-Caveat Lector-
Newsweek
February 26, 2001
US MY TURN
Is Our Society Making You Sick?
By Stephen Bezruchka, M.D.
Americans are obsessed with health. Just look at today's 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 world's 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 world's history, this is a disgrace.
As a physician obsessed with understanding what makes groups of people
healthy, I'm dumbfounded that our low ranking doesn't raise more concern in
the medical and public-health communities. Is it because experts in these
fields don't 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, people's 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 someto 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 today's 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.
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