Staying Alive —
This week is the five year anniversary of Fierce, Freethinking Fatties. I’m pretty proud of all we’ve accomplished over the years, but what I’m most proud of are the interviews I’ve been able to conduct with some of the most influential and knowledgeable experts on a great number of subjects affecting weight and health.
Recently, I published the roundtable (Part 1 and Part 2) I put together with Health at Every Size® (HAES) experts about its invigorated emphasis on the social determinants of health (SDH). Some of the conversations I had about the SDH with some experts seemed fairly hesitant about suggesting solutions or actions that could be taken to address the problem of the SDH, even something as modest as increasing the minimum wage.
Yet I had read papers from a number of (primarily Canadian) scientists and researchers who have been studying the problem of the SDH for decades and had a long list of ideas on how to dig up the roots of the SDH.
Next to Sir Michael Marmot, the second most frequent name I saw associated with the SDH was Dennis Raphael, a professor of Health Policy and Management at York University in Toronto with a staggering list of publications on the SDH.
I contacted Dr. Raphael and he agreed to an interview. I think you’ll see some of the challenges of a HAES movement in the United States (in particular) promoting solutions to the SDH. We live in a hyperpartisan nation and many of the public policy recommendations that Dr. Raphael suggests would be a nonstarter for more than half of the nation, considering that “socialism” is treated as a four-letter word these days. To put this interview in perspective, at one point Dr. Raphael says that President Barack Obama is too far to the Right. And this is the point in our interview where what few Conservative readers we have will start screaming at the screen.
I hope you find the interview as fascinating and illuminating as I did.
Note: My questions are in green bold.
Dr. Raphael sent me numerous papers that he and his colleague, Stephen Bezruchka, had written on the SDH, as well as a fascinating interview from Unnatural Causes (PDF). I began the interview by pointing out something that surprised me.
The interesting thing that I noticed is that you don’t seem too impressed with Canada’s response to the SDH.
Let me put it this way, Stephen Bezruchka at the University of Washington always says, “You’re too hard on Canada. You’re light years ahead of us.” Here’s the difference: basically, if you look at the range of OECD [Organisation for Economic Co-operation and Development] countries, in wealthy, developed countries in terms of their general approach to public policy, what you see is that Canada’s much closer to the United States than we are to all of the European countries. In terms of general, actual public policy; in terms of inequality, poverty, lack of support for people across the lifespan, provision of childcare, provision of home care — on those kinds of important public policy issues, we’re much closer to the United States. So that’s nothing to brag about.
But we’re profoundly different from the United States. But if you look at it from a big, broad perspective, every country provides affordable child care. In Canada and the United States, we don’t. Labor legislation, in terms of providing people with security, ability to unionize, the kinds of things that make work more rewarding, we’re much, much closer to the United States.
In one sense, it’s a lot better up here. The union movement’s much more open, we have the ability to write and publish [about the SDH], and we basically have room to talk about this stuff with the potential that our more progressive political parties could take us up and actually do something. In terms of our ability for intellectual interaction, our ability to be published, our ability to be heard in the media, we’re light years ahead of the United States. But in terms of actual public policy, in terms of what we do, our poverty rates, our inequality, when you plot it out on a line from 0 to 10 where the United States is 10 and the Scandinavian countries are 0, we’re about 7 or 7.5.
Is the US the worst country in terms of the SDH?
Let’s limit ourselves to OECD countries. Turkey and Mexico are the worst, and then the United States. In terms of poverty and equality and developed welfare state, Turkey and Mexico are the last places you want to be. However, the United States is a profound outlier. In fact, when people published studies where they’re doing correlations between inequality and crime, or provision of childcare and child development, they always run two analyses: they run an analysis with the United States and they produce a correlation coefficient, then they remove the United States because it’s such an outlier that it dishonestly inflates the correlation.
One of the things I always like to show, because I grew up in the States in the ’50s and ’60s, is from 1945 to 1975, if you break the American population into quintiles, each quintile increased in real income significantly. The people in the bottom 20% doubled their income in real dollars, the people at the top doubled their income, so growth in income and wealth was evenly distributed across the population.
How much of that is attributable to FDR’s New Deal?
