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| Sick
of It All |
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| Economic
equality: good for what ails you |
| by
Stephen Bezruchka |
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
anyway?
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 Japan.
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 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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