A Need to Shift to Social Determinants: We Can Not Afford Individualism

Social determinants are systematic social and economic conditions that influence a person’s health. They include income, housing, education, gender and race, and have a greater impact on individual and population health than biological and environmental conditions. Their impact can even be greater than that of the health care system itself. The consequences of poverty on health are well established and include lower life expectancy, higher disease burden, and poorer overall health. Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment. Many people low on the socioeconomic scale are likely to carry a higher burden of just about any disease. The societal cost of poor health extends beyond the cost to the healthcare system: healthier people lose fewer days of work and contribute to overall economic productivity.

The level of spending for healthcare in the US is by far the highest in the developed world according to the Organization for Economic Co-Operation and Development. Even with all this money being spent on healthcare, the World Health Organization ranked the U.S. 37th in healthcare systems, and The Commonwealth Fund placed the U.S. last among the top eleven industrialized countries in overall healthcare. Most other developed countries control costs, in part, by having the government play a stronger role in negotiating prices for healthcare. Their healthcare systems don’t require the high administrative costs that drive up pricing in the U.S. As the global overseers of their country’s systems, these governments have the ability to negotiate lower drug, medical equipment and hospital costs. They can influence the mix of treatments used and patients’ ability to go to specialists or seek more expensive treatments.

Income inequality creates disadvantage for particular segments of the society. Widening inequality also has significant implications for growth and macroeconomic stability, it can concentrate political and decision-making power in the hands of a few, lead to a suboptimal use of human resources, cause investment-reducing political and economic instability, and raise crisis risk.  Policies that focus on the poor and the middle class can mitigate inequality. Irrespective of the level of economic development, better access to education and health care and well-targeted social policies, while ensuring that labor market institutions do not excessively penalize the poor, can help raise the income share for the poor and the middle class. Income distribution matters – IMF findings suggest that raising the income share of the poor and ensuring that there is no hollowing-out of the middle class is good for growth through a number of interrelated economic, social, and political channels.1

The disparity between top earners and everyone else is staggering in nations such as the United States, where 10 per cent of people accounted for 80 per cent of income growth since 1975. The life expectancy gap between the affluent and the poor and working class in the US, for instance, now clocks in at 12.2 years. College-educated white men can expect to live to age 80, while counterparts without a high-school diploma die by age 67. White women with a college degree have a life expectancy of nearly 84, compared with uneducated women, who live to 73. And these disparities are widening. The lives of white, female high-school dropouts are now five years shorter than those of previous generations of women without a high-school degree, while white men without a high-school diploma live three years fewer than their counterparts did 18 years ago, according to a 2012 study from Health Affairs.

What will happen when new scientific discoveries extend potential human lifespan and intensify these inequities on a more massive scale?  “In just the last five years, there have been so many breakthroughs,” says the Harvard geneticist David Sinclair. There are now a number of compounds being tested in the lab that greatly slow down the ageing process and delay the onset of diabetes, cancer and heart disease. The consequence of the development of novel compounds that slow or even reverse ageing, is an ever-expanding longevity gap. The wealthy will experience an accelerated increase in life expectancy and health, and everyone else will go in the opposite direction, says S. Jay Olshansky, a longevity researcher and professor at the School of Public Health at the University of Illinois at Chicago, “And as the technology advances, the gap will only grow.”2

Statistics Canada tracked mortality rates of 2.7 million Canadians aged 25 or older between 1991 and 2006. Out of this group, 426,979, or 16 per cent, had died by the end of the study period. Those who were in top 20 per cent for family income were most likely to still be alive after 15 1/2 years, and that probability shrank as one moved further down the income ladder. For men, those in the second-highest fifth of people for income were 12 per cent more likely to die during the study period than those in the richest category. There was a 21 per cent bigger chance of death for those in the third highest income group, 35 per cent for the fourth, and 67 per cent for the poorest group. It was a similar pattern for women. Those in the second-highest income group were seven per cent more likely to die than those in the top income group, 14 per cent more in the third group, 25 per cent more in the fourth, and 52 per cent more for the lowest income group.

This latest Canadian report said that if all income groups had mortality rates equal to those in the top category, there would have been 19 per cent fewer deaths among men and 17 per cent fewer among women, or the equivalent 40,000 fewer deaths annually if these proportions were applied to the whole country. It was found that the steepest differences in mortality rates among income groups were found when deaths were linked to risk-based behaviours such as smoking, alcohol consumption and drug use. For example, men in the lowest income group were more than five times as likely to die from an alcohol problem than those in the top income group. Women at the bottom of the income scale were more than four times as likely to die from an alcohol disorder than those at the top. “This is consistent with research indicating that, compared with people in higher socio-economic categories, those in lower socio-economic categories are more likely to engage in health-risk behaviours,” the report said.3

Individualism, a powerful philosophy and practice in North America, limits the public space for social movement activism. The challenge is not the amount of democracy rather it has to do with public policies that determine how the resources of the nation are to be distributed among the population. A primary component of individualism is individual responsibility – being accountable for one’s personal choices. It leads to placing the focus of responsibility for one’s health status within the motivations and behaviors of the individual rather than health status being a result of how a society organizes its distribution of a variety of resources. It fits perfectly with a declining welfare state and also influences responses to health inequities. Individualism creates barriers to the quality of social determinants of health outcomes. In the 21st century, liberty and self-determination, available to those who have sufficient financial resources and cultural capital, is out-of-reach for much of the population.

We need to move to stop social problems from being continually framed as individual ones rather that societal. There is a need to shift from the biomedical model that Nettleson calls the “holy trinity of risk”, of tobacco, diet and physical activity – the dominant lifestyle health paradigm – to social determinants of health perspective. Policy options that support the social determinants of health must reduce the incidence of poverty, reduce social exclusion, and restore and enhance social infrastructure. Policies to reduce the incidence of poverty include raising the minimum wage to a living wage, improving pay equity, restoring and improving income supports for those unable to gain employment. Policies to reduce social exclusion include ensuring families have sufficient income to provide their children with the means of attaining healthy development, assure access to educational, training and employment opportunities especially for the long-term unemployed, and create housing policies that provide enough affordable housing of a reasonable standard.

The high cost for health-care in the US is driving the debate for change. Consumers are paying more money in the form of higher premiums, deductibles and additional expenses. Forced to paying bills and having health coverage, many Americans are risking it and going without. The most difficult role is to develop the political will to support action to refocus agendas on the determinants of health. The quality of any number of social determinants of health within a jurisdiction is shaped by the political ideology of governing parties. The rich, via lobbyists and Byzantine tax arrangements, actively work to stop redistribution. The philosophy of individualism provides the support within the general population that keeps this system of privilege in place. However, the social determinants of health concept can help make the links between government policy, the market, and the health and well-being of citizens to surmount the barriers to change.

1 Era Dabla-Norris, Kalpana Kochhar, Frantisek Ricka, Nujin Suphaphiphat, and Evridiki Tsounta. (June 2015) Causes and Consequences of Income Inequality: A Global Perspective  https://www.imf.org/external/pubs/ft/sdn/2015/sdn1513.pdf

2Linda Marsa (02 July 2014) The Longevity Gap https://aeon.co/essays/will-new-drugs-mean-the-rich-live-to-120-and-the-poor-die-at-60

3 Derek Abma (18 July 2013) Poorer Canadians more likely to die younger, report claims https://o.canada.com/news/national/poorer-canadians-more-likely-to-die-younger-report-claims

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