The Social Determinants of Health

I am nearly finished reading Successful Societies: How Institutions and Culture Affect Health and couldn't be happier with the state of research on the social determinants of health. While my work focuses more on health care, I am pleased to see this field progressing so quickly. Public policy which references the social determinants of health is likely years away in the U.S. (though it is beginning to gain traction in some European countries). However, I am definitely beginning to see it filter through discussions of health care policy. Most people recognize that the recent health reform law signed into law by President Obama is really more of a health insurance reform. The law creates a system where more Americans will be insured but it doesn't constrain the excesses of the insurance industry other than to prevent them from doing particularly deplorable things, like refusing to pay for cancer treatment because someone underestimated their weight when they first applied for coverage.

A recent post highlights the continuing danger the insurance industry poses as the law begins to be implemented. Not surprisingly, insurance companies are working to purchase legislators who will be favorable to their profiteering. This was one of the reasons that many people felt that any health reform should further limit the power of these insurers. In some other high-income countries you still have insurance companies through which care is rendered. Such a system can work as it has in the Netherlands and Germany. However, when these companies are singularly focused on profit and not on providing the best care for their clients, it is difficult to not wish for further regulations.

Also, the Commonwealth Fund recently released a fascinating (if not surprising) report which highlights how the U.S. health and health care system is doing in relation to other high income countries for which comparable data is available. The results are not good. The U.S. is in the bottom 2-3 (out of 7 countries) for nearly all of the measures and only on two does it make the top 4. All of this despite the U.S. having the most expensive health care system in the world. However, the authors of the report are optimistic that some of the measures in the recent health reform bill may give the U.S. better results over time.

Health Care is a Human Right

With all the discussion of health and health reform, some key facts have been overlooked and, for the most part, insufficiently examined in the debates. While there has been some acknowledgement of the high cost of treating chronic diseases, rarely is it raised that treatment of these diseases accounts for 75 cents of every dollar spent on health care in the U.S. This fact helps us understand that while coverage for everyone is a crucial and fundamental right, the goal of keeping down costs requires more acute awareness of where the money is actually spent.

Another key fact that is discussed infrequently is the high concentration of health care expenditures in a small population. A recent study found that five percent of Americans are responsible for nearly HALF of all health spending in a given year. An earlier study found that it was over half. Also, almost half of the U.S. incurs little to no health care costs and thus the other 50 percent make up about 95% plus of the health care spending. This concentration is interesting at other levels as well. The top 30 percent of spenders make up 90% of health spending; while the top 10 percent make up nearly 70%.

These statistics speak the need for a more holistic view of reform. Increasing quality, decreasing costs, and expanding coverage all are worthy goals but they cannot be goals divorced from the social reality of health care needs. Both studies find that the elderly are more likely to bear the burden of high expenditures. Also, they found that people with chronic conditions had much higher out-of-pocket expenses than average. Better, more cost-effective treatment is needed for these folks. Often their situation is compounded by the fact that they may reach their lifetime spending cap and lose coverage. In turn, due to pre-existing conditions clauses, they may have an extremely difficult time getting other coverage, and if they do it will be exhorbitantly expensive until they are so drained of money they can qualify for Medicaid.

All these factors indicate the importance of having a coherent, nationally focused health care reform. The reform must be tailored to meet the needs of different populations and levels of care. However, everyone should have to have insurance; at the very least, catastrophic coverage. It is in the best interest of the long term health of the American people and in the best interest of our financial well-being, both individually and as a society. People without insurance coverage that require medical treatment incur higher costs and are much more likely to face bankruptcy as a result. Of course, there must be subsidies to help those who would not be able to afford coverage themselves.

During the current health care reform I have continually been dismayed by the process and how easily many of those involved lose sight of the overall goals and the purpose reform serves. We don't need reform for the sake of reform. Sure the system is broken, but a patchwork solution will only push the need for a more significant reform off the radar for another decade or two. We have hard decisions to make. Until we face those decisions with a sense of history and an eye to the future, we will continue to create policy that only serves to line the pockets of those who are currently abusing the system.

