08 June, 2010

community can fill the gap

I recently visited Chicago in search of an apartment, and some of the things I observed really got me thinking. I was in the suburbs rather than downtown, but many areas had a very urban feel. What surprised me was the great contrasts that existed from one block to the next. One moment I would be in a very nice residential area, full of rather idyllic-looking homes with gardens and happy families. Then, just a few blocks away, I would see a homeless man talking to himself, somebody eating out of a garbage can, or a woman who had clearly had a very rough night. I began questioning how this could be. Not, "why doesn't somebody keep these two groups of people more neatly separated?", but rather, "why do these extreme differences coexist? how can we see this every day and do nothing about it?" Now, I am by no means suggesting any kind of martyrism or asceticism. There are so many reasons that we should be able to have happy, comfortable lives without constantly feeling guilty. What I would like to discuss is the socioeconomic gap.

More specifically, I am interested in the socio- part, and in its effect on health. Socioeconomic status (SES) is the highest behavioral predictor of almost every health-related condition, including cardiovascular disease, respiratory disease, ulcers, psychiatric diseases, and stroke. By behavioral predictor I mean that it is the most accurate way to guess whether somebody will get one of these diseases once things like gender, age and ethnicity are ruled out. It's even more important than smoking cigarettes. And this is no minor prediction. A study done across Europe found SES to account for 68% of the variance as to who has a stroke. In some cases, the prevalence of a specific disease is ten times higher among those with the lowest SES than those with the highest. In some countries there is up to a ten-year difference in life expectancy when comparing the poorest and the wealthiest.

Why are SES and health so tightly linked? The first thought that came to my mind: lifestyle. Poorer people are more likely to drink, smoke, eat unhealthy foods, and engage in high-risk activities. Somewhat surprisingly, even when one controls for all these factors (i.e., compare poor smokers to rich smokers, etc.), lower SES is still linked to more disease. (As an aside, there are many fascinating studies linking stress to a broad range of diseases. Living in poverty certainly has its own unique set of stressors, such as long working hours, multiple dependent family members, and the unpredictability of keeping a job or having enough money for the next month's rent.) One extraordinary study looked at a single group of elderly nuns, all of whom took their vows as young adults and spent the rest of their lives in the same monastery with the same diet, etc. The patterns of disease, dementia and longevity were still predicted by the SES status they had before they became nuns 50+ years ago.

My second guess at an explanation: access to health care. Interestingly, European countries that have recently switched over to universal health care systems have not seen any improvement. Of course, even in countries with universal health care systems the wealthy do still have access to better, more timely care. However, one study conducted at the University College of London indicates that this still does not explain everything . Workers in the British civil service system range from blue-collar workers to upper-class administrators, but they all have roughly equal health care access, are paid a living wage, and do not have much fear about losing their jobs. Despite these automatic controls the rate of death due to cardiac disease is four times higher amongst the poorest. Finally, what I find to be the best argument against the idea that this gradient is simply explained by health care access, is that the same is true for diseases like juvenile diabetes and rheumatoid arthritis, which have very little to do with lifestyle or preventative health care.

So, poorer people have more disease and die sooner simply because they are poor.  This actually has an even greater effect across society than you might expect. In countries with the greatest socioeconomic gap everybody has more disease and the overall mortality rate is higher. But, isn't wealth relative? Yes, it seems that considering yourself to be rich or poor is relative and the key here is the gap itself. Income inequality has a profound effect on the health of any group of people. The SES-health gradient is much stronger in societies with greater inequality, and more subtle in more egalitarian societies. This has been shown repeatedly and on many levels. For example, income inequality predicts higher infant mortality rates across many European countries, and higher mortality rates across all ages (except the elderly) in the United States. Louisiana, the least egalitarian state has about a 60% higher mortality rate than New Hampshire, the most egalitarian. Those are overall rates, not just rates for those on the bottom of the gap. 

We seem to have figured out why this gradient cannot be explained away by the previously discussed, more obvious, factors. Kawachi explains this phenomena with the sociological concept of "social capital." Higher social capital is found in communities with a large amount of volunteerism and organizations, where people feel like they are a part of something bigger than themselves.  This is definitely lacking in  American communities, where few people know their neighbors and the rights of mobility and anonymity are sacred. 

This all comes across as rather depressing information. It means that even if we successfully provide universal access to health care, this SES gap will still exist, the poor will still be unhealthy and even the rich, try as they might to build their castle on a hill and put up a wall around it, will not be able to remain untouched by the rest of their society. This is not just about not having money, it is about poverty, and it is complex. I could most grasp the difference when I read Robert Evans' statement that "most graduate students have had the experience of having very little money, but not of poverty. They are very different things." 

Now then, where is the beauty in this? I feel like I can actually do something about it. Universal health care and welfare programs are big and complicated. I do not even have the knowledge to really understand the long-term effect these kinds of things have on individuals or on society at large. The economics and politics are so convoluted that I just want to shy away from them. But I think I can help strengthen a community. And your community isn't confined your neighborhood. It seems to me that many people have coped with the psychological distance placed between American neighbors by creating less traditional communities, like a book club or church, even though they may meet several miles away from their home. I plan to use this knowledge for inspiration to participate in or create programs for community outreach programs to educate people about a healthy lifestyle, and to let them know what resources and activities are available in their own community. 

This information came from Robert M. Sapolsky's Why Zebras don't get Ulcers. It offers an accessible, entertaining overview of the link between psychological stress and disease, and I highly recommend it. Please reference the book or send me a message if you would like more specific citations to any of the studies mentioned.

1 comment:

  1. Good post. It's good to see we're not alone in looking thoughtfully at the context in which we live. You might find it interesting to visit http://www.AnEconomyOfMeaning.wordpress.com. We're very interested in Wicked Problems such as health care, education, high-consequence industries, and socio-economic scenarios. The wicked problem signature is that there are multiple participants creating too many pieces in play to enable final answers. However, there's often a way to make critical aspects less grim, and also to bring other aspects into more systemic operational clarity.


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