BIG medicine for achieving population health in the US

USBIG Discussion Paper No. 71, January 2004
Work in progress, do not cite or quote without author’s permission
Stephen Bezruchka MD, MPH
Department of Health Services
School of Public Health and Community Medicine
Box 357660
University of Washington
Seattle, Washington 98195-7660
(206)932-4928, Fax (206)685-4184
BIG medicine for achieving population health in the US
The United States today is less healthy, compared to other rich nations, today than it was
50 years ago. We are so unhealthy so that if we eradicated all deaths from our number one killer,
heart disease, we still wouldn't be the healthiest country in the world. The reason for this decline
is not our health care system, we spend half of the world's medical care bill in the USA. The key
reason is the existence of so much poverty in the richest and most powerful country in world
history. In the last 40 years our income gap has increased dramatically. The gap between the
rich and the poor has been shown to be the critical determinant of a population's health. Among
all rich countries, we have the most child poverty, the highest teen birthrate, the highest child
abuse death rate, the lowest life expectancy, and the lowest voter-turnout. The medicine we need
to treat the American population is related to decreasing the gap between the rich and the poor.
A basic income guarantee is one way to achieve this. The story of our health decline, the
determinants of population health, and the kinds of population medicine needed will be
presented. BIG would decrease the gap between the rich and poor in the US and benefit us all,
not just the poor.
It is little known among citizens of the richest and most powerful country in world history,
that they pay the ultimate price for that wealth and power, namely that they die much younger
than they need to. By any measure of health of a population, people in the USA, compared to
other rich countries, and a few poor ones, are less healthy. Our health, compared to other
countries, continues to decline, and the reason is the increasing gap between the rich and the poor
that is not only tolerated but produced by conscious efforts. This paper will review the
epidemiology on population health, demonstrate the relative health decline in the US and suggest
steps to stem that by decreasing the gap between the rich and the poor. A major step to improve
our health as a nation can come from having a basic income guarantee.
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Studies beginning about 25 years ago have extended the concept, well-known in public health
circles, that poorer people have poorer health, to demonstrate a relationship between that concept
and income distribution. There are some 50 studies looking at various populations in the world,
using various measures of income distribution, that have demonstrated that the bigger the gap in
income, the worse the health of the population. This has extended the consistent finding in
public health for the last one hundred and fifty years that there is a gradient between health
outcomes and socioeconomic status. For the last decade or more, studies have demonstrated
pathophysiologic pathways through which increasing hierarchy affects health. Activation of
chronic stress responses play a major role. (Kawachi, Kennedy et al. 1999)
These ideas are well known to US agencies, such as the Institute of Medicine which in its
2003 report "The Future of the Public's Health in the 21st Century" states: "more egalitarian
societies (i.e., those with a less steep differential between the richest and the poorest) have better
average health" (Institute of Medicine 2003)
The other well-known piece of evidence is that health in the United States has declined
profoundly over the last half-century. The same US agency source reports "For years, the life
expectancies of both men and women in the United States have lagged behind those of their
counterparts in most other industrialized nations. Life expectancy in the United States was
slightly below the OECD median in 1999 ... In 1998 the United States also ranked 28th in infant
mortality among 39 industrialized nations. In the area of chronic disease, reported incidence
rates in 1990 for all cancers in males and females were highest in the US among a group of 30
industrialized nations."
In what I call the Health Olympics, the ranking of countries by life expectancy, using data
from the annual United Nations Human Development Report, in the 2003 report we were tied for
26th, and the year before we were 25th. (Bezruchka 2001; UNDP 2003)
The gap in health between people in the USA and the world's healthiest country, Japan, could
not be bridged by even measures such as curing heart disease, the number one cause of death in
this country. There is no medical doctor practicing who would consider such a phenomenal
accomplishing of ending heart disease as possible within our lifetimes. However, some fifty
years ago, the USA was one of the five healthiest countries in the world (precise data for that
period are lacking), so our relative standing today, when we are less healthy than pretty well all
rich countries, and a few poor ones, constitutes an emergency of phenomenal proportions.
(Oeppen and Vaupel 2002) However, neither our leaders, nor our medical community, nor
public health agencies, nor citizens of this country express concern.
