Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
This morning’s “Science Times” includes an item by John Tierney titled “To Explain Longevity Gap, Look Past Health System.” The piece starts out strong, noting that the health system—by which he means the notably narrower universe of personal health services—is not the only reason this nation scores poorly in international lifespan rankings. Tierney also cites work by the terrific demographer Samuel Preston on this topic.
The pull quote provides the string which, when pulled, reveals a basic problem. Tierney writes: "Americans are fatter and more diverse, and they used to be quite heavy smokers." It’s not great to be fat or to be a former heavy smoker, but being "diverse" doesn’t seem quite as lethal. There are more Korean-Americans and Pakistani-Americans than there used to be. That’s not what he’s talking about. Paris and London are pretty diverse, too. The real problems connoted by the word "diverse" are the unacceptably bad population health among Hispanics and African-Americans.
These raise the most telling omission in this piece. There is virtually no discussion of the social determinants of health. Over the past two decades, epidemiologists have documented the deleterious impact of educational and income inequality on many health outcomes, particularly cardiovascular mortality. Our European peers have much stronger safety nets. They provide much better education to disadvantaged youth. They have better public health systems. They provide better supports to families with young children. They provide greater economic security and more equitable fiscal policies. They have better policies towards gun violence and substance abuse.
The causal pathways are complicated, but they are there. (If you want to learn more, I co-edited a book on this topic, Making Americans Healthier: Social and Economic Policy As Health Policy, with three leaders in the field, Bob Schoeni, James House, and George Kaplan.) Some of these pathways involve social, cultural, and economic factors that promote the very unhealthy personal behaviors Tierney cites to excuse America’s poor global health rankings.
Both the stimulus bill and the current draft health reform legislation include admirable, readily-overlooked provisions that seek to address social determinants of health. Sadly, many of these provisions were stripped or weakened by self-avowed fiscal conservatives.
Tierney is right that we place too much reliance on medical care to address bad health outcomes that arise and must be addressed outside the formal health care system. When we really examine the implications of this insight, our nation’s approach to population health looks even worse.