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]
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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]
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