To detail some of these concepts, the health of a population is usually measured by death
rates, and computed from these average length of life, or life expectancy represents a summary
statistic allowing comparisons of health status. Other commonly used measures include infant
mortality rates, and indicators that factor in disability and quality of life. There are no measures
of health in which the United States performs well, compared to other countries. Other examples
of our poor health status, compared to other rich nations, demonstrate that we have the highest
teenage pregnancy rates, the highest child poverty rates, the highest homicide rates, the highest
incarceration rates, the highest child abuse death rates, and among the highest rates of other
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health-related conditions. (UNICEF Innocenti Research Centre 2000; UNICEF Innocenti
Research Centre 2001; UNICEF Innocenti Research Centre 2001; UNICEF Innocenti Research
Centre 2002; UNICEF Innocenti Research Centre 2003)The United States of America is a very
sick society if we compare ourselves with other nations.
Commonly, health and health care are conflated. The words are often used interchangeably
even by educated people, and various agencies. The United States spends close to half of the
world's health care bill, so logically, if we are less healthy than most other rich nations, who
spend far less on health care, it cannot be health care that produces health. Even our expensive
health care system, does not compare well with those in other countries which spend far less,
according to the World Health Organization. (WHO 2000)To understand the disjunction
between health and health care, consider health care as analogous to the army medical corps.
The army medical corps did not decide whether to invade Iraq or not. It did not decide on the
battle strategies, whether to invade from the air, or to launch missiles or drop bombs, and
whether to send in ground troops. It did not decide on the ordnance to be used, or the protective
gear for the combatants. Victims of such conflicts usually die immediately from the blast, bomb,
or bullet. The corps role was merely to go in after the conflict began and pick up those who are
fortunate not to be killed outright and who demonstrate some signs of life. These lucky
individuals are splinted, major bleeding stemmed, and then evacuated to a field hospital where
heroics are carried out to save lives. Few Iraqis had this option. Eventually the survivors would
have prosthetic limbs attached, and spend consider time in rehabilitation facilities. Some of them
would return to productive lives but many would not. This is the best that can be expected of
medical care. It does not produce health. This is well documented in the public health literature,
such as in the definitive Oxford Textbook of Public Health where we find: “The impact of
personal medical services on the health and survival of individuals seems readily apparent. With
modern investigations and treatments, patients are now regularly saved and make very good
recoveries from infections, injuries, and a variety of other conditions that were almost uniformly
fatal even a few years ago. Surprisingly it is more difficult to demonstrate conclusively the
impact of these medical advances on the health of whole communities” (Jamrozik and Hobbs
The best studies demonstrating the relationship between the range of hierarchy in a society
and its health have been conducted in the United States of America using income distribution.
(Kawachi and Kennedy 2002)In societies in which most goods and services have to be
purchased, as is the case in the US, income and its distribution represents a good measure of the
hierarchy. In other countries with consider able behind income re-distribution mechanisms, such
as the Western European countries, and to some extent, Canada, other ways to relating hierarchy
to health must be employed. (Ross and Wolfson 1999)
Within the US, then, states with a smaller income gap have better health than those that are
structured to give the rich a greater proportion of income. This is also evident at the city or
country level across the country. Numerous studies demonstrate a relationship between income
distribution and social capital, the sense of community and trusting that is also related to health.
There are others that relate women's political participation to both men's and women's health.
The surprising finding is that where women do better, healthwise, men's health is improved to an
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even greater extent. In states where there are more racist attitudes, African American health is
In addition to income distribution being related to mortality measures of health, there are
many other associations. For example, voting rates, smoking rates, obesity rates, and teenage
birth rates have been shown to be related to the income gap within the United States. This
suggests that the hierarchical structure of society may be the most important factor affecting the
critical aspects of life and well-being.(Kawachi and Kennedy 1997; Kawachi, Kennedy et al.
1997; Kawachi and Kennedy 1999; Kawachi, Kennedy et al. 1999; Kawachi, Kennedy et al.
1999; Blakely, Kennedy et al. 2001; Blakely, Lochner et al. 2002; Kawachi 2002; Subramanian,
Belli et al. 2002; Blakely, Atkinson et al. 2003; Subramanian and Kawachi forthcoming)
There has been little criticism of this material to date, which is surprising, considering how
much criticism there is surrounding almost any medical issue. As an emergency medicine
physician, I find this remarkable, since in my specialty there is little that we can say with
certainty. The existing criticism comes from two economists who attempt to over control the
relationship for proxies of income distribution and thereby negate the findings. (Mellor and
Milyo 2003) Other issues are how to deal with race in the US. (Deaton 2003)
The panoply of studies points to the hierarchical structure of a society as being perhaps the
most important factor impacting its health. The increasing income gap in the United States over
the last thirty years can be considered as the primordial factor that has resulted in our relative
health decline among nations. The most graphic example of the gap is the CEO average worker
pay ratio. The New York Times, Jan 25, 2004 reports this figure to be 531 times in the US,
while only 10 to 1 in Japan, the world's healthiest country and 21 to 1 in Canada, which is almost
as healthy as Japan. Business Week reported the pay ratio to be only 42 to 1 in the US in 1980.
