IS OUR SOCIETY MAKING YOU SICK?
© Stephen Bezruchka, 2004
Seattle University Lunch Forum
Le Roux Conference Center,
Seattle, February 9, 2004
I've just been handed a late breaking news bulletin: The Weapons of Mass Destruction have been found! Wonderful news. I have to wait for my operative to get clearance from the Department of Homeland Security before I can divulge their location. So please bear with me. I hope that before the end of this session, I can tell you where they have been located.
So, thank you. I'm really excited at trying to engage in discussion with others so will try to make my remarks brief. One of the reasons, I think, for having this session is to see if there is some way for this university to take a leadership role in the community to get us healthy again.
Let me begin by mentioning the four points I want to make today:
How did I come to think these thoughts? At places such as Seattle University, epistemology is a fruitful subject to consider. I'm always interested in what led people to think the way they do. Often there are a variety of reasons such as:
How I came to think this way?
I was interested in becoming a doctor at a young age and wanted to cure cancer
I was socialized into thinking of the importance of seeing a doctor and of medical care, and my brother dying at age 4 when I was 2 probably had something to do with that.
I didn't really question what produced health, but assumed the correct messages were being beamed at me to not smoke, exercise, eat right, not shoot up, and wear my seat belt
I was interested in abstract concepts of theoretical physics and mathematics, and eventually wound up at Harvard University working towards my PhD in mathematics but I became disillusioned because I wanted to do something more useful and reverted to becoming a doctor because there was no doubt of medicine's utility.
While in medical school over thirty years ago, I came across data suggesting that this country wasn't that healthy compared to other nations, in fact there were some 16-17 countries that were healthier
I was surprised when I discussed this with teachers and fellow students that no one seemed concerned, especially when I questioned the role of medical care in producing health
I then worked as a doctor in a remote Himalayan valley in Nepal where people had no health care services and I was surprised how healthy people were once they survived childhood, and later I reflected on the people and children that got sick and realized for the most part, they were the poorest segments of society there, even though if you took a look at their lives, you'd say everyone there was desperately poor. But I could see status, caste and class differences in which those lower down in the hierarchy got sick.
I came back to the US and worked as an emergency physician, the kind of person that is featured in the series ER, which I have never watched, I noticed that whether I worked in an ER in a rich neighborhood such as Bellevue, or in a poor one such as around Tacoma General Hospital, mostly I saw poor people, and it seemed like they caused most of their problems. I thought of these poor people as taking advantage of welfare, and griped about that along with many of the nurses and other doctors with whom I worked.
As an ER doc, I blamed my patient's behaviors for their illnesses. I continued to look at the comparative health statistics and found that the US kept dropping in health status, and one country kept rising so that by 1978, it was the healthiest country in the world. I had no idea why.
Reflecting on my work and life experiences, I realized I didn't know what made a population healthy, because I began looking at the healthiest country in the world and discovering that they smoked the most of all rich countries. And all the healthier countries than the US had a less advanced health care system. I was quite perplexed.
I went back to school, to Johns Hopkins University because they had the world's biggest public health school. I was trying to understand what made a society healthy. I knew it wasn't medical care. I left there depressed because no one there was interested in that question. Some of the most progressive folks were excited by Hillary Clinton's efforts at reform of the health care system. Yes, they all admitted health care had little or nothing to do with health in rich countries, but they couldn't get their eyes off the pot of gold that was shining in front of them to work on the reforms. Meanwhile, health in the US, compared to other countries continued to decline, and no one seemed to be concerned.
So I've had to reflect on why this has been happening and what makes a population healthy on my own. I think this is a critical concept. For anything really important in your life, you have to figure it out for yourself, you can't rely on others to tell you. If you think about anything important you have learned in your life, this is how you have done it, on your own. One and One is TWO. Why you put one thing with another and you have two. It makes sense, and you can verify it.
That is how I approach health. It has to make sense and I have to be able to verify it.