Fairness vs Injustice

Issues of race, gender, and ethnicity have been a hot issue in recent weeks. Many in the media are writing about whether the election of Barack Obama represents the beginning of a "post-racial" America. This notion, that race no longer defines a person's status and trajectory, is in theory interesting but in reality serves only to further marginalize those who suffer under the yoke of injustice. The very fact that it is such a big deal to elect an African American president speaks to the fact that we have not come as far as many seem to hope. 

Race and ethnicity have always been tricky and taboo subjects not only in the U.S. but around the world. Most people take race as a given category that people fit into, largely ignorant of the fact that races and ethnicities are socially constructed. By socially constructed I am referring to their origin in the historical context in which the categories are created and then changed over time. For example, in many countries in Latin America, race is viewed extremely differently. In some countries there are fifty or more gradations of perceived ethnicity on a spectrum of white, black, and indigenous. In many of these countries, while skin color is taken into account, other factors like wealth, dress, and social status serve to determine a person's "true" ethnicity.

We often lose sight that when we talk about someone being African-American or White, that these categories lack real meaning and are just the most current incarnation of labels. To try to homogenize such diverse groups of peoples into simple categories often leads to spurious assumptions. For example, the issue of hypertension in African Americans is often tied to a variety of things, from genetics to adaptive selection during slavery. However, these simple notions break apart when we understand that genetic differences between any two given African Americans are larger than between any given African American and a person of any other race. We know definitively that the genes that affect skin color have nothing to do with hypertension, particularly on the large scale that is proposed. However, social forces have been found to be the most likely candidate for being the reason for higher rates of hypertension. Feelings of stress/anxiety and perceptions of discrimination have been found to play a major role in creating higher rates of hypertension among almost all populations. This has been found to be particularly true among African Americans. I don't for a moment want to imply that just because these categories are socially created that they do not have power. They have real power in how people are treated, how they are perceived, and even how they perceive themselves. However, their overwhelming power does not mean that knowing they are socially constructed is fruitless. It allows for a better understanding of what can and must be done to bring about a more just and equitable system.  

I don't want any of the above to take away from the overwhelming happiness I feel about Barack Obama being elected President, but we have to keep in mind the vast inequities suffered by African Americans and other marginalized populations. There is much work to be done, and understanding where we stand is a good place to start.

Confusing Correlation with Causation

A recent article on MSN Health does a great job showing how the medical view of individuals can miss the social determinants of both health and crime. The article cites a recent study in PLoS Medicine which found that increased levels of lead in children is linked to crime later in life. They article goes on to discuss the dangers of lead and the neurological effects that it has. Even though it notes the connection between lead exposure and poor communities, it completely misses the connection between poor communities and crime. Instead in assumes that the effects of lead on the brain are what lead to crime.

This lack of a larger perspective shows how entrenched the medicalized, atomized version of society is. Individuals who are born into socially marginalized communities often have no real opportunity for engagement and often end up being involved in delinquency. While there is still the presence of agency, it is difficult to disregard the widespread patterns of crimes in marginalized populations worldwide. Nothing links these groups (race, religion, creed, education) except for their marginal status. It is difficult to see how policy makers cannot make the connection that it is not something intrinsic to these individuals but something social that is happening. Social patterning of all aspects of our lives is something continually overlooked by the media and not well understood by those in power. We must learn to look past simple individual level explanations and ask why these patterns are so consistent across place and time. Only then will we be able to find adequate social and economic policies to mitigate the ill effects of poverty and marginalization.

Social Determinants of (Google) Health

Google recently added an interesting new feature to their online empire, Google Health. It has the making of a useful and helpful tool for many people that want a place to keep track of their medical history and required prescriptions. You can enter your personal information, update your existing conditions, and even import your medical history and records from a variety of sources. It can also be used to find a doctor in your area or to seek online medical help.

One area where it is woefully insufficient is on social determinants of health. It would seem a more appropriate name for the site would be Google Medical, because that is its sole focus. The social determinants of health have been found to play a significant and varied role in individual health. Factors that are social determinants of health include things like where you live, what type of social capital the area you live in has, what is inequality like, how much income do you make, what kind of discrimination do you face, etc. However those critical factors are completely absent from Google Health. This reinforces the myopic medical view of health that divorces the health of the individual from the health of others. All health is patterned. Even things we consider random and tragic, like cancer, follow social patterns and gradients across factors like income. Ignoring these issues on a health site is at best ignorant and at worst neglectful of a whole host of factors many people may not be aware of.

