Newsweek - February 26, 2001
MY TURN Is Our Society Making You Sick? Americas health lags behind that of more egalitarian nations. Economic equality is the medicine we need
By Stephen Bezruchka, M.D
Americans are obsessed with health. Just look at todays magazines, TV shows, Web sites, self-help books--and where we put our dollars. As a country, we make up about 4 percent of the worlds total population, yet we expend almost half of all the money spent on medical care. We should be pretty healthy.
YET I HAVE ALWAYS been amazed at how poorly the United States ranks in health when compared with other countries. When I began medical school in 1970 we stood about 15th in what I call the Health Olympics, the ranking of countries by life expectancy or infant mortality. Twenty years later we were about 20th, and in recent years we have plunged even further to around 25th, behind almost all rich countries and a few poor ones. For the richest and most powerful country in the worlds history, this is a disgrace.
As a physician obsessed with understanding what makes groups of people healthy, Im dumbfounded that our low ranking doesnt raise more concern in the medical and public-health communities. Is it because experts in these fields dont want to question the role of medical care in producing health? Does our focus on diseases--including the search for risk factors, cures and specific preventive answers--stop Americans from looking at what would really keep us well?
Research during this last decade has shown that the health of a group of people is not affected substantially by individual behaviors such as smoking, diet and exercise, by genetics or by the use of health care. In countries where basic goods are readily available, peoples life span depends on the hierarchical structure of their society; that is, the size of the gap between rich and poor.
How can hierarchy affect health? Consider the feelings that predominate in a hierarchical situation: power, domination, coercion (if you are on top); resignation, resentment and submission (if you are on the bottom). Compare them with feelings in an egalitarian environment: support, friendship, cooperation and sociability. Studies with baboons in Kenya and macaque monkeys in captivity, both of which feature strong hierarchical relationships, show that high-ranking animals are healthier than those lower in the pecking order. Human population studies show additional findings. The death rate from heart attacks among middle-aged men is four times greater in Lithuania than in Sweden, which is much more egalitarian.
We can learn something by looking at countries that do well in the Health Olympics. In 1960 Japan stood 23d, but by 1977 it had overtaken all the others in the health race. Today, at No. 1, Japan has a life expectancy on average three and a half years longer than the United States. Twice as many Japanese men as American men smoke, yet the deaths attributable to smoking are half of ours. Why? After the second world war, the hierarchical structure of Japan was reorganized so all citizens shared more equally in the economy. Today Japanese CEOs make 15 to 20 times what entry-level workers make, not the almost 500-fold difference in this country. During their recent economic crisis, CEOs and managers in Japan took cuts in pay rather than lay off workers. That the structure of society is key to well-being becomes evident when we look at Japanese who emigrate: their health declines to the level of the inhabitants of the new country.
Did this health-hierarchy relationship always exist--is it part of human nature? Archeological records from burial mounds and skeletal remains indicate that human populations were relatively healthy before the advent of agriculture. The development of farming allowed food to be produced in quantities and stored, enabling some to live off the efforts of others--a hierarchy. With agriculture, health declined, nutrition worsened and workload increased. Why has the medical community, as well as the popular press, essentially ignored these findings? I suspect that part of the explanation lies in Americans "cradle to grave" relationship with the health-care industry, which represents one seventh of the U.S. economy.
If equality is good medicine, then what can be done to improve Americans well-being? Our primary goal should be to reduce todays record gap between rich and poor. Prescriptions for such "structural medicine" might include a tax on consumption rather than income, or increased support for public transportation, schools and day care, all of which would reflect a change in how the population shares in the economy. We must put our eyes on a new prize: doing better in the Health Olympics. The best prescription for health is not one we will get from doctors.
Bezruchka teaches at the University of Washington's School of Public Health.