So I came to make my four points by :
HOW DO I CONSIDER OTHER IDEAS AND INTERPRETATIONS IF I AM CONCERNED ABOUT SOMETHING IMPORTANT?
As a scientist, I don't want to be seen with egg on my face, especially if I am talking about something that most people may not agree with.
For almost any issue you may come across, there are usually many perspectives, facts, and the like. Almost every concept has a totally opposite view. The flat earth society still exists. But on the basis of my flying around the world a few times, I tend to not give them much credence. I can live with a flat earth, at least I wouldn't change anything I am currently doing, or have done, if everyone said the earth was flat. It wouldn't bother me a bit. It does bother me that we die young, however.
So when I begin to feel an idea or concept is important, I look for what others who should have some insight, say.
Modern computerized search scholarship is very helpful here. One wonderful way is by looking at citations of a published work, to see what others think about it. Science and Social Science Citation services are phenomenally powerful. If anyone has cited some publication to disagree with it, I can find it and read it and see if it makes sense. That is a very important way.
Another thing I do is talk with people in a variety of cultures and societies, I seek them out and have discussions. If they are dead or in prison, I read their memoirs or talk to people who knew them.
I also try to listen to speeches and other real-life based episodes that give me an idea of what kind of people they are. So I will cross the continent or the ocean to find these people or get to know about them virtually which is a phenomenal way these days.
I also pose questions for my students, and see if they can be stimulated to think critically. We have this amazing problem-based master's in public health program at the University of Washington in which the students don't take courses, but meet in groups and address problems. I have the privilege of creating the first month's problems, one a week. I'll tell you the first problem the students get when they enter the program. The scenario is that you are a speech writer for the president and he wants to make a speech about how the USA is the healthiest country in the world. Your job is to write the speech. That is what you do for the first week's problem. Simple enough.
Another thing I do is express my ideas in public and ponder reactions. Have arguments, lock horns, so to speak. This is really critical if you are telling people the earth is flat or some other far fetched ideas, as I am trying to do today.
Now I announced that the weapons of mass destruction had been located. Consider the evidence that was presented more than a year ago? How much evidence was there? What was the evidence? It sounded pretty flimsy to me. But now that we have found the WMD. Let's go on with the evidence for my 4 points since that is important for evaluating any statement.
Please take note that anything I say has plenty of supporting documentation, and for starters you could go to the references at our University of Washington's population health forum's website (http://depts.washington.edu/eqhlth/) which is on the handout which itself is full of references. None of this material is classified.
First point: WE ARE LESS HEALTHY THAN PEOPLE IN OTHER RICH COUNTRIES
I challenge my public health students to come up with some measure which shows the US as a healthy country, compared to others. Even our federal bodies admit this, so it is official. (FUTURE OF PUBLIC's HEALTH in the 21st century (2003) on page 20 it states) "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. ... In the area of chronic disease, reported incidence rates in 1990 for all cancers in males and females were highest
Whenever you make comparisons of the US with other countries, this is the refrain.
Who are these other countries that are healthier than we are? To begin with they include almost all the rich countries, and a few poor ones such as Costa Rica, Malta, Israel, Cyprus, Greece, etc. We are about as healthy as Cuba, the country we have been strangling for 45 years. Think of it, we've been making Cuban's lives as miserable as possible and they are as healthy as we are. Last month, I was in Nepal and talked with the US Agency for International Development's health section about these ideas. One astute lady asked "Is Cuba as healthy as we are because of or in spite of the sanctions?" I'll let you ponder that.
Now you might say I don't care about life expectancy, I care about quality of life, rather than living long. But there is no measure of health, including quality of life measures, in which we compare well with othercountries. For example, we have, among rich countries,
Now all of the above measures might be construed to have some relationship to health. But taken more broadly, among all nations we have the lowest voter turnout
Among the OECD countries we have
I COULD GO ON AND ON, BUT WILL SPARE YOU.