Possible Turning Point

A recent ruling in California on rescinding health insurance will hopefully have a industry wide impact on the way health insurance cases are managed. As the article notes the woman was diagnosed with breast cancer and was undergoing treatment for it. Midway through treatment, the company, Health Net Inc., canceled her policy leaving her with hundreds of thousands of dollars in debt. The reason given was that there was some weight discrepancies on her application and possibly missing information about a heart condition. This type of health care is deplorable and just another example of the dangers of for-profit health care.

The current system has Americans paying the most per capita for health care by a wide margin. (see table below). This massive discrepancy between what is spent in the U.S. and the level of health that is attained is a fundamental contradiction of our system. The fact that 50 million Americans go without health insurance (which often means going without health care) helped to increase this discrepancy. When people without insurance go for care they pay up to four times as much as those with insurance.



Source: uscs.edu

Administrative costs are also a significant reason for this vast discrepancy in spending. The bloated insurance company system makes health care less efficient as opposed to the "common sense" notions that are typically expressed around issues of public versus private. Using simplistic theories from economics may give particular policy prescriptions, but the empirical data often indicates something much different.

Many recent polls indicate contradictory factors in people's perceptions of health care. While approximately two-thirds of Americans support the idea that the government is responsible for providing health care to everyone, only forty percent would like to see the system changed to a single payer system.

The thing that I fail to understand is how Americans don't make the connection between the per capita spending and the cost of a single payer system. When we are paying significantly more for health care and receiving less benefits, it is hard to justify the current system. Due to the cultural fear of taxes present in the U.S., it is difficult to imagine an increase in taxes being a possible method of funding health care. It must shown that an increase in taxes would actually save Americans money. What they pay to insurers as well as the decreased direct pay that they receive due to the cost of company provided health care likely exceeds the tax increases that would be required to fund this system. Overall the expenditures of Americans on health care would decrease under a single payer system for a variety of factors including the ones mentioned above, but also other factors (ability to practice preventative medicine, decreased cost for prescription drugs, and increased risk sharing to name a few).

While the road to a single-payer system is neither simple or clear, it stands as the most likely and successful measure. While many countries are repealing aspects of their health care system, it is largely at the behest of those who stand to make profit. Those who require health care are often the first to decry these cut-backs. Though a single-payer health system would impose problems of its own, it is hard to imagine that it could be anywhere near as bad as the current system for the fifty million Americans without insurance and the tens of millions who are underinsured or likely to be dropped if they do get sick.

Social Problems Require A Social Solution

A recent report from the UK finds that obesity is not the individual problem that most people seem to think. Instead, social factors appear to play a larger role in determining whether or not someone becomes obese. For someone in sociology this seems reasonable, but for those not familiar with the field it may be hard to understand how social forces can create social problems.

Some will still argue that it is an individual's "choice" and responsibility to control and regulate themselves. This atomistic view of the world misses the way in which our choices and ideas are constrained by the social world in which we live. For example, energy dense foods (e.g. fast food) that are cheap and available to the poor are more likely to lead to obesity than more nutrient dense food (e.g. fresh fruits and vegetables). While many would say that this just means that the poor need to "make better choices," the fact that these findings show a clear pattern by sociodemographic factors indicate that ideas of choice and responsibility are not sufficiently nuanced to get at the reasons for difference.

Societal factors such as sedentary lifestyle, energy saving devices, automobility, and energy dense cheap foods are all on the rise. Social problems require social solutions and this report just highlights this. A considered response is necessary to combat this problem. It is important to identify and attempt to work on structural factors and not just the symptoms. Issues of consumerism and excess consumption must be examined along with things such as education. We also must come to hold corporations more accountable for their actions and products. Simply providing the nutritional information of the products is not sufficient. It is true that people have the ability to decide what they are consuming. The fact that it is often easier to consume something fast and unhealthy than something self-prepared and nutritious shows a failure of the market to provide adequate alternatives.

