We obsess over health care in the United States, because we all want to be healthy. In the process, new evidence suggests, we're ignoring the social dynamics that actually determine our health.
The U.S. Supreme Court this week begins the process of deciding the fate of the Obama health care reform, and much, as the pundits like to say, will be at stake in the high court’s decision. The extent of federal authority. The political momentum into November. Access to health care for millions of Americans.
What won’t be at stake in the Supreme Court’s health care reform decision: the ultimate health of the American people.
Most Americans, of course, assume otherwise. We’ve become totally accustomed to equating “health care” with “health.” If you have health care, our conventional wisdom goes, you’re going to have health.
But that connection — in real life — doesn’t hold. And last week brought stunning new evidence of the disconnect between health care and health from a respected professional journal, the Annual Review of Public Health.
The United States, this new evidence shows, has been spending more and more on health care over the last half-century, much more than any other nation, and we have precious little, as a society, to show for that investment.
On nearly every global yardstick that measures life expectancy and health, the just-published Annual Review of Public Health analysis shows, the United States now ranks either last among major developed nations or close to it.
What’s going on here? Inequality is going on. Inequality generates a chronic stress that saps and zaps our physical health, and no major developed nation has become more unequal over recent decades than the United States.
The research on inequality’s adverse health impact has built steadily over recent decades, as the author of the new Annual Review of Public Health analysis, the University of Washington’s Dr. Stephen Bezruchka, knows quite intimately. A Bezruchka essay on inequality and health, published in Newsweek 11 years ago, gave the linkage one of its earliest public exposures.
In his new Annual Review of Public Health paper, Dr. Bezruchka brings together for the first time ever all the many metrics that compare nations on how long and how well their populations live, everything from infant and maternal mortality statistics to the numbers on life expectancy at birth and age 50.
Some of these yardsticks go back decades, and the United States, decades ago, ranked high on most all of them. In the 1950s, the numbers demonstrate, Americans lived in one of the world’s healthiest and long-lived nations.
On maternal mortality, for instance, the United States rated as the world’s safest place for the 1951-1953 period. On overall life expectancy, Americans ranked seventh in the world in the early 1950s, not all that far from first place.
But since then dozens of other nations have leapfrogged over the United States in what Dr. Bezruchka has come to call the “health Olympics.” The United States, the latest data detail, ranks 39th in maternal mortality, 34th in life expectancy at birth, and 29th for remaining years of life at age 50.
One somewhat newer global yardstick, Dr. Bezruchka notes, traces how many 15-year-olds die before they hit 60. The United States, on this metric, ranks 44th in the world. American males at age 15 now have “twice the chance of dying” before age 60 as have 15-year-olds in this category’s top-ranking nation.
These American 15-year-olds are living in a society that outspends every other nation on earth — by a vast margin — on health care. In 2009, the $2.5 trillion the United States spent on health care represented 42 percent of the entire world’s spending on health care.
Why haven’t America’s vast outlays on health care produced better health outcomes? Dr. Bezruchka discusses — and dismisses — the various rationalizations for America’s declining global health standing.
Some blame the low U.S. rankings on the increased immigration of unhealthy people into the United States. But Americans of Hispanic origin, Dr. Bezruchka notes, turn out to “have better health status than do non-Hispanic whites.”
Others blame Americans’ poor personal health habits. But Americans have better personal health habits — lower levels of smoking, for instance — than people in many more longer-lived nations.
Access to health care doesn’t explain the poor U.S. global health standing either. Americans with access to health care don’t live as long or as well as their counterparts with access to health care elsewhere in the developed world.
We can only make sense of America’s declining global health ranking, Dr. Bezruchka posits, if we look at the nature of our social relations, most particularly at how economically unequal the United States has become since the middle of the 20th century.
Health care, as Dr. Bezruchka points out, “mainly treats disease manifestations later in life.” Health care cannot treat the basic “social determinants” of health that make and keep us sick.
And just how does inequality make us sick? Another veteran observer of the American health scene, American Journal of Health Promotion editor Michael O’Donnell, has just taken a noble stab at an explanation in a passionately penned column just published in his journal’s most recent issue.
What difference does inequality make? The more unequal a society, O’Donnell explains, the more people “judge themselves negatively relative to other people” and the more they feel threatened.
This sense of threat has a biological impact. The stress triggers the “release of cortisol and pro-inflammatory cytokines” that wear down human immune system functions and invite a wide range of diseases and disorders.
The heightened “importance of maintaining status” in an unequal society, O’Donnell adds, also “increases the social pressure to divert limited financial resources” away from basic necessities that help preserve good health to purchases that signify higher social status — or to outlays for drugs or drink “to help cope with the stress.”
Elevated stress, O’Donnell’s American Journal of Health Promotion editor’s column continues, can be especially damaging during pregnancy, “increasing the likelihood of low birth weight, premature birth, or other congenital defects.”
Against all these dynamics, modern medicine in and of itself can only have a limited impact.
In fact, notes Dr. Stephen Bezruchka’s Annual Review of Public Health analysis, if modern medicine somehow eliminated all U.S. cancer deaths, average American life expectancy would increase by just three years, not enough to cover the life expectancy gap between the deeply unequal United States and the much more equal Japan, the nation with the world’s longest life expectancy.
For better health, in short, we need a political overhaul that encourages a substantially more equal distribution of income and wealth.
“Medicine and politics,” as Dr. Bezruchka concludes, “cannot and should not be kept apart.”