Remember Bill Clinton’s 1992 mantra, “It’s the economy, stupid?” Well it is, but it is also the economy's social impact that has the  most powerful impact on the nation's health. The research into that has been pursued for at least three decades in the U.K., particularly by Sir Michael Marmot and Richard Wilkinson.

A new meta study in the British Medical Journal reports that if the gap between the richest and poorest people in the 30 developed countries of the OECD were reduced, 1.5 million deaths per year could be prevented. The findings reveal that people living in regions with high income inequality are more likely to die younger, regardless of their income, socio-economic status, age, or gender. Despite the mounting evidence for the adverse systemic impact of social inequality, this phenomenon remains controversial.

In an accompanying editorial, Kate Pickett and Richard Wilkinson suggest that this is possibly because of the “deep political implications of a causal relation between better health of the population and narrower differences between incomes.” The evidence leads them to conclude that, although the benefits of greater equality tend to be largest among the poor, those benefits seem to extend to almost everyone, and that “a more equal society might improve most people's quality of life.” The factors underlying this are psychosocial stress resulting from invidious social comparisons that are divisive and corrosive, and the erosion of social cohesion.

The authors write, “it is now clear that unequal societies have an increased prevalence of a host of social problems, including violence, bullying, teenage births, higher rates of imprisonment, low educational performance, reduced social mobility, low levels of trust, and longer working hours.” They conclude that “it is a task for politicians and policy experts to repair our ‘broken society’ by undoing the widening of inequalities that has taken place since the 1970s.”

One of those studies on which this is based is Daniel M. Hausman’s, “Benevolence, Justice, Well-Being and the Health Gradient” in which he finds that “for most people the good life lies in close and intricate social ties with others which can flourish only when inequalities are limited. The health gradient suggests that there is a story to be told in which egalitarian justice, solidarity, health and well-being go hand-in-hand.”  

Infant mortality is the most commonly used indicator for the quality of a nation’s health care system, and it is an indicator of social inequality as well. In November, the government’s National Center for Health Statistics released a report ranking the U.S. 30th in the world in infant mortality using 2005 data. The U.S. rate was 12th in the world in 1960, fell to 23rd in 1990, to 29th in 2004, and 30th in 2005.

The United States also has the greatest inequality in wealth of any industrialized nation. This inequality is unjust in itself, and it also increases the cost of our health care through both depreciated health status and the income gradient that is inherent in the delivery of health care itself. For example, as a multiple of average wage in each nation, physician income is 1.4 in the U.K., 1.5 in Sweden, but 5.5 in the U.S.

It’s Neoliberalism, Stupid!

What I find remarkable about all well-intentioned pleas to reduce widening social disparities is a failure to address its causes. It is its causes that are controversial, for they are to be found in the neoliberalism that has become an international orthodoxy promoted by those rich in resources, led by the United States over the last three decades.

The WHO Commission identifies the problems but not the solutions:

Any serious effort to reduce health inequities will involve changing the distribution of power within society and global regions, empowering individuals and groups to represent strongly and effectively their needs and interests and, in so doing, to challenge and change the unfair and steeply graded distribution of social resources (the conditions for health) to which all, as citizens, have claims and rights.

Perhaps the greatest question for public health in America to answer in this century is whether and how it will adopt a social medicine agenda to eliminate the disparity between its goals and its means. For decades, it has focused its attention on individuals whose morbidity is taken as a given in a socio-political context also taken as a given, implicitly operationalizing the neoliberal policy model of assignment of responsibility for health status to the individual. Will public health be able to meet its responsibilities for promoting all that is encompassed by the hope and promise of good health and become “politicized” without losing its credibility?

The radical difference between private interests and public interests in health and in health policy development has been obscured from voters. The message that needs to be taken to heart by public health is that it is social (including political and economic) determinants driven by a neoliberal agenda that do greatest harm to population health, and so it is incumbent upon public health to confront that agenda, an agenda not for health and health system improvement, but for rapacious health and health system exploitation.

It is the empowerment of the population as an imperative of human rights that results in the sought-after benefits of better population health, and these ensue only from good governance. No professionally honest attempt at policy development in light of the social determinants of health can any longer ignore the political determinants of health. 

And in The Lancet on Dec. 5, WHO Director-General Margaret Chan wrote:

The pursuit of economic wealth took precedence over protection of the planet's ecological health, and over the most vulnerable in society. Fundamentally we are all facing a choice about values: improving lives, protecting the weakest, and fairness. These are the same values that motivate public health, and the health community is a willing partner in addressing this challenge.