitive abilities relative to their peers as time passed, whereas those from low-SES families dropped. More specifically, a cohort of children from high-SES families who tested at the 10th percentile at 22 months averaged scores at the 55th percentile at 118 months, whereas those from low-SES families averaged scores at the 28th percentile at 118 months. Similarly, high-SES children who tested at the 90th percentile at 22 months averaged scores at the 68th percentile at 118 months, whereas low-SES children averaged scores at the 39th percentile at 118 months.39 It is important to acknowledge the racial bias in cognitive testing in interpreting these findings,40 but it is hard to not conclude that poverty has a depressing impact on cognitive development. This childhood development effect is exacerbated by the fact that social standing and peer acceptance are especially important to adolescent children. Those with depressed cognitive development tend to have lower social status, which produces more stress and the physical problems caused by stress, as well as increased temptation to perform risky behaviors to get attention or join gangs to enhance social relationships.

Racial discrimination is no doubt closely aligned with income inequality. Wilkinson and Pickett21 do not specifically address racial discrimination in their book and a thorough review of this is beyond the scope of this paper, but a few key points need to be acknowledged. The most obvious link between income inequality and racial discrimination is that oppressed racial groups have lower incomes,41 and thus suffer from all the negative income inequality effects described above. In addition, some people are victims of discrimination because of their race, independent of their income. In addition to increased threats of violence and exclusion from many opportunities, this discrimination creates the same type of stress caused by social evaluative threat, and the resulting physical consequences. For people with high or middle income who suffer racial discrimination, this subjects them to stresses they would otherwise be able to avoid. For people with low income, it increases the stress they already endure from poverty and income inequality.

Read the whole article here.

Again, another very good read that is worth your time.

I think one of the main challenges the United States faces is the belief of so many of its people that it has the greatest health/health care system in the world. Neither is true. Neither is even close to true. If only they were true.

Once people become more aware of these facts, there may be more of an appetite to seriously delve into these issues in order to find solutions. (One can naively hope, right?)

Soooo … looking back at the length of this post, I’ve done more than a little protesting. This protest went all batons and pepper spray. Sorry. I had just read a lot of good information on the subject recently and felt the need to share.

Having taken the time to digest all this credible information, don’t I have a responsibility to apply it as I am covering day-to-day events? I think so.

If that’s considered as trying to fit everything into my own world view, so be it. I call it trying to utilize the knowledge I’ve (perhaps to my own astonishment) managed to gain and using it to engage with my subjects.

And now you say in unison: “Protest noted. Please rest your case before you wake us up AGAIN.”

With pleasure …

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