Certainly I think it was the attitude and the mentality of the New Deal. For example, one of the things I remember, being in grade six, this was the case in Canada as well, the highest marginal tax rate in the United States was 90%. And then going back to those charts, from 1975 to the present, beginning with the Reagan era, you now have growth more or less being limited to the top 20%.
When you look at the history of the United States, you have these spikes, but that’s the anomaly. The progressive era in the 1880s/1890s, those were anomalies because the way the Constitution was set up, you have a country that’s kind of frozen in time. The progressive era, the 1930s, the New Deal, the 1960s — those were always the deviation from the path. And the path is primarily similar to Canada and the UK — it’s an absolute celebration of free enterprise and, in theory, the individual.
But the way it plays out is that it ends up, when business and corporate interests dominate the operation of the economy and of the political culture, you end up with the kinds of inequality and disparities that lead to poor health. Because free enterprise doesn’t do a great job on things like universal education, universal healthcare, housing.
In the European countries, there’s two traditions that emerged to oppose this so-called liberal approach, and that, of course, was the Bismark and the conservative approach of the 1870s, where basically Bismark found that you couldn’t just let the market dominate the society. The so-called conservative approach (not to be confused with Conservatives in the United States) is one of promoting solidarity, watching out for each other, and basic provisions.
Those countries, of course, are France, Germany, Belgium, Holland, Switzerland. The other alternative was the social democratic. The social democratic approach, which is of course in the Nordic countries, was one of managing or controlling the economy in the public interest.
The United States is the extreme opposite: government is bad, get government out of the way. And it’s so pervasive that the average businessman in Europe is more likely to believe that government has a role providing people with jobs, providing people with education, providing people with enough to live, than most people in the United States. It’s really quite remarkable.
It’s an exaggeration of what has always been the American case with significant anomalies, like when I grew up in the ’50s and ’60s. For whatever reason, they were willing to put a 90% tax on the super-rich. But over time, beginning with the Reagan era, that gradually became watered down.
[This] is being driven by three things: one is any semblance of managing the economy is gone and the most obvious manifestations was, of course, Clinton and the derivatives. And Obama basically hasn’t really outlined any alternative to that. In fact, we were struck by the fact that once he got elected he took all the Bush guys into government. So, you have even less of a willingness on the part of society to manage the economy, so any kind of pressures by business have absolutely dominated civil society and any attempt to manage the economy. So that’s pretty bad.
It’s been reinforced by the American exceptionalism, such that Robert Woods Foundation actually does research where they try to point out to Americans that we’re not doing to well in terms of health outcomes. And what they find is really unbelievable when they come out and say America is really good at a lot of stuff, but, you know, compared to countries like France and Germany and England, our health isn’t that good.
What you find is in most European countries, a progressive vision is put forth by the labor movement and the labor movement is virtually nonexistent in the United States now. The New York Times had a story about how membership is down to 7%.
I’m literally 23 minutes away from Cleveland across the lake and I had this period a couple of years ago where I went down there literally four times in a year-and-a-half, and I would get up there and put up a chart and would compare life expectancy between 12 OECD countries and people just tuned out. I was on a panel and I say one of the things we have to do is strengthen the labor movement. The guy who followed me would say “Yeah, that’s certainly true, but that’s not going to work here so let’s forget about it.”
Whether it’s possible or not is another question. But in terms of this issue of health and inequalities and introducing these broader concepts, I think somehow it has to be communicated. In the 1970s the United States was number one, or near the top, in terms of life expectancy. And somehow, a movement has to somehow break people’s mindsets that [the United States] can do no wrong; that in the 1930s, America did this, America did that, but since then something’s happened.
In terms of values and thinking, somehow it has to be communicated that not only are we not doing that well, we’re doing very badly. In the 1970s, when I was just finishing university, that’s when the SAT scores began to plummet and people were making the argument, oh it’s because so many Black kids are now taking the test, when, actually, the effects of inequality were beginning to show.
The second thing, the labor movement here has a whole bunch of public ads that says the labor movement is here for all of us and it talks about education, healthcare. Somehow, a lot of research indicates that a good driver of equity and health is a strong labor movement. Of course, the United States has a long way to go.