Utterly Appalling

A recent report identifies that the Millennium Development Goals in the area of maternal death are woefully off target. This critical issue is something that is often overlooked when health policies and practices are being implemented in international development. This absence is a a crucial one and one that I can't honestly understand. As has been noted by distinguished authors like Amartya Sen, health costs are much lower in countries that are just implementing health policies. This is because the initial steps taken to set up a clinic or extend the range of health care professionals in most developing countries is much smaller.

Another important aspect that is identified in the article is the estimated twenty million unsafe abortions that go on every year. This is a significant contributing factor to maternal death. Safe, legal, and accessible abortions are something that must exist as the need for them is always there. The article does not identify how many of these unsafe abortions are actually illegal but it can be assumed that many unsafe abortions are the result of nation wide bans on abortions. This forces all women, even those who have life threatening pregnancies, to have a "back-alley" abortion.

The report concludes that one reason for such little progress is that in many societies women are viewed as nothing more than a vessel for reproduction. This extremely disheartening conclusion indicates the importance of positive action on behalf of women all over the world to increase their status. Cultural relativism must have its place in discussion of international development, but it cannot be used as a tool to allow domination of marginalized populations.

Future Plans

I am unsure if I will be going on for my PhD directly after my MA. This is because at some level I have become disillusioned with a large part of academia. I feel that many of the debates that are carried out between the smartest people in the world are more semantic than substantive. While two researchers may, for the most part, agree on some fundamental issue, they are split on something like the "level of analysis" or whether a particular hypothesis adequately takes into account context. Though the differences may seem huge to the individual researchers, the policy prescriptions that would come out of them often seem rather similar.

Currently I plan to work within the field of public policy. For me public policy or possibly an activist oriented NGO would be a good place for me. I am interested in working on what I see as issues of substance. I really enjoy studying issues of inequality and neo-liberalism. I think that neo-liberalism is an overarching hegemonic social structure that affects our daily lives in a myriad of ways. These include things as distant as the rise and fall in the value of the American dollar and as close as the price of food and gas. Most interesting for me is that it represents a fundamental shift in the way governments think about legislation and their role in public policy.

Through my graduate work I have come to focus specifically on health and health policy as an important area of legislation. For me health policy represents a fundamental social good that the state must play a role in for it to function adequately. The pitfalls of health for profit can be seen through the structural inadequacies and inequalities that are experienced throughout the U.S. system. The argument goes that the market can provide goods and services at a lower cost and more efficiently than with government "interference." In the empirical literature on health we see no support for this notion. The U.S. has some of the least efficient health distribution and the highest per capita costs for health in the world. While this post is not about health policy per se, I do see myself as working towards fundamental changes in health in the U.S. I appreciate and plan to use a wide range of empirical and qualitative academic literature to inform the policies that I eventually will work toward. I feel confident enough in my training to be able to interpret the literature and create informed and relevant measures that could be implemented at a wide range of levels of government. Though I still think that it is important for my work to face the scrutiny of peer review. For that I plan to still look at trying to publish in academic journals. Simply the creation of "gray" papers doesn't sufficiently fulfill my ideas about the role of a sociological researcher, even in the realm of public policy.

Irresponsible and Negligent... What's New?

The Bush administration has again struck a blow against appropriate and prudent public policy. Bush has vetoed a bill that would extend basic health care insurance coverage to 10 million children who parents earn too much to be eligible for Medicaid but cannot afford insurance on their own. In recent polls it was found the policy was favored by over seventy percent of Americans. This in a country that is traditionally against social spending, even for the poor. The fact that Bush said that he vetoed this measure because it was too big of an increase in spending is impossible to justify in light of the billions spent each year on subsidies to large companies and pointless military purchases and research. It is difficult to comprehend how providing unneeded subsidies to those who don't need it is unquestioned while providing health care to children left behind by the system is considered a burden. The audacity of Bush to attempt to prove that he is a "fiscal conservative" at this point is bewildering. Even Republicans realize that he is not and never has been a fiscal conservative. Hopefully Congress can push through the desperately needed bill and get back with more "important" business like flag burning amendments.