Even if we cured heart disease in the US, we still wouldn't be the healthiest country in the world. Heart disease will kill almost half of you in this room, it is our leading cause of death. As a doctor who has treated heart disease for 30 years, I consider this clinically impossible, and I dont' think there is another doctor who feels we could accomplish such a miracle. So the health gap is enormous.
Second point DECLINE OVER LAST 55 YEARS
Again, no question about this, and the federal body statement above, namely "for years life expectancies in the US have lagged behind" make a clear reference to the fact that before they, they were better. And the scientific literature is solid here, and there is no debate.
SO FAR, NO ONE WHO HAS CONSIDERED THE EVIDENCE CAN DISAGREE WITH POINT ONE OR TWO.
Third point REASON FOR DECLINE
The reason for this decline has to do with changing the structure of this country, who gets what share of the pie. Once again, our federal bodies are quite explicit.
FIRST THE FED'S QUOTE:
"more egalitarian societies (i.e., those with a less steep differential between the richest and the poorest) have better average health" so the feds know this. It is very clearly stated. We could end there as I'm verified my point with authority. But let me interpret this concept further for you.
There are lots and lots of data, studies, and the like that demonstrate that more egalitarian societies are healthier. We have statistical evidence on populations, as well as multi-level studies using individual and societal evidence. Now you would say there are "lies, damned lies, and statistics" and you can make that argument for the earth being flat so what else is new here.
Sometimes, I heard public health students say that a good epidemiologist can pick anything apart. So skeptics will want me to get into the arena with epidemiologist lions. I'm happy to do that
At this point, we need to address one thing I'm sure you are all wondering about, that I touched on at the beginning when I described how I came to think this way. Namely health care. There is no uniform relationship between health and health care, the two are different concepts. We conflate health with health care. Thomas Pychon wrote in Gravity's Rainbow: "If they can get you asking the wrong question, the answers don't matter" and so most people in this country are stuck on health care. I could spend enormous amounts of time talking about health care, but let me dismiss it with a quote from the authoritative Oxford Textbook of Public Health, a huge, 3-volume monograph, and in the 2002 edition, volume 1, page 238, in the chapter on Medical Care and Health, in the conclusion, it states: The impact of personal medical services on the health and survival of individuals seems readily apparent. ... Surprisingly it is more difficult to demonstrate conclusively the impact of these medical advances on the health of whole communities In other words, there is no convincing evidence that medical care benefits whole populations. If there was, the US would be expected to be considerably healthier than it is since we spend half of the world's health care bill. I don't expect you to believe this, but let me point out that in other countries where I present these ideas, Canada, England, France, and Nepal, there is much less incredulity than in the USA
If you are having trouble seeing the role of medical care in not producing healthy populations, consider the analogy that medical care's role is the same as that of the army medical corps in keeping us healthy. You've been reading about all these soldiers that are coming home from Iraq with legs blown off, or other serious injuries. Now the army medical corps goes in after the blast and picks up the victims, splints the limbs, starts IV's transports them to where they can get blood, and then to a field hospital station where bullet holes are closed. Their heroics are carried out and hopefully the stricken soldiers survive. We feel grateful in such cases. But most casualties, those who die, are killed outright by the blast, by the bullet or bomb. The army medical corps can't do anything for them. The army medical corps did not decide that we were going to invade Iraq, they didn't decide the battle strategies, that we were going to bomb targets including civilians, from the air, that later we would send in ground troops. They didn't decide on the day-to-day combat decisions or the ordinance used. They didn't decide on the protective gear that troops would wear. All they do is go in and pick up the pieces, those fortunate ones who still have signs of life. That is the best that medical care can do, try to keep the survivors alive.
So more egalitarian societies, those with a smaller gap between the richest and poorest have better average health
I have spent the last ten years understanding that idea. What I have learned, is that poorer people have poorer health and the amount that poorer people's health is poorer depends on the gap between the rich and poor in that society.