I think an attitudinal thing is somehow trying to educate people that we’re not doing a great job for most Americans: the healthcare, of course, is the most egregious, but stagnating wages of 80%, the concentration of wealth. The problem is that ties into the American exceptionalism that 80% of kids think they’re going to be rich some day.
So it’s really hard. What we’re doing up here, we’ve been able to get the Canadian Medical Association, the Canadian Nurses Association, pretty well all the institutional players have bought into [the SDH]. The problem is that none of it has moved up to the political level. So even the new Democrats will have something on their website about the SDH, but they haven’t come to the realization that this will be a way to get people to vote for them. There are also Americans who would be receptive to this. In Maine, you’ve got Bernie Sanders.
Well, there is Elizabeth Warren.
Yes, yes, we know about her. We certainly know about her attempt to manage Wall Street. The fact is, she comes from a working class background. So, yeah, if she could be brought on to it, it has to resonate, but the problem, again, is they can’t make everybody happy. Maybe you’ll never get people from Nebraska won over.
There are certain things here that I’ve got to celebrate because we forget about them. For example, funding for education of elementary schools in the province of Ontario is not based on local taxes.
The United States is notorious for that.
What happens here is not only is it equal no matter where you are in the province, but the poorest areas get more money. I’m still in a neighborhood that’s considered to be lower-middle income and we get more money per kid on the basis of need.
There are some things that are built into the [American] system that are just atrocious. The funding for education, the weakening of labor laws in the South. It’s not just the South any more, it’s Wisconsin. In Wisconsin they banned unions. I find it really helpful to put up the slide that says the minimum wage in France is double what it is in Canada. People look at that and say “Why can’t we be more like France?” Or we show childcare in the Scandinavian countries or we try to show public transportation. Actually, in public transportation, the United States is now moving ahead of Canada.
What would need to be done is organizations like the American Public Health Association, somehow joining together with other civil societies: the NAACP, Urban League, all of these NGOs [non-governmental organizations] that have a modicum of respect for the American people. In Australia, they’ve created what they’ve called the Social Determinants of Health Alliance.
Somehow, there has to be some recognition that things have gone awry, which I think most Americans feel at least intuitively, and that we can begin to make sense out of this. Maybe the same way that people around the world learned from America about Microsoft and Google and Hollywood; maybe there’s something we can be learning from these other countries.
What do you make of the proposals President Obama made recently: free community college, free preschool for all?
The average kid up here is completely disengaged and I think Obama’s a really good guy. One of the things I say to my students is, forgetting about what these guys would like to do or what they would say to you over a few beers, when you look at Obama’s political positions on the role of the market, on healthcare, on a whole bunch of things, he’s actually to the right of Stephen Harper.
What!?! I find that hard to believe.
Well, Medicare, healthcare, in terms of managing the markets. I mean, basically, the Canadian banking system, we didn’t have that much of a problem in 2008 because it’s really well regulated. You don’t see Stephen Harper coming out and calling for right-to-work laws, certainly not gun control, and certainly even in public policy, as bad as we’ve become, we’ve had relationships with Cuba and Venezuela for a very long time. But I guess I’m saying that the politics in the United States has shifted so far to the right…
… that you kind of have to be to the right of the Left.
That’s right. Or else people will just ignore you and think you’re insane.
You’re too radical.
Yeah. So, in terms of Obama, he can come out and say these things, like increasing the taxes on the super-rich or the free community college, in the State of the Union message. I think that he feels he can come out and say that, but there’s not a chance in hell that it’s going to be accepted.
He’s got nothing to lose now.
That’s right. If he did it earlier when he still had control of the House, then he would have these conservative Senators and Congressmen knocking on his door.
Yeah, but he spent all that capital on healthcare.
And all he’s done is, Obamacare is simply forcing people to buy into private insurance. Ted Rall is a pretty radical cartoonist in the United States and he said it’s hard to believe, but every President since FDR has been worse than the one before.
Isn’t there a case to be made that, like you said, from ’45 until ’75, we were fairly progressive and Reagan kind of broke that fever and took us the other way to deregulation and all that. Couldn’t Obama serve as a kind of left-wing Reagan where it’s the turning point where the conversation starts to shift to the left?