While today, it is only the richest segment of society that sees income gains, when we were more
healthy compared to other countries, in the 1960s, for example, it was the poorest fifth of US
families that saw the highest percentage increase in income.
We can consider ways in which the income gap has increased over the last several decades.
Taxation is one mechanism. In the late 1940s, when the US was one of the world's healthiest
countries, the highest individual marginal tax rate was over 90%, and now it is below 40%. The
lowest tax rate has changed little during that time. Today's individual income tax cuts affect
mostly the rich. Corporate taxation has been vastly reduced. Corporate taxes represented 40%
of the federal tax bill in 1940, whereas now they account for just 7% of revenue.
Income has become untied from the value of work. CEO compensations of greater than a
hundred thousand dollars an hour exist. The purchasing power of the minimum wage is a
fraction of what it used to be. And there is evidence of many people in this country receiving
less than the minimum wage. Low income people work at two and three part-time jobs, to try to
make ends meet. Workers in this country put in about 9 weeks more per year than those in the
healthier Western European countries. This has spawned the take back your time day movement.
(de Graaf 2003)
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Subsidies to various sectors of the population represent another modality. As has become
evident in the debates surrounding globalization, big business receives massive government
subsidies in both manufacturing and agriculture. This strongly distorts market mechanisms. At
the same time, subsidies for poorer people or welfare payments as they are called have been
drastically slashed. Furthermore, outsourcing of production has produced a huge job loss with
attendant effects on unemployment. The subsidies for low cost housing that were wiped out in
1981 created a huge homeless population in this country. The homeless in the US have now
become a fact of life, and many citizens cannot remember when they didn't encounter homeless
people on a day to day basis. There are considerably more than a million homeless children in
the richest and most powerful country in world history, and their numbers do not produce a cry
for a solution. (Egan 2002)
Considers systems dynamics concepts on the effects of intervening in various parts of the
system. (Meadows 1997)Checking numbers to see if our health relative to other countries
improves is the easiest to do, and clearly we have been steadily declining over the last few
decades, so something must be done if health production were to become a goal in this country.
Changing material stocks and flows is a more effective step. Given that we spend the most on
health care and have nothing to show for it, we might consider spending less. Regulating
negative feedback loops might require a maximum wage. Driving positive feedback loops would
suggest we could offer our leaders automatic re-election if the USA stood better than tenth in the
Health Olympics. Focusing information flows on the problem at hand might suggest that the
president in the State of the Union address would have to describe the US standing in the Health
Olympics. The most effective might be changing the values and paradigm that influences the
system. Given the individualist mentality present today, the American Dream of working to
achieve anything you want, and the increasing numbers of poor present in this society, the
Dream has turned into a nightmare. The societal, caring sharing focus that de Toqueville wrote
about in Democracy in America over a century ago, could be restored.
Proximate steps to decrease the gap would be easier to accomplish by lifting the bottom up,
rather than trying to put a cap on the top. We have talked income, but household wealth is an
even better measure of hierarchy, albeit one that is not easily obtained or monitored. Wealth
distribution has always more lopsided than income disparities and differences have grown
immensely in recent years. Asset-building policies are one way to influence wealth distribution.
(Boshara 2001; Boshara 2003)An individual development account could be set up to give each
newborn an asset account, depositing say, $6000 that in a safe investment portfolio would
amount to a substantial sum by adulthood.
A more saleable idea may be a Basic Income Guarantee. There are various strategies and
there is evidence that this would reduce the hierarchy in a society. This paper is not about the
details of such a policy, but to point out that it may be the most practical step in the short-term
that could counter the increasing hierarchy in this country that has such profound health impacts.
One way to sell this concept is to point out that it would benefit those who do not receive a basic
income from the policy, by improving their health. That is, every one would enjoy health
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benefits if this country had a smaller gap between the rich and the poor. Such a structural change
would not just benefit the poorer segments of society, but would produce better health in all of
us. The health improvements would be most marked in our children and grandchildren, as there
may be lag effects in changing hierarchy through influencing income distribution. But we must
stem the hundreds of thousands of needless deaths in this country because of our policies that let
the rich have an ever increasing share of the resource pie.
Stephen Bezruchka MD, MPH
Department of Health Services
School of Public Health and Community Medicine
Box 357660
University of Washington
Seattle, Washington 98195-7660
(206)932-4928, Fax (206)685-4184
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