More Hype Without Details or any Chance of Real Follow Through

The recent G8 meetings have come to a close. As per usual they recognized that they didn't hit the goals set previously but pledged even more money this time around. Now this type of display is disgusting to say the least. These pledges are just that. If it is inconvenient or if one of the donor countries decides something is amiss they can easily (and usually do) pull out in part or entirely. Many in the development sphere are already calling this recent pledge a "farce."

Hypothetically, if the G8 does provide the money promised (60 billion alone for AIDS research, among other pledges) it will not be in the form that many would accept as reasonable. Anyone familiar with the Bush administration's past work on AIDS will know how disastrous and ill-informed the strict rules that come attached to the money. Because the U.S. pledged to donate 30 billion of this sum it is likely that they will have a large say in the contingencies and policies on which the money can be spent.

Among the most insulting of the ludicrous ties that AIDS money to Africa has endured in the past is the focus on abstinence. Much of the money was earmarked for groups that only push abstinence as a method of stopping the spread of AIDS. When the money goes through a recipient government there are strict "abstinence only" financing rules that must be followed for the money to keep coming in. This despite the fact that abstinence does not make sense when used alone as a method to prevent AIDS. Studies have continually found this to be true worldwide. I will acknowledge that it can play a minor role in an overall sexual health and well-being program. Use of only abstinence has been shown in many instances to not decrease the rate of transmission but has actually increased the rate of transmission by decreasing funding to other services. When abstinence becomes the focus of a government targeting teen and pre-teen boys and girls, other important issues like birth control methods, safe-sex practices and use of condoms falls aside.

These AIDS grants are also incomplete because one of the best ways to mitigate the devastating effects of AIDS is to drop the price of drugs that serve to decrease the effects of the actual virus. Also drugs that when taken by a child born to an HIV positive mother can severely decrease the chance of contracting AIDS. These steps are blocked at every turn by pharmaceutical companies that cite the cost of research of the drugs as the reason for the high prices. When these companies are having record breaking profits and at the same time receiving much of their R&D at highly subsidized rates from public universities and grants, they could at least take a "loss" (though the idea that they would take a loss is severely suspect) on these necessary drugs.

Hard to Comprehend

In a stunning example of the dangers of insufficient health care, a boy in Maryland has recently died from what began as a rotten tooth. This situation brings to mind the unconscionable consequences of our current system of health care. It also illustrates the dangers of negative freedoms versus substantive freedoms (capabilities). Using the capability approach put forth by Amartya Sen, we can see how the current system in the U.S. could have allowed this to happen. While this boy's family experiences, in theory, many diverse negative freedoms (freedoms from things), such as freedom of speech (freedom from censure), freedom from imprisonment without due process (clearly in theory here), etc., their ability to express these freedoms is significantly limited by unfreedoms that diminish their ability to achieve desired functionings. In the capability approach these unfreedoms represent capability disabling elements that restrict what an individual can do.

In the United States there is no substantive freedom to have basic health care. Being free of preventable disease is a core functioning for Martha Nussbaum, another author who has written extensively on the capability approach. The lack of basic preventative health care for millions of Americans serves to magnify the effects of the income inequality that continues to grow in the U.S. Inequality experienced in Canada and Europe is significantly less extreme than what is experienced in the U.S. Even for cities with comparable inequality, those in the U.S. experience significantly more extreme gradients of health as there is not a basic health care system in place to mitigate some of the effects of inequality.

This particular example displays the extreme effects that deprivation can have on individuals. It brings to light larger issues that go unnoticed by media. In the article it is noted that the boy's sibling also had rotting teeth and there was an attempt to take care of his because they seemed to be more pressing. Discussion of these sorts of "personal" problems are ignored because they are often not considered interesting because they are experienced widely by the poor in the U.S. By minimizing these problems that are being suffered by millions, their collective power is diminished in an era of "individual responsibility" that has come about in the current neo-liberal era.

