[Hpn] Economic Equality Improves Public Health - by Dr. Stephen Bezruchka Bezruchka

Tom Boland wgcp@earthlink.net
Wed, 3 Jan 2001 02:28:40 -0800 (PST)

FWD - Copyright 2001 - FREE to Street Newspapers



      By Dr. Stephen Bezruchka <sabez@u.washington.edu>

Most of us hear that we don't do enough to stay healthy. The doctor is
always on our backs to quit smoking. We leave the clinic or E.R. hearing
their advice: give up the pleasure of a smoke. Is smoking all that bad

Suppose there was a mythical place, Smoke-utopia, where people puffing
away enjoyed good health. Not possible, you say? It happens that the
world's healthiest country has the most smokers per capita. It's not the
United States, since we don't have that many smokers. Smoke-Utopia is

Three times as many men smoke in Japan as in America, yet more than
twice as many American men die of lung cancer. Yes, smokers in Japan
have worse health than non-smokers, but not that much worse.

Despite being the most powerful and wealthiest country in history, the
U.S. isn't such a healthy place to live.

To understand why, let's define the health of a country as its life
expectancy: born today, at the mortality rates today, how long can you
expect to live? If we rank countries this way, it may be no surprise
that Japan has the highest life-expectancy of any country in the world,
and we've fallen from 13th among all nations in 1960 to 25th by 1997 -
behind all the other rich countries, and a few poor ones as well.

How could we be so unhealthy? We have the most expensive and
sophisticated health care system in the world; it costs us one-seventh
of our total economy. Could it be that our health care system doesn't
buy us health? Can any health care system make a population healthy? The
answer to both questions is, apparently not.

To understand that, ask the question: what makes a population
healthy? The answer is clear. Countries with healthy citizens enjoy a
relatively small gap between rich and poor.

This has been carefully studied on many different populations, including
in the U.S. If you live in Louisiana or Mississippi, your chances of
dying early are 50 percent higher than if you live in Utah or New
Hampshire. That is because the healthier states are those in which
income is better shared than the worst states. The healthier states have
a smaller gap between the rich and the poor - people share more equally
in the pie. Those states spend less money on health care, have a greater
focus on primary care, and spend less on specialty care.

Another study of U.S. cities shows that among rich cities, as well as
cities in the middle, and those that are poor, the health of their
populations depends on the gap between high and low incomes within rich,
middle or poor groupings of cities. So the gap affects all of us, not
just the poor.

What kind of a society will have a smaller gap between the rich and the
poor? One in which people see one another as equals. The norms of
behavior are those of friendship, support, cooperation, trust,
sociability, and community. Those are healthy-sounding words.

In societies where there is a big gap between the rich and poor, the way
to get things done is through power, coercion and domination. People
with no power feel resignation, submission and resentment. These aren't
healthy feelings. The quality of the psychosocial environment determines
a population's health.

Japan's lung cancer death rates are so low because Japan has the most
equal society of any rich country. Japan restructured its society after
the Second World War to be more egalitarian. The Prime Minister makes
four times what an average worker makes. Bosses make 10 times what an
entry level worker makes. (In the U.S. now, CEOs make 475 times what a
factory worker makes). During their recent economic crisis, Japanese
bosses and managers have taken cuts in pay, rather than lay off
workers. Could you imagine that happening here? Japan attains health by
having an egalitarian society, and this allows it to deflect the (pardon
the pun) smoking gun.

The income gap in the U.S. has increased immensely, beginning in the
1970s, when there were few homeless people on the streets. Our gap,
while always higher than most rich countries, has now become
extreme. The richest one percent of the U.S. now controls 42 percent of
the wealth in the country. Seattle houses three of the four richest
people in the world! Such a situation has come about because the rich
have not had to face "market discipline." There have been no reforms in
the system that produces the rich. Reforms are necessary for the poor,
but apparently not for the rich.

It is difficult to abandon the notion that if, as a country, we all went
to the doctor and did what she said, we would be much healthier. There
are no studies to support that idea, and plenty of information to
suggest that medical care may in fact cause more harm than good. In the
U.S. alone, perhaps one in 10 deaths may be related to medical care. We
have all heard of mistakes made in hospitals, but that is less than a
quarter of the harm caused by health care. Japan is no better here. They
spend about half as much money on health care, and probably do
comparable amounts of harm. At surgery for appendicitis, a normal
appendix is often removed, about six times more frequently than in the
U.S. It isn't their health care system that accounts for
"Smoke-utopia" it is the structure of their society.

To change our dismal standing will take structural medicine, the kind a
doctor can't give you. It will only happen when the poorer people in
society organize for changes in the economy that require the rich to
conform to market discipline, not just the poor. Everyone should have
their share. Then we will all benefit from America's economic growth,
not just the rich. Everyone's health will improve. We must work to close
the gap.


Stephen Bezruchka is a doctor who works in the emergency departments of
Group Health and Virginia Mason Hospitals and teaches at the University
of Washington's School of Public Health and Community Medicine. For more
information, check out his web site (http://depts.washington.edu/eqhlth),
where the scientific studies underlying these assertions are available.


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