July/August 2012 The words “health care” and “crisis” have become inseparable in any discussion about health policy in Canada. Stories about long waiting lists for surgery, interminable delays to see specialists, spiralling costs and the spectre of a two-tier system flood our media. With baby boomers reaching their senior years, things are only going to get worse. As numerous studies and Royal Commissions have pointed out, there’s much that can be done to make the system more efficient and responsive. But unless we do more in the way of prevention, the system threatens to collapse under its own weight.
Our healthcare system is more aptly named our sickness care system. It does a pretty good job of treating illness, but when it comes to prevention, it’s mostly up to us: don’t smoke, eat lots of fruits and vegetables, keep physically active, take time to relax. It’s hard to avoid the messages that bombard us from the media and our doctors that our health is our responsibility. Healthy lifestyles are no doubt good for us, but it turns out that the social conditions in which we live and work are more important in determining our health than either the health care system or our personal habits.
It’s hardly a new idea. Back in the mid-19th century, the Council of Berlin asked the brilliant German pathologist Rudolph Virchow to investigate a typhus epidemic in Upper Silesia. He reported back that the problem was caused by “mismanagement of the region by the Berlin Government.” Among his recommendations were full democracy for Upper Silesia, a shift in the burden of taxes from the poor to the rich, universal education, and the separation of church and state. Needless to say, the members of the Berlin Council were not pleased. They claimed that Virchow’s report wasn’t a scientific document at all, but was rather a political tract. To which Virchow retorted, “medicine is a social science and politics is nothing but medicine writ large!” He added, “If medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?”
Indeed, some of the greatest gains in health have come from laws addressing those defects; laws banning child labour, setting minimum wages, creating the 40-hour work week, establishing social safety nets, and mandating universal access to education. None of these reforms were passed in the name of health, but all have contributed enormously to our health and longevity. Unfortunately, our political leaders today are as reluctant as the Berlin councillors to recognize the connection between social conditions and health, preferring instead to blame the victim. To drive home the point, the diseases that plague North Americans today have been labelled lifestyle diseases. Heart disease, stroke, obesity, diabetes and even cancer have been blamed on our wayward habits — too many fatty foods and sweets, too much alcohol, too little exercise. But a large body of research over the last 30 years has confirmed the importance of the social realm in determining our health.
The heart of the matter
Leonard Syme is considered the father of the discipline known as the social determinants of health. He’s an epidemiologist at the University of California at Berkeley who has spent much of his career exploring the causes of heart disease. For the last half century, the reigning theory has been the diet/heart hypothesis — the idea that a diet high in saturated fat and cholesterol raises blood cholesterol levels, which, in turn, leads to heart disease. The diet/heart hypothesis is received wisdom in both lay and medical populations, yet Syme says there’s not a shred of evidence to support it. After doing an exhaustive search of the medical literature, he failed to find a single study proving that the amount of fat in your diet has anything to do with either serum cholesterol or heart disease.
In a groundbreaking study in the 1970s, Syme and his colleagues followed a group of Japanese men who migrated from Japan to California. They found a staggering five-fold increase in heart disease rates among the California migrants. Their first assumption, given the diet/heart hypothesis, was that adoption of a fatty Western diet was the main culprit. Yet, according to Syme, “the Japanese in California did eat a more Western diet than they did in Japan, but that didn’t in any way explain the five-fold increase.” In fact, the increase couldn’t be fully explained by any of the usual risk factors, including diet, smoking, high blood pressure or high cholesterol levels. What the researchers did discover, to the surprise of all, was that those men who retained “traditional Japanese ways,” who kept strong ties with the Japanese community, attended Japanese churches, went to Japanese doctors, lawyers and the like, had only one fifth the heart disease rates of their counterparts who integrated more fully into American life, despite the fact that both groups were eating a more fatty diet. In trying to understand why, Syme made several trips to Japan and interviewed hundreds of people. Wherever he went, he says, people kept telling him, “the real problem is that Americans are so lonely.” The Japanese migrant study spawned a whole new line of research demonstrating that social support and human connectedness are more important in determining people’s health than any of the usually cited risk factors.