Now I am talking, as the Federal Government in the Institute of Medicine's report does, about averages. There will always be individual exceptions, such as the tragic early death of Princess Diana who was not poor, and Grandma Moses, who was still painting when she died at age 101, and was a poor farm girl for most of her life.
As I implied earlier one of the reasons I believe this is true comes from my 25 year experience working in emergency rooms. Fortunately in this country, we can't turn people away from them because they don't have money. Whether I work in Overlake Hospital, where some of the richest people in the world live, or at Tacoma General Hospital, or Providence Hospital, mostly the people that get sick and need attention are poor. The rich don't get sick as much, and every study shows that. They live much longer as well.
Most of my life, I used to believe it was individual behaviors that mattered in producing health. Whether or not you smoked, what you ate, whether you exercised or not, the usual stuff I used to preach to my patients. I even used to get complaints from patient's families for not doing anything more to, say an end stage emphysema patient who continued to smoke, than tell him he had to quite smoking. The family would say "he is trying to quit, but isn't there something else you can do?" And in those cases, there really isn't. I harped on the need to stop smoking. These days, I no longer do that. The reason is that I discovered that individual behaviors don't matter that much when you look at average health.
Let me give you an example to illustrate that. The healthiest country in the world, Japan, is the country which has the most smokers, amongst men. Yet Japanese men are the healthiest population in the world. They smoke twice as much as American men, yet their deaths from smoking related diseases are half of ours. Imagine that, they smoke twice as much and pay half the price. I'm not saying that smoking is good for you and the reason Japan is so healthy. Smokers will on average always be less healthy than non-smokers. It is just that there are other factors that produce health that matter more. And the Institute of Medicine states it explicitly, namely countries that have a smaller gap between the rich and poor should have better average health. Is that true for Japan?
How do we measure the gap between the rich and the poor? There are many measures used by economists and sociologists who study this stuff. One of the simplest to conceive of is the pay gap between CEO's and bosses, and average workers. For data lets go to the New York Times January 25, 2004 it gives the CEO average worker pay gap in the USA as 531 to one, while in Japan it is ten to one. So we pay our bosses 53 times more than an average worker, compared to what they do in Japan. I'm sorry, but we have to get a little quantitative, it is the mathematician in me creeping out. But I'm sure you all know how much more the bosses get paid in this country.
Just to digress, many of you may not be aware of what the highest pay is in this country, but it works out to be about a $150,000/hour if you consider that boss working a 70 hour week. As Cole Porter's song goes, "nice work if you can get it and you can get it if you try." The minimum wage is $6.01/hr, about a twenty thousand-fold difference, not the 531 fold that the New York Times reported, but that is an average. Averages hide extremes, even thought the average gap is obscene to begin with.
Now, back 55 years ago, when the US was one of the healthiest countries in the world, the pay gap was much less, and has been growing steadily since. In 1980, it was 40 to 1 according to Business Week.
Why would a small gap between rich and poor influence average health? Relationships and feelings:
THEY SOUND HEALTHY, DON'T THEY?
NONE OF THE ABOVE SOUND THAT HEALTHY, DO THEY?
How would one look at evidence to decide if it is causal or just a spurious association for a common refrain is association does not imply causation. Just because we can fly around the earth and see it as a disc from outer space does not prove that the earth is a sphere.
The Surgeon General's report on Smoking and Health published in 1964 outlined how to infer causality, using something called the Bradford Hill criteria These criteria fit in this case, and so I say we can use the same concepts to infer causality here. To use the Surgeon General's schema for inferring causation, we have many studies by my different investigators on different populations, at different times and they all show pretty much the same thing, consistency there is a dose response, namely more inequality leads to worse health. The next step is the direction of causation, inequality leads to worse health, rather than worse health leading to more inequality, and clearly it is the poor that get sick for the most part, not that people get sick and then become poor.
Finally, there is biologic plausibility, which I will speak about.