Absolutely, if he did this consistently and it wasn’t just a one-off, you’re right. You’re absolutely right. Because things were going fairly well until Reagan convinced everybody they weren’t. So Obama could come along, but I don’t think he has it in him. I think he’s young, I think he has to worry about income, although he’s done well from his books, but you’re absolutely right. If he went out to Gary, Indiana to these decaying factories, any person in authority could become that kind of person. That’s good. He could.
I have a hunch that’s what the next two years are going to be: focused on income inequality.
And him up there somehow trying to build a groundswell for the next Congressional election.
I personally would love Elizabeth Warren for President.
It’s so different that even in the literature on poverty, poverty looks different in the United States.
The SDH is completely off the radar here. It’s almost unheard of here.
It’s been really big. The World Health Organization, the European Union — health inequalities has been on its agenda since 1992. They identified reducing health inequalities. Until the Bush era, the Centers for Disease Control used to report on it. It used to be called “Health United States 1998,” and they produced the same kind of charts that we produce here. Then it was off for eight years during the Bush era; they weren’t allowed to do anything about it, and now the CDC is starting to report. They use the term “health disparities.” So there is some attempt out there.
Claudia Chaufan is with us for six months as a Fulbright Scholar. Claudia is the only person in the United States, literally the only person in the United States, who says that an awful lot of what’s causing and driving diabetes is inequality, poverty and insecure living conditions. [Editor’s note: after this interview, I discovered the work of David Spero, who has written a book with a similar message]
Where do weight-related issues fit into the SDH?
The 1970s, when they did all the Whitehall Studies, the assumption was that you could explain the differences in heart disease on the basis of weight — they did BMI, they did smoking, they did cholesterol, they did glucose intolerance and they found that once you were lower on the socioeconomic ladder, these things didn’t make a difference.
What we found in all our diabetes studies — and these were both cross-sectional studies and longitudinal studies — is once you were low-income, that was a really good predictor of you getting adult diabetes and it didn’t matter if you were fat or not.
There’s a researcher in Michigan who does cardiovascular disease, and she finds that once you’re living in a poor neighborhood, it doesn’t matter what your weight or physical activity is in terms of your likelihood of getting cardiovascular disease.
What you have with obesity, I think it’s the same way as income: income has direct effects on health. And those direct effects, of course, are crowding, infections, poor diet, danger, all that kind of stuff. But income inequality is not the end all and be all, that’s simply an indicator of a whole bunch of other processes.
Obesity, at its extremes, is not good for health. However, being overweight is a protective factor, especially for the elderly. So, obesity in the United States, I think for some people can be a direct cause of poor health. I think it’s more of an indicator of all the other things that aren’t working.
I guess what I’m saying is that if you identified all the people in the United States that had decent, secure jobs and happen to be fat, you’d find no effect of fatness. I think obesity is one of these things that politicians and everybody latched onto to show that they’re concerned about health without having to deal with all of this other stuff. Plus there’s this whole big literature in Western thought demonizing fat people and all that kind of stuff. So there’s a whole anti-obesity literature.
My approach is, yeah, of course you don’t want people to weigh 500 pounds, of course you don’t want them to smoke, but in terms of the major health issues facing us, they’re pretty well low on the scale compared to whether it’s poverty or precarious work or food bank use or poor housing or that kind of stuff. I think it’s something that, to me, is generally the attention being paid to it is divisive in terms of diverting people from things that are a lot more important.
Going back to the Whitehall Studies, something I’ve wondered is that it shows two people can have the same lifestyle behaviors but if they’re in different socioeconomic classes then they’ll have different health outcomes.
Absolutely. What this means is that if you’re a wealthy person at the top of the hierarchy who smokes that will have less of a health effect than if you’re someone lower on the hierarchy who smokes
What if you compare two people on the same level who have different behaviors? Is it a muted impact?
Maybe it will count for 15% of variance. What will happen is, if you take, let’s say, a hundred people that are wealthy and you separate them into smokers and nonsmokers, you’ll find a difference. But it won’t be at the magnitude that you have between wealthy people and not-so-wealthy people. So it’s pretty consistent. If you have to bet who’s going to get heart disease, ask them what mom and dad did for a living and ask them what they do for a living. Once you know that, then you place your bet. If they smoke, you’re a little more sure. But it really is remarkable, it’s pretty striking.
