On Widening Inequalities and Health

A peer remarked to me recently that MH Blog has in part started to look like "Social Determinants of Health Blog."  This was meant as observation, not criticism, but the observation is a fair one.  To be sure, the medical humanities is significantly more expansive than concerns over health disparities, public health policy, and the social determinants of health.  One of the challenges of working on an interdisciplinary blog like this is that I cannot possibly hope to cover the breadth and length of the medical humanities.  That's one reason I rely so heavily on the skills of the various contributors to this blog, to help me try to expand the reach of the posts here. 

However, from the outset, I freely admitted that this blog will undoubtedly reflect my own interests and pursuits, even though it is not, per se, a personal blog.  This is itself a humanist precept, of course, as we've noted here before.  Moreover, work on health disparities, health policy, and the social determinants of health touches on the medical humanities in important ways.  I think of it as evoking Plato's fundamental question: how shall we live? What kind of society do we want to practice being? I hope the answer to this question is in part, "a society that consciously works to ameliorate human suffering."

Of course, the translation of that general principle into local, particular action is obviously fraught, but this, too, is a quintessentially humanist concept.  In short, I think the medical humanities have much to offer for the socially minded health policy commentator (and what other kind could there be?!?), and that is reflected in this blog.

With that said, the N.Y. Times ran an article on the widening health inequalities in the U.S., continuing the recent spate of coverage on the SDOH.  Excerpts:

WASHINGTON — New government research has found “large and growing” disparities in life expectancy for richer and poorer Americans, paralleling the growth of income inequality in the last two decades.

Life expectancy for the nation as a whole has increased, the researchers said, but affluent people have experienced greater gains, and this, in turn, has caused a widening gap.

[ . . . ]

Some health economists contend that the disparities between rich and poor inevitably widen as doctors make gains in treating the major causes of death.

Nancy Krieger, a professor at the Harvard School of Public Health, rejected that idea. Professor Krieger investigated changes in the rate of premature mortality (dying before the age of 65) and infant death from 1960 to 2002. She found that inequities shrank from 1966 to 1980, but then widened.

“The recent trend of growing disparities in health status is not inevitable,” she said. “From 1966 to 1980, socioeconomic disparities declined in tandem with a decline in mortality rates.”

This is significant for a variety of ethical and policy reasons, not least of which is the burgeoning evidence that population health is itself connected in significant ways to overall socioeconomic inequalities.  The idea is that one of the most promising means to improving population health is by reducing inequalities (and there are many ways of doing so that do not expressly rely on wealth redistribution).

As they say, go read the whole thing.

Comments

[Jim Lebeau]

Which is the cause, and which the effect? Poor health can lead quickly to poverty.

Also, who is poor? At times in my life I have been among the penniless uninsured. Now I am fairly well off. When I die, do the rich or poor times count? What if I die of a heart attack upon learning the Bill Gates has given me a billion dolloars? Would I be Very rich?

[Daniel S. Goldberg]

Hey Jim,

The issue of cause and effect in poverty and health is an extremely old issue -- though no less legitimate for its being old. The short answer is "both," but there is some outstanding and rigorous analysis in the SDOH and social epidemiology literature that makes it quite plain that while poor health causes poverty, poverty is much more likely to be productive of poor health.

The best source for this is the collection on SDOH edited by Marmot & Wilkinson.

As for who is poor, that's a methodological question that would depend on the particular study being evaluated. As far as I know, no one seriously questions our ability to specify the population by class and socioeconomic status at any given point in time.

[Jim Lebeau]

I have seen (and heard of) people who live in real poverty all of their lives, but true poverty, in my experience cannot be measured in dollars. By using money or a lack thereof as a substitute for poverty, we get a real systemic error.

Look at the works of Thomas Sowell if he is not too heretical for your eyes.

[Daniel S. Goldberg]

Jim,

Several points: first, when we are discussing the social determinants of health, we need to go way beyond a conception of absolute poverty, as Michael Marmot's work makes clear. African-American males in Harlem "enjoy" a GDP of just under $30,000 and have a life expectancy of 62. Costa Rican males have a GDP of approximately $6,000 and have a life expectancy of 71.

Work on the SDOH goes far beyond absolute poverty.

Second, your point that dollars is a limited way to conceptualize poverty has some merit. However, socioeconomic status factors in more than simply absolute wealth, although there is excellent evidence that income in and of itself is a crucial factor in SES.

Third, I should probably mention that I disagree with Thomas Sowell on almost everything, though what that has to do with heresy is beyond me.