Last quarter I made the point that medical care isn't
uniquely important in improving people's health.
More important than medical care are the conditions under
which people live and the choices they make.
Unemployment remains high, particularly in rural
America. Now there's a lot of controversy about the
Supplemental Nutritional Assistance Program
(“SNAP,” formerly known as food
stamps) and unemployment assistance. When wondering
about policy questions, I tend to see what's going on in
the rest of the world.
One succinct report, published in 2003, has had great
impact across Europe. The report covers what its
Social Determinants of Health: The Solid
Facts. It has several references to the
original research for each of its points. The
review was written by Richard Wilkinson and Michael
Marmot and published by the European Office of the World
Health Organization. It's often referred to as the
“Marmot Report.” Here's a
summary of its first six points:
The Social Gradient. For many years
Britain has had a National Health System with the same
medical care available to all its residents.
Between 1997 and 1999, professional men were five years
older and professional women over seven years older
when they died than their counterparts who had worked
in unskilled manual occupations in England and
Wales. Where you live on the socioeconomic ladder
determines how long you live, regardless of medical
Stress. Our stress response is
appropriate for short-term
situations—fighting or running away from
danger. It raises blood pressure, heart
rate and various hormonal levels. When the
threatening situation goes on for months and years due
to unemployment or impending home foreclosure the
health impact in terms of hypertension, diabetes and
mental disorders can be quite damaging.
Early Life. Much of adult health,
including risk of adult diabetes, is influenced by
prenatal and early childhood health. These, in
turn, will be influenced by the mother's education and
health before she conceives.
Social Exclusion. “Life is
short where its quality is poor. By causing
hardship and resentment, poverty, social exclusion and
discrimination cost lives.” (Marmot Report,
pg. 16) Of 18 countries documented, the United
States had the largest percentage of children living in
poor households (i.e., with incomes below 50 percent of
the national average household income).
Work. Jobs that are very demanding,
and give the employee little or no control over their
work, impose up to 2.3 times the risk of heart disease
than jobs in which people feel more control over their
Unemployment. Higher rates of
unemployment are associated with physical and mental
illness, and early death. The British unemployed
had over 150 percent of the chronic physical illness
and twice the rate of poor mental health as the
Each of these sections is presented in more detail, with
research references and policy recommendations. For
example, the section on
“unemployment” includes the
following: “For those out of work,
unemployment benefits set at a higher proportion of wages
are likely to have a protective effect.”
Elizabeth Bradley at Yale, and her colleagues there and
at NYU, writing in the British journal, BMJ
Quality and Safety, looked at how much all the 30
—members of the Organization for Economic
Development and Cooperation (OECD) —spend on
health care and on social services as fractions of their
total economies, and how that spending correlates with
the health of the respective countries.
They found that though the United States spends far more
than other countries on medical care, it is near the
bottom in spending on social programs, the sorts of
things Dr. Marmot is talking about. Only Mexico and
South Korea, among the “developed”
countries, spend less.
Second, when they analyzed the health outcomes of the 30
countries against their health care expenditures and
against their social services expenditures, social
services spending turned out to correlate with health of
the population at least as well as health care spending.
The developed countries spent an average of 26.3 percent
of their economies on health care plus social services in
2005. We in the United States spent 29.3
percent. We spend most of this on medical care
including very high drug and insurance charges. We
do seven times as many leg amputations on diabetics per
capita as the British. Apparently we're not good at
actually taking care of people so they don't need
amputations (see chart on “Diabetes
lower extremity amputations,” from
Why U.S. Health Care Is Obscenely Expensive,
Huffington Post, 2013). According to the Bradley article,
the medical and drug prices we pay are so high that
there's not much left for social services.
The bottom line: social services for low-income
people and the unemployed are just as important to health
as health care. Claims that our social support
programs are excessive are not justified by comparison
with other developed countries.
The marked increase in income inequality that people in
this country have experienced over the last 35 years is a
major factor in our poor health. The recession,
with its unemployment lingering in rural America, will
have long-term health consequences and costs. We
may choose which costs we pay as medical costs, as
immediate social or economic program costs, or as rising
illness and mortality, but these consequences and costs
won't go away.
Wayne Myers is a retired pediatrician and rural
medical educator. He directed the federal Office of Rural
Health Policy from 1998 through 2000, and was President
of the National Rural Health Association in 2003. He and
his wife, JoAnn, farm in rural Maine.
Opinions expressed in this column are those of
the author and do not necessarily reflect the views of
the Rural Health Information Hub.
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