Mechanisms through which hierarchy produces worse health have to do with chronic stress. Our societies today are like baboon troops in Africa, for example. There is the alpha male, or the top dog, and there are those in the pecking order below the alpha male. The alpha male gets the best food, and the pick of the females to mate with. The beta and gamma males have very different lives. Those lower down are always on the alert that the alpha male will take the choice bit of food they have found, or chase them away from the female they were going to mate with. Their lives are under constant stress. We know that the alpha male is healthier than the beta and gamma males, the alphas have different physiology, a different stress response, than the baboons lower down. The gamma males, the lower ranking baboons are less healthy than the high ranking ones. Human studies show the same thing, that is: poor people with low incomes have the stress responses of low ranking baboons. Coronary artery plaque develops in low ranking cytomologous monkeys fed an American diet
So what is it about societies that decide to have most people share in the pie? They are caring and sharing societies, who don't believe that the poor should have to pull themselves up by their bootstraps and work hard to achieve their individual goals. The rich never do that so why should the poor?
We have shown, or at least the common consensus, even among our federal health agencies is that more caring and sharing societies are healthier than ones with a big gap between the rich and the poor. The feds say that and the science says that. It is of course not just true in the US, but everywhere, there is nothing special about the USA.
We could ask how many extra deaths there are because we have made this country one in which we subsidize the rich and rob from the poor, a kind of inverted Robin Hood transposed as Hood Robin to use a vernacular. In the United States, this works out to be three to four hundred thousand excess deaths a year because we have a Hood Robin rather than a Robin Hood mentality.
Worldwide, we can do the same calculations, since we are mostly responsible for the decision being made on who to subsidize and who to rob, the Hood Robin concept. If we do that, we find that about one fifth of all the deaths worldwide are related to the gap between the rich and the poor. That works out to about 20 million excess deaths a year.
To put this in perspective, in the last century, we had about 110 million violent deaths due to wars, genocides, other forms of violence and the like. So in about 5-6 years of day to day life, we have about the same number of deaths as occurred in the entire past century from what I would call behavioral violence.
Now notice, that most of the 20 million deaths a year are from the usual diseases, heart attacks, strokes, cancer infectious diseases and such. There is no smoking gun. No direct behavioral violence that we can observe. The deaths are continuous and from common causes of death, not like the catastrophic ones of September 11, 2001.
James Gilligan, a professor a psychiatry at Harvard, who was a Massachusetts Prison Psychiatrist for 25 years, calls this form of violence, structural violence, to distinguish it from the more observable behavioral one. Of course, we are all concerned with the behavioral forms of violence and don't even consider the much more costly in terms of human life, structural forms of violence. But it is violence just the same, meaning an act that causes harm to an individual or population.
Fourth Point: To produce health to be healthier, to not die so young, we have to care more for each other and share more. It is most important to recognize that this is how we need to set the ground rules for society, it should not depend on what individuals do or don't do. We need to change the structure of society.
We can see societies that have done this and can see what remarkable health they have achieved, and Japan is the most remarkable example.
The USA gave Japan the medicine it needed to become the world's healthiest country. At the end of the war, Japan's health, relative to other countries, was much that that of the USA compared to other countries, today. In other words some 40 to 50 countries were healthier than Japan in 1946. We only have about 25 countries that are healthier than we are.