Preventing diabetes
Type 2 diabetes is the disease that’s most directly linked to people’s personal behaviours. It’s also the fastest growing chronic condition in Canada and threatens to overwhelm our health care system. According to Richard Glazier, a family physician and senior scientist at the Institute for Clinical Evaluative Sciences in Toronto, with a proper diet and sufficient exercise, the disease is highly preventable. Yet, despite years of advice about healthy lifestyles, the incidence of type 2 diabetes is only getting worse. To come to grips with the problem, Glazier and fellow physician Gillian Booth headed a 2007 study mapping the incidence of diabetes in the City of Toronto. They weren’t surprised to find that diabetes rates were highest amongst low-income groups and recent immigrants, but what did surprise them was how the incidence varied by neighbourhood. The suburbs and outlying areas had far higher rates than many downtown neighbourhoods, even though these housed some of the lowest-income groups and highest concentrations of recent immigrants. On further investigation, they found that the areas with the highest diabetes rates had very poor access to healthy food, fewer amenities like parks, community centres and bike paths, poorer access to public transportation and greater dependence on cars. Those factors, combined with low income and a food system that makes junk food cheaper than healthy alternatives, have created a perfect storm when it comes to type 2 diabetes. According to Glazier, addressing what he calls “upstream factors” would do far more to prevent the disease than focussing exclusively on diet and exercise.
The social gradient in health
The biggest upstream factor when it comes to health is income. It’s been known for as long as we have had records that those at the top of the social ladder are healthier and live longer than those at the bottom. In Canada, there’s a four-and-a -half-year gap in life expectancy between the richest and poorest quintiles for men, and a two-year gap for women. If you look at premature deaths before age 75, the gap is considerably bigger. The poor bear a greater share of the burden of virtually every disease and condition, from heart disease, diabetes and cancer to addictions and mental health problems. It makes intuitive sense that this would be so. The poor live in substandard housing and blighted neighbourhoods, can’t afford healthy food, are more likely to drink and smoke, and live stress-filled lives with little economic security. But research over the past 30 years has shown that it’s not just a matter of a gap between the poor and everyone else. In every society that’s been studied there’s a social gradient in health; for almost every disease and disorder, the higher you are on the social ladder, the healthier and longer-lived you’re likely to be.
According to Richard Glazier, in Canada “even those earning over $100,000, who live in wonderful homes, take expensive vacations and can afford healthy food, don’t do as well as the super rich.” For some diseases, he says, the gap between the middle and upper income groups is as big as that between the middle classes and the poor. While researchers don’t know exactly what’s causing the gradient, Glazier says there’s obviously something beyond diet and exercise that is affecting us all to varying degrees. He believes it has to do with our level of psychosocial stress, which in turn is affected by the amount of control we have over our lives, the amount of social support we have to buffer whatever stresses we encounter and how we feel about ourselves and our place in society. These are all strongly related to our position in the social hierarchy.
Inequality matters
Social hierarchies will always be with us, so it’s unlikely we’ll ever completely eliminate the social gradient in health. But we can do something about its steepness. In their 2009 book The Spirit Level: Why Equality is Better for Everyone, British epidemiologist Richard Wilkinson and co-author Kate Pickett analyzed health and social data for 22 of the world’s developed countries and from the 50 American states. Their findings were consistent and stunning. On almost every measure of human health and well-being, from life expectancy, infant mortality, obesity and mental illness to teenage birth rates, addictions and homicides, they found that more equal societies performed better than less equal ones. What’s more, the gradient in health was steeper. Even those at the top of the economic ladder were worse off in more unequal societies than their counterparts in more equal societies. Wilkinson and Pickett stress that the differences between countries have nothing to do with absolute levels of income. What the data shows is that, once a country reaches a certain level of development, what matters is not how rich the country is, but how equal it is.
The US, one of the world’s richest countries and also one of the most unequal, scored at or near the bottom of the scale on almost every indicator Wilkinson and Pickett examined, while Japan and the Scandinavian countries, which are among the world’s most equal countries, did best. As usual, Canada was somewhere in the middle.
Although the US has the world’s highest per-capita spending on health care, it ranks 50th in global life expectancy. Within the country, there’s an enormous gap in life expectancy between the rich and poor. The gap is as large as 20 years between rich whites living in Maryland and poor blacks living just 20 miles away in Washington, DC. That’s one year of life for every mile.
While the dismal mortality rates among the US poor can be attributed, in part, to people’s personal behaviours, the gap has everything to do with the conditions under which people live and work. According to a report by the World Health Organization’s Commission on the Social Determinants of Health, “Unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon, but is a result of the toxic combination of poor social policies and programs, unfair economic arrangements and bad politics.”