Tthe problem is, even up here we couldn’t get this stuff published. We get a lot of this stuff published in international journals. They’re more receptive to all of this stuff than even Canadian journals are. And the American journals we don’t even bother with anymore.
On that individual level, speaking of someone on the low economic side of the scale, are there things that an individual can do to personally reduce or mitigate or counteract the effects of the SDH?
Clearly at an individual level, the most obvious ones are don’t smoke, don’t drink yourself into a stupor. But I would argue, I say to my students that it’s probably healthier, probably more important whether you vote or not, or become engaged. And there’s this whole literature that came out of the [Alameda County Study]. I’m not a big fan of it because it avoids broader issues, but they found that people that were socially isolated were much more likely to die as they got older.
If I was a community developer and I went into a poor neighborhood, I’d say to people, “You know, you hear a lot about not smoking and exercising and, of course, these things are all really important. But another important thing you can do is try to get engaged in order to improve living conditions around here.” What you do is take people who really don’t understand what’s going on, they see their friends getting sick, and somehow you engage them in some kind of activity that gives them some hope and connections and, at the very minimum, builds relationships with other people.
For example we have something called the Good Food Box. The idea is that you go up and down the street and you say “For $20 a week, we can get this stuff directly from farmers.” It started out as being really for poor people. It’s not so much that you get them fruits and vegetables, but that you get people connected and engaged. Because when you go to a food bank, you’re not engaged, you’re not connected.
What could people do? I think people need to begin to understand the roots of this, but also that as difficult as it may be, we can do things like they’ve done in Seattle, we can do things like they’ve done in New Westminster, British Columbia, where you get involved with the local public health unit and you try to get some immediate gains, but you also recognize that we’ve got a long way to go.
Along those lines, I have another question: how do you look at the effects of the SDH, especially if you are working with other NGOs trying to make a difference, how do you not look at the enormity of the institutions that ensure the ongoing existence of the SDH and not succumb to feelings of futility or immutable fate?
No matter what I do, it’s still going to make it easier for the people that come after me. Now, in terms of the average person, I say this to myself when I get disgusted with the so-called new Democratic party here. We have no choice. We literally have no choice, we have to stay with it, we have to become engaged because the alternative is for things to get even worse. So, what do you do? You look for examples. There’s a lot of good stuff that happens in the United States, but it’s localized and it’s not publicized. The problem is they’re tremendously isolated and they’re very small.
But it’s what you’re up against here. It’s pretty bad. And the people that are tuned into it have really decided to keep their heads down. In some places in the Midwest or maybe in the South, if you’re too outspoken then they go after you. We heard about people being unable to use university emails or stuff like that for something that’s perceived as being anti-American. So I don’t envy anybody down there. I really don’t. It’s really a difficult situation to be in. But, again, there are pockets across the country and one way to do that is to publicize it and bring it together and give people a little bit of hope.
Knowing everything that you know about the SDH, the gravity, the impact, how does it affect your understanding of individual health behaviors? Are they just not that important when you look at the grand scale or are they still vital on an individual level? How do you put that in perspective?
There’s this guy, David Seedhouse, who wrote a book called The Foundations of Health, and he made the argument, philosophically, that unless you provide people with the basics, you can’t go after them on these other issues. What I suggest to people is that all things considered, you want to do what you can. You do what you can no matter what level. If you’re an anti-smoking person, you do anti-smoking, but you don’t do it like “You guys are just stupid, stop smoking.” You do it in terms of empowering them.
Any time somebody comes along and says “We gotta stop Latinos from smoking,” although they don’t smoke that much, you come out and say, “Yes, of course we do, but don’t you think we should be spending some time on the kinds of employment opportunities and educational opportunities that kids have?” So you just try to shift that 99% of attention to 95% or 90%, or just work its way down.
Do you think the United States has crossed the tipping point? Are we too far gone?
Well, you know, we were too far gone until the New Deal came along, right? And who would have thought that Vietnam War stuff would have happened? So, yeah, you never know. It seems to me when you see something like Seattle and it happens and it works, or you see a guy like Bernie Sanders gets elected in Vermont, then anything is possible.