Yet the USA gave it the medicine it needed to become the healthiest country in the world by 1978. The medicine was prescribed by the greatest population health doctor who ever lived, General Douglas MacArthur. The medicine administered during our occupation of that country from 1945 to 1950 had 3 ingredients and I will review them here. The first was demilitarization. Japan was forbidden to have an army. The second ingredient was democratization, as MacArthur wrote the country's constitution, providing for a representative democracy, free universal education, the right of labor unions to organize and engage in collective bargaining, and the right of everyone to a decent life. It also included a clause for the Japanese government to extend public health which is what they did. The third D was decentralization, as MacArthur broke up the 11 family zaibatsu that ran the huge corporations that controlled the country. Japan had gone into the war because the US had annexed the Phillipines a hundred years ago so the family corporations felt threatened by that presence and fear mongered the people into going to war to protect their interests. Those of you who have seen the Last Warrior movie, most of which is fiction, pretty accurately depicts the resentment towards the US, however. So he legislated a maximum wage for the country of 65,000 yen, the equivalent of $4333 in US dollars. He also carried out the most successful land reform program in history. Japan was a rice farming country, with 37000 landowners owning the land that tens of millions of peasants farmed. MacArthur bought the land at a fixed price per acre, and sold it at the same price to the tenants and gave them a thirty year interest free loan to pay for the land. In the next few years, 90% of Japan's land changed hands. What this did is bring down the economic hierarchy, and level the playing field. The resulting rise in health is the most rapid ever seen on the planet before or since.
We could take our own medicine or ask Japan to give it to us.
Some elements of the medicine:
I'd like you to reflect on why we have the lowest voter turn-out of all democracies, and consider that it is the poor that don't vote, or if they vote, they often vote against their interests. This is critically important in this election year. Also take note that no president in recent times has drawn attention to our gold medal in the non-voting Olympics, at least to want to do something about it. As Greg Palast said, we have the best democracy money can buy.
I'd welcome more discussion from the audience on various ways to get us healthier again.
Now the news you have been waiting for can now be released, as my operative has obtained the necessary clearance. The Weapons of Mass Destruction are in your hands, you the people, who have the power to make policies that decide how caring and sharing the US is and also how generous we are to the rest of the world. The weapons are the choices we make as to who gets what in this world. This is incredible news. In other words, we, you and I, decide who gets what share of the resource pie in the world, and since the USA is the richest and most powerful country in world history, this is an awesome responsibility. But the science is clear. As Pogo said, we have met the enemy and he is us.
To conclude, I've presented some concepts that may make you feel less well than you were feeling earlier this morning.
OR you may think this is all nonsense, if this country was so sick, surely more people would be sounding the cry
OR you may think these ideas conflict with your beliefs and you don't know whether or not to try to resolve this cognitive dissonance.
As students, your job is to learn, and I feel you can only learn by an active process of approaching ideas and information and coming to terms with them. I'm excited that you people at Seattle University are interested in unpacking these ideas.
Let me close with the words of some others such as Amartya Sen who won the Nobel Prize in Economics in 1999 said "I believe that virtually all the problems in the world come from inequality of one kind or another."
Jimmy Carter at Nobel ceremonies in 2002 "I was asked to discuss, here in Oslo, the greatest challenge that the world faces. I decided that the most serious and universal problem is the growing chasm between the richest and poorest people on earth. The results of this disparity are root causes of most of the world's unresolved problems, including starvation, illiteracy, environmental degradation, violent conflict and unnecessary illnesses that range from Guinea worm to HIV/AIDS." and finally,
Martin Luther King, Jr. said: "True compassion is more than flinging a coin at a beggar; it comes to see that an edifice which produces beggars needs restructuring."
I hope there is interest here in doing this restructuring. and that we do not just follow Benjamin's Law, namely that when all is said and done, more is said than done.
You may think my observations on Weapons of Mass Destruction are a farce. But consider that even the atomic bombs we dropped on Japan, and our fire bombing of Tokyo during the second world war only killed a half million people, but this is nothing compared with the toll of the real weapons of mass destruction that kill silently, without any outcry from the victims or their families. They kill people without a blast, bullet hole or explosion. The victims die from the usual diseases. But we are the perpetrators of this destruction worldwide. We chide the Germans who knew about the Holocaust and did nothing. We revile the scientists who conducted the Tuskegee experiments and withheld treatment. In thirty years time will history look back on this era and say: "Look they knew how relative poverty was the most important preventable cause of death, and they did nothing, but watched the experiment progress and cause 20 million avertable deaths a year."
Now that we have found the weapons of mass destruction, and know where they located, I ask that you not rest in peace.