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Feb 12, 2014

Socioeconomic Policy Is Health Policy

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

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 title promises, 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:

  1. 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 care.
  2. 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.
  3. 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.
  4. 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).
  5. 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 work.
  6. 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 securely employed.


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 “developed countries” —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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