thanks for forwarding this very interesting commentary.

"d.raphael" wrote:

> Societal hierarchy and the health Olympics
> Stephen Bezruchka
>
> Canadian Medical Association Journal 2001;164(12):1701-3
>
> (http://www.cma.ca/cmaj/vol-164/issue-12/1701.asp  web site has links to
> journal articles in the references as well as a pdf file that has a figure
> which is not in the html file)
>
> What makes a population healthy? Advising individuals about the avoidance
> of risk factors is certainly important, but that is probably not the most
> efficient way to improve the overall health of a population. (1) The
> effects of the usual do's and don'ts that we all preach pale in comparison
> with the effect of society's structural factors on population health,
> especially the amount of hierarchy as measured by income distribution.
>
> With its life expectancies of 77.6 years for men and 84.3 years for women,
> Japan is the current leader in what might be called the health Olympics
> (the ranking of countries by life expectancy), a position it has held
> since 1977. Canada also ranks among the top countries, with life
> expectancies of 76.2 years for men and 81.9 years for women. Although
> Japan has twice as many male smokers per capita as Canada does, Japan's
> smoking-related mortality rate is half that of Canada. (2) Thus, although
> smoking is bad for health, it may not be that bad. Asking what makes a
> population healthy could lead us to discover other factors that affect
> health.
>
> It has long been known that the health of a population is directly related
> to its average income, at least for populations with a per capita gross
> domestic product below a threshold of $5000 to $10 000; above that
> threshold there is no consistent relation. (3) It is also becoming clearer
> that at any given level of overall economic development for a country or a
> region within a country, the populations of countries and regions with
> smaller gaps between rich and poor are, in general, healthier than the
> populations of countries and regions in which the gap is larger.
> (3,4,5,6,7) These observations imply that the economic structure of a
> nation may be the most important determinant of the health of its people.
>
> Why would income equity  the width of the gap between the very rich and
> the very poor  have such a profound effect on the health of the
> population? And why does this influence on health affect the wealthiest
> countries as well as the poorest? Several reasons have been advanced,
> including stress and its biologic effects on the distribution of risk
> factors, the level of support for positive early childhood development,
> the availability of acute health care and emergency services, and finally
> the organization of health services, particularly primary health care and
> services for children. (8)
>
> Stress may be an important mechanism. Many studies demonstrate such
> effects, and some suggest biologic explanations, for example, processes
> affecting feedback inhibition of cortisol. (3,5,9) The human body adjusts
> to chronic societal stress by altering its physiologic characteristics and
> processes, which leads to what are known medically as risk factors. (9)
> These include, among others, hypertension, lipid alterations and insulin
> resistance, which clinicians recognize and treat so as to improve
> individuals' health. These proximate risk factors may be the cost of
> repeatedly turning on and off various physiologic mechanisms in response
> to the stress caused by inequitable social structure. (10,11)
>
> Medical care tries to limit the effects of the risk factors or to modify
> behaviours so as to change the risk factors. However, known behavioural
> and other individual risk factors do not explain most of the socioeconomic
> gradient in medical conditions such as heart disease. (12)  Evidence from
> Japan, particularly that concerning smoking rates, suggests that
> individual behaviours may not be that important. Other mechanisms may
> exist to explain the strong relation between hierarchy and health that
> would link work environments, social support, early childhood development
> and personal attributes with disease. (3,8,10)
>
> Most people probably consider health care services in developed countries
> such as Japan and the United States important in prolonging life and
> improving the population's life expectancy. But there are few, if any,
> studies demonstrating the impact of medical services on the health of
> populations, a situation lamented in the Oxford Textbook of Public Health.
> (13) Some maintain that acute health care services can be thought of as
> the ambulance waiting at the bottom of the cliff to retrieve the victims
> cast off by the violent aftermath of societal structure. (14) Indeed some
> studies, particularly from the United States, suggest that acute health
> care can itself inflict significant harm. (15) People everywhere ascribe
> great powers to the health care system and seek its services. A major
> benefit of this phenomenon may be a placebo effect on the population at
> large, an effect comparable to the strong placebo response observed at the
> individual level. In spite of long waiting lists, increasing demands for
> health care and budget limitations, most Canadians feel satisfied with
> their equitable system, although they fear for the future. (16)
>
> We might ask if there is a "best part" of the health care system that is
> responsible for the gold medals in the health Olympics. Shi and associates
> (17) have shown that in those US states where income equity is greater
> (smaller gaps between the rich and poor), primary care services are
> favoured over specialty services, and better health obtains. Primary care
> may mitigate the adverse effects of income inequality or it may indicate
> that a society with a strong focus on such services is relatively
> egalitarian.
>
> An understanding of the social and economic determinants of health helps
> us to understand how Japan has done so well in terms of life expectancy.