The article also notes the significant costs that the family now faces for the emergency care that was required to attempt to save the life of the child. While the initial extraction would have cost less than a hundred (a cost too high for many to bear for something as seemingly small as a rotten tooth) the bill has now risen to hundreds of thousands of dollars in the cost of surgeries and other emergency care that was given. It is hard to imagine how a family that could not afford a tooth extraction will deal with such an extreme form of debt. I noted in a previous post how this sort of emergency is one of the largest reasons for bankruptcy in the U.S.

This case is provocative because it points out glaring disparities in the current U.S. health system. There are many other examples of lesser problems that go unnoticed in the media but are experienced be individuals without a voice or real political power. In order for the family of this boy to get any sort of attention, a death had to be involved. Until this system is reformed in a meaningful and structural way, little improvement can be expected.

Going Without Health Care

With more than seventy-five million Americans going without health care, it is tough to imagine how a health care system could perform more poorly. It is increasingly difficult to justify the private health care and health insurance system that exists in the U.S. The U.S. regularly spends significantly more, per capita, on health care than any other industrialized country. It is time that we take a look at what other countries are doing right and wrong in terms of health policy. Our current health care scheme is clearly not sustainable and is negatively affecting the lives of millions of Americans. When millions of Americans are declaring bankruptcy as a result of health care bills, it is clearly time for a significant change.

One important thing that must be addressed is that there will be no perfect policy to address the health care needs of everyone. This issue must not be left to politicians who are largely out of touch with successful social policy. We must learn the lessons that the successes and failures that other countries have faced, and use that information to create a coherent policy that can work for the U.S. It is difficult to imagine a significant new policy coming about at a time when public well-being is up against billion dollar industries. While most Americans would benefit more from nearly any other health policy, many will continue to be fooled into voting against their interests. Those in power are quite skillful at using wedge issues to crush real attempts at meaningful reform.

A Decent Start

An interesting new plan has been developed that would increase the likelihood of creation of vaccines for diseases that largely affect countries in the developing world. While this is a step in the right direction, it misses some of the large issues that surround the pharmaceutical companies. These companies constantly bemoan the difficulties that they face in creating medicine, while at the same time recording higher profit margins than most other sectors. Confounding this situation is the fact that pharmaceutical companies receive significant subsidization from the U.S. government, both directly and indirectly. Directly through government grants for research and indirectly through funding of public universities that cooperate with pharmaceutical companies to create new products. If the company is genuinely concerned with financial solvency, perhaps it is time to reduce CEO pay and put some of those millions into developing new drugs.

Also important to recognize is why developing countries are unable to represent a suitable market to pharmaceutical companies. Many of the billions of people that would benefit from drugs for preventable diseases live on less than $1 a day, and nearly all that would benefit live on less than $2 a day. When basic sustenance is difficult to achieve, it is hardly likely that there will be sufficient out-of-pocket funds for vaccinations.

Also significant is that measures such as this fail to get at some of the core issues that create the problem in the first place. Issues such as for-profit medicine, which bring about the terrifying 10:90 divide: where 90% of investment in pharmaceuticals is directed toward diseases that affect only 10% of people in the world. Of course, this 10% are the wealthiest. This frightening discrepancy between those who need and those who have only shows further the moral bankruptcy under which we exist. This is an industry where the majority of products released are knock-off drugs that are about to lose their patent or drugs that closely emulate products put out by their competitors. A more democratic form of research and development of pharmaceuticals would be extremely beneficial worldwide. It seems the only people that are benefitting from the increasing concentration of pharmaceutical companies are those companies themselves. When large parts of the research are carried out in public universities, it makes it difficult to identify what role these pharmaceutical companies are really playing in facilitating a more healthy world.

*If anyone is unable to access the article linked above, let me know and I can provide a copy over email.

Drug Marker Stalling Generics

Eighty-five percent of Americans are hoping for a measure that would help provide some relief from the high prices of prescription drugs. Sadly, but not surprisingly, Bush has threatened to veto such a measure. This situation just underscores the danger of special interest money in politics. One of the major justifications Bush has made for vetoing a measure of this kind is that there are generics available and that the competition they create brings down prices. It is kind of hard to make that argument when pharmaceutical companies continue to stall release of important generics. Of course, with this administration, actual relief for millions of Americans will always take a backseat to protecting corporate interests.