How does today’s economic governance affect population health? Thomas Piketty observes capitalism in the 21st century has concentrated so much wealth in the hands of so few, while the millions left behind are now angry at the system. The middle-class society that flourished for a generation after World War II has vanished. After 1980 the lion’s share of economic gains went to the top end of the income distribution, with families in the bottom half lagging behind. Piketty’s argument is that in an economy where the rate of return on capital outstrips the rate of growth, inherited wealth will always grow faster than earned wealth. Every human society must justify its inequalities: reasons must be found because, without them, the whole political and social edifice is in danger of collapsing. The coronavirus pandemic exposed the violence of social inequality. Economic neoliberalism creates levels of inequality that for all intensive purposes is not reversible by itself.
Trump’s corporate tax cuts failed to deliver promised economic benefits; and paved the way for inflation. Trump Administration officials claimed their centerpiece corporate tax rate cut would “very conservatively” lead to a $4,000 boost in household income. New research shows that workers who earned less than about $114,000 on average in 2016 saw “no change in earnings” from the corporate tax rate cut, while top executive salaries increased sharply. Similarly, rigorous research concluded that the tax law’s 20 percent pass-through deduction, which was skewed in favor of wealthy business owners, has largely failed to trickle down to workers in those companies who aren’t owners. Like the Bush tax cuts before it, the 2017 Trump tax cut was a trickle-down failure. On the other hand, health care spending – in both the public and private sectors – has long grown faster than the economy and is projected to continue doing so.1
Freud described the reality principle, the ability to evaluate the external world and differentiate between it and the internal world. The reality principle did not replace the pleasure principle, but represses it, such that, a momentary pleasure; uncertain of its results, is given up, but only in order to gain in a new way, an assured pleasure coming later. The reality principle strives to satisfy the id’s desires in realistic and socially appropriate ways. In neoliberalism the reality principle is replaced by the performance principle. The performance principle presupposes particular forms of rationality for domination that stratifies society, Herbert Marcuse observed, “according to the competitive economic performance of its members.” Domination is exercised by a particular group in order to sustain and enhance themselves in a privileged position. The neoliberal performance principle teaches us to conceive of social problems as personal problems – emphasizing individual responsibility while failing to address systemic state violence in all its manifestations – healthcare, education and the war on the poor.
A large and compelling body of evidence has accumulated, particularly during the last two decades, that reveals a powerful role for social factors – apart from medical care – in shaping health across a wide range of health indicators, settings, and populations. The limits of medical care are illustrated by the work of the Scottish physician, Thomas McKeown, who studied death records for England and Wales from the mid-19th century through the early 1960s. He found that mortality from multiple causes had fallen precipitously and steadily decades before the availability of modern medical-care modalities such as antibiotics and intensive care units. McKeown attributed the dramatic increases in life expectancy since the 19th century primarily to improved living conditions, including nutrition, sanitation, and clean water. While advances in medical care also may have contributed, most believe that nonmedical factors, were probably more important; such as public health nursing, including its role in advocacy, may have played an important role in improved living standards.
An example of the limits of medical care is the widening of mortality disparities between social classes in the United Kingdom in the decades following the creation of the National Health Service in 1948, which made medical care universally accessible. Although spending on medical care in the U.S. is far higher than in any other nation, the U.S. has consistently ranked at or near the bottom among affluent nations on key measures of health, such as life expectancy and infant mortality; furthermore, the country’s relative ranking has fallen over time. Other U.S. examples include the observation that, while expansions of Medicaid maternity care around 1990 resulted in increased receipt of prenatal care by African American women, racial disparities in the key birth outcomes of low birthweight and preterm delivery were not reduced. Although important for maternal health, traditional clinical prenatal care generally has not been shown to improve outcomes in newborns.2
Recognizing that health is much more than health care – political, economic, and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to focus solely on increasing productivity. The scope of the scale of the influence of social determinants illustrates that social and environmental influences are highly significant, contributing to between 45% and 60% of the variation in health status. Social determinants of health are the interconnected non-medical factors that affect our well-being. They include the conditions in which we are born, grow, work, live and age, such as income, education and housing. 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.
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.”3
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. This fits the neo-conservative political ideology whereby social problems are being continually framed as individual ones rather that societal (e.g unemployment, poverty, racism, etc,). The most difficult role is to develop the political will to support action to refocus agendas on the determinants of health.
Motivation is about shifting public, professional and policy maker’s focus. There is a need to shift from the biomedical model that Nettleson calls the “holy trinity of risk”, of tobacco, diet and physical activity. This means within the traditional health sciences approach health problems remain individualized, localized, de-socialized and de-politicized. This fits the neo-conservative political ideology whereby social problems are being continually framed as individual ones rather that societal (e.g unemployment, poverty, racism, etc,). This dominant lifestyle health paradigm needs to shift to social determinants of health perspective by collecting and presenting stories about the impact social determinants of health have on people’s lives. Improving people’s health means taking care of both medical needs and non-medical, health-related social needs. For example, making sure people have access to nutritious food, quality housing and critical social supports.
There was a time when the middle class – really anyone who falls between the rich and the working poor – occupied a wide and comfortable place in society. It meant a stable job, a house with a yard, a two-car garage, a perhaps a nice pension. Where did the middle class come from? During the 1950s the gradually expanding economy created prosperity throughout North America. The 1950s are considered the decade that eliminated poverty for the great majority of Canadian and US citizens. The decade was associated with the shift from suburban areas to suburbs, with the supply of housing increasing 27%. With a shorter workweek and increased disposable income the middle class adopted conservative values. The problem during the last four decades is the middle class has not grown (household incomes peaked in 1973). The existing middle class is now earning less compared to those higher up on the wealth scale, and they are working harder for what they get.
Hope and optimism of the future is key to health and well-being. A big part of wellness is having meaning in one’s life and the sense that one is contributing to the world whether it be making a difference in the lives of friends and family, ecology or vocation. This has a great deal to do with attitude. The healthiest (and happiest) countries in the world are not the richest, rather the countries where wealth is shared widely and more equally. These differences create health inequities. Removing barriers to health creates health equity – allowing everyone to reach their full health potential and not be disadvantaged from attaining this potential as a result of their class, socioeconomic status or other socially determined circumstance. This includes removing barriers to those with disabilities and creating opportunities to access good healthcare. Removing barriers to good health requires addressing the income gap between the wealthy and the rest of society.
While opportunities to advance health equity through clinical care continue to be important, addressing the ways in which social determinants of health increase or decrease the risk of poor health outcomes is critical to improving the nation’s health and wellbeing. By acknowledging the social determinants of health, we recognize that, although disease is a biomedical outcome, socioeconomic inequities are important drivers of disease variation in all jurisdictions. More specifically, socioeconomic factors alone may account for 47 percent of health outcomes, while health behaviors, clinical care, and the physical environment account for 34 percent, 16 percent, and 3 percent of health outcomes, respectively. These social determinants include access to affordable and safe housing, food security, reliable transportation, economic stability and many others. Understanding these factors in your community – and engaging with partners to effectively address them – are foundational activities as health systems expand their focus to population health strategies and outcomes.4
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/
3 Linda 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