> After World War II, the Japanese restructured their society, a change that
> resulted in a much more egalitarian distribution of income. (18) The
> concept of income equity is now firmly entrenched, and in spite of
> pressures to reform during the recent economic crisis in Japan, executives
> and managers took cuts in pay rather than lay off workers. (19) Other
> aspects of Japanese life may also be shared more equitably by the
> population. For example, even though Japanese society is reputed to be
> very stressful, with crowded cities, tiny apartments, long commutes and
> workers who push people into subway cars in order to shut the doors,
> everyone shares that stress. Social obligations and support systems
> produce a very cohesive society, one that happens to enjoy excellent
> health despite some harmful personal behaviours such as smoking. (20)
>
> Canada has finished in the top 5 countries in the health Olympics for the
> past decade, just behind the leader, Japan, whereas the United States has
> typically come in at about 25th place. (21) Among wealthy countries, the
> United States has the largest gap between rich and poor, which may partly
> explain its dismal health standing. According to Ross and associates, (22)
> Canadian provinces and cities are clustered with the best of the US states
> and cities in terms of health outcomes and income distribution (Fig. 1).
> (23) These authors found that the relation between income distribution and
> mortality rates (for infants, children, youth, working-age men and women,
> and elderly men and women) was highly statistically significant (p <
> 0.01), for the US states and Canadian provinces combined. However, only 4
> US states had income distributions similar to those of Canadian provinces.
> The strongest relations (r = 0.81) were for working-age men and women.
> Even the weakest relations (r = 0.44), for elderly men and women, were
> notable. When the Canadian provinces were considered as a separate group,
> the slope of the regression line was in the expected direction, but it was
> not statistically significant, which suggests an important effect of
> federal policies on the relation between income distribution and health,
> as described below.
>
> The policies that Canada has developed to improve population health
> reflect its more egalitarian structure. Examples include various tax and
> economic transfer policies that help to limit income differences across
> the country, as well as provision of important social services. But with
> the World Trade Organization's policies to extend the North American Free
> Trade Act, as well as other global changes, Canada is under increasing
> pressure from transnational corporations to join other countries in
> changing its equity-enhancing programs so as to "globalize" the economy,
> by shifting production to low-wage countries. (24)
>
> What does all this mean for the typical Canadian family practitioner? In
> addition to providing excellent clinical services, primary care providers
> offer understanding and moral support to their patients through many
> medical and nonmedical crises. Both of these aspects of care are
> important. Yet the effects of these clinical and nonclinical services,
> while certainly critical to some patients, may be less important overall
> to the general population than the structure of the society in which the
> patients live. If a healthy population is the goal, clinicians must enter
> the political arena and fight to maintain the social contract that has
> sustained Canada as one of the world leaders in health.
>
> Canadian physicians should not be seduced by the sophisticated (but, on a
> population basis, haphazard) "non-system" of medical care south of the
> border, nor should they be discouraged by cutbacks in funding. Caring for
> less than 5% of the world's population in a for-profit system costs the
> United States an amount that accounts for 42% of all health care spending
> worldwide, yet this country ranks behind all other rich countries in the
> health Olympics. (25) Canada should avoid this form of "damaged care" at
> all costs. Much more important for health is the need to control the
> forces of globalization that aim to turn health care into a commodity that
> is for sale to the lowest bidder. (16)
>
> Geoffrey Rose concluded his seminal book The Strategy of Preventive Health
> Care by stating, "The primary determinants of disease are mainly economic
> and social, and therefore its remedies must also be economic and social.
> Medicine and politics cannot and should not be kept apart." (26) Working
> to change the structure of society so that population health is optimized
> (and so that all countries tie for gold in the health Olympics) should be
> our goal.
>
> Competing interests: None declared.
>
> Dr. Bezruchka is with the Department of Health Services, School of Public
> Health and Community Medicine, University of Washington, Seattle, Wash.
>
> This article has been peer reviewed.
>
> Correspondence to: Dr. Stephen Bezruchka, Department of Health Services,
> University of Washington, PO Box 357660, Seattle WA 98195-7660; fax 206
> 543-3964; [log in to unmask]
>
> References
>
> 1.    Rose GA. The strategy of preventive medicine. New York: Oxford
> University Press; 1992. p. 42-52.
> 2.    Corrao MA, Guindon GE, Sharma N, Shokoohi DF, editors. Tobacco
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> Relation between income inequality and mortality in Canada and in the
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> 26.    Rose GA. The strategy of preventive medicine. New York: Oxford
> University Press; 1992. p. 129.
>
> Dennis Raphael, Ph.D.
> Associate Professor
> School of Health Policy and Management
> Atkinson Faculty of Liberal and Professional Studies
> York University, 4700 Keele Street
> Toronto, Ontario CANADA M3J 1P3
> email: [log in to unmask]