But those variables are amenable to change. Nancy Krieger, a professor at the Harvard School of Public Health, investigated changes in the rate of premature mortality and infant death in the US from 1960 to 2002. She found that inequities shrank from 1966 to 1980, at the same time as socio-economic disparities in the US were declining. She credits the creation of Medicaid and Medicare, community health centres, the US war on poverty and the Civil Rights Act of 1964. Since the 1980s with the advent of neoliberalism, the mortality gap has steadily widened, in tandem with the growth in income inequality.
Similar changes have taken place in Britain. Not coincidentally, the health gradient got steeper during the Thatcher years, which were accompanied by social cutbacks, employment insecurity and a growing income gap between rich and poor. According to Michael Marmot, Director of the International Institute for Society and Health at University College, London and head of the WHO Commission on the Social Determinants of Health, there was a five-and-a-half-year difference in life expectancy between the richest and poorest men in 1970. By the end of the Thatcher years, that had grown to a nine-and-a-half-year difference.
Why greater inequality leads to worse health
As Marmot says, it’s not how much you have that counts, it’s what you can do with what you have. If a society provides social security, education, health care, transportation, recreational opportunities, child care, parental leave and so on, than income doesn’t matter that much. But if you have to buy all those things yourself, income makes a huge difference. The less you have, the greater your stress load. And yet, as societies become more unequal, those with the power to influence public decisions are less likely to support investment in the public sphere. Alex Himelfarb, former Clerk of Canada’s Privy Council, puts it this way: “When inequality grows too great, you cannot find a public interest, because people’s experience of society is so diverse.” As a result, the rich secede from the public sphere and support declines for everything from public infrastructure and education to social security and health care.
The growth of income inequality has other insidious effects which undermine people’s health. The widening of the gap between the rich and the rest of us exacerbates the consumer anxiety that is so pervasive in our culture. As the rich get richer, they spend more; they build bigger mansions, install fancier kitchens and throw more elaborate parties. Cornell University economist Robert Frank says this ups the ante for everyone and sets up what he calls a series of spending cascades. The average house size in the US is now 50 percent larger than it was 30 years ago. The average wedding costs $28,000 compared to $11,000, adjusted for inflation, in 1980. But while incomes for the top 1 percent have soared, incomes for the vast majority have stagnated or declined. For the middle classes, the pressure to “keep up” has meant going ever deeper into debt, and with more debt comes more anxiety and stress.
For the poor, the pressures of growing inequality are even worse. As the standards rise for what constitutes a good life, the poor are increasingly left behind. As Michael Marmot says, “if those lower down on the income scale can’t fully participate in what it means to be part of society, that creates a huge amount of stress. If your neighbour’s kid has the latest sneakers and goes on skiing holidays, you want that for your kid too — you want to be a full social participant.”
Where does Canada stand?
In 1974, former Liberal Minister of Health Marc Lalonde published a report titled A New Perspective on the Health of Canadians. It was the first public document in any country to emphasize that the major determinants of health lay outside the health care system. Since then, Canada has been a leader in the field of social determinants of health. Academics and health policy analysts have held major conferences and published scores of papers dealing with everything from the importance of early childhood education, to the need to rebuild our cities and fix our broken food system, to the need to give workers more control in the workplace, to the impacts of poverty and isolation in old age. The evidence is compelling, yet for the last three decades government policy has moved in precisely the opposite direction. Since the mid-1980s, following the election of Brian Mulroney and the imposition of his neoliberal agenda, social programs have been slashed and income inequality has grown. Fully one third of all economic growth in Canada has gone to the top 1 percent, while wages and incomes for the majority of Canadians have stagnated. At the same time, life has become far less secure for the majority of Canadians as job security vanishes, pensions come under fire and the social safety net weakens. The Harper government’s attack on unions and its planned cuts to Old Age Security will only worsen these trends.
A World Health Organization document on the Social Determinants of Health states that “if policy fails to address the links between social inequality and health, it not only ignores the most powerful determinants of health in modern societies, it also ignores one of the most important social justice issues.” By working toward a more fair and just society our health will follow. So too might our happiness.
-Jill Eisen is a freelance writer and documentary radio producer, primarily for CBC Radio’s Ideas program.
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