Class and Health

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,
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

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

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

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.”
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
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?

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