Left Behind —
Trigger warning: Discussion of diet and exercise as healthy lifestyle approaches.
Yesterday, we heard from Dr. Dennis Raphael, an expert on the social determinants of health (SDH). Today’s interview is with Dr. Raphael’s collaborator and colleague, Dr. Stephen Bezruchka, Senior Lecturer at the University of Washington School of Public Health. You might expect these two gentlemen to have similar approaches to the SDH, but I noticed a slight difference in their messages (although I’m sure they would agree with the ideas of the other). While Dr. Raphael emphasized civic involvement, Dr. Bezruchka promotes investment in early childhood development as the best bang for the buck. As for what each of us can do to fight back against socioeconomic inequity, it’s so simple you just need half an hour and an unwitting telemarketer.
Where does obesity, diabetes, cardiovascular disease fit into the SDH worldview?
There’s something called the thrifty phenotype hypothesis and what that says is that as a species we try to economize our physiology in order to survive to reproduction. All sorts of factors in our physiology are programmed early in life through epigentic means, which are factors in the environment, broadly considered, that dictate levels of gene expression.
The human genome project found we have somewhere between 10 and 20,000 genes and we’re not all that different from a pufferfish or earthworm, though we appear to be much more complex. So how do we address this complexity? The current thinking is by differential expression of that genetic material. So, what produces these differences in expression?
If you consider obesity, rewind back two or three generations. If we think back to the 40s and 50s after the Second World War and think about food; food was relatively expensive compared to today, it was time consuming to prepare, you tended to eat it at traditional meal times, and it was relatively low caloric density. We ate a lot of food, we consumed a lot of calories, because we had a lot of physical work to do. Through epigenetics, this has been programmed into our physiology. Namely, eat a lot of food because you’ve got a lot of work to do.
Fast forward to the present: food is incredibly cheap, it is high caloric density, it is eaten almost continuously throughout the day, takes seconds to prepare. So here we are, surrounded by this food and we’re programmed to eat as much as we can because we were supposed to have a lot of work to do.
But what kind of work do we do now? We’ve lost manufacturing jobs; mechanization has made it difficult to do physical work. Some of us who are privileged can pay money to do physical work — that is, we can join gyms, have a personal trainer, take adventure vacations, have exercise machines at home. So, the more privileged of us [who are] programmed to eat have ways of working off that energy. Some people don’t.
If you look at the demographics of obesity, the poor are by and large the more obese. That’s one way of looking at today’s obesity epidemic. Not the only way, but one that I think is actually pretty important. Relating this to the social determinants of the health, that depends on what you mean by the social determinants of the health. I think of the determinants of the health as the factors that produce health in populations. You might consider the social determinants of the health the nonmedical factors that produce health in society.
If you look at pretty much any mortality indicator of health, we’re behind pretty well all of the other rich countries. Cuba does better than we do. Slovenia, Costa Rica, Chile. Forget all the other rich countries, we’re far behind.
This is not something that most of us want to look at. The stress in our society is a major factor in the health issues and why we’re not doing so well. International surveys show we report some of the highest stress of all countries. This is a subjective measure, but nevertheless, this is what people report.
It’s not that hard to observe how stressful American society is now. Stress is hurry, worry and eat too much. What does that mean? We try to cope with this society by engaging in behaviors that make it easier. I worked as an ER doc for 35 years and I’ve worked in innercity situations and I’ve worked in hospitals where some of the richest people in the world live. And in innercity situations, your bread and butter is heroin overdoses and cocaine chest pain and injection abscesses, among other things. It’s poor people who do all this stuff and I used to blame them for making me work so hard. But I came to see that their behavior are a response to the stress in society and their inability to cope.
This is programmed early in life. Eating is a way of relieving stress and you see this constantly now with people on the streets. When I teach a class, people are eating during the class now. Thirty years ago, nobody brought food to class. If you want to have some kind of function at school, like I make my students organize a community event, they always have to serve food or nobody will come. Obesity is a response to programming that happened generations ago and the stress of modern life.
In the chapter that you wrote, you mentioned Elizabeth Warren’s book The Two Income Trap and how in 1970 a median two parent, two child family with one parent working outside the home had more disposable income than a similar family in 2000 where both parents work outside the home. Haven’t we engineered cooking and fitness out of our society entirely, rather than just a function of the response to stress? Haven’t we made it more difficult for people to cook meals from scratch or even just go for a walk because they don’t have as much time or money?
Yeah, but how did that come about? How could the 1970 family be situated economically better than the 2000 family with both parents working? If you look at productivity historically from the 1800s to the present — productivity is the amount of stuff produced per unit input — what seemed to be the case from 1820, when we first started having this data in the United States, productivity rose and hourly wage rose. And they more or less paralleled. You worked harder, you get paid more.
The curves diverged, a lot of things diverged, in the early 1970s. Productivity kept increasing, but the average wage has remained stable in inflation-adjusted dollars. We are no longer making more money for working harder as a nation. So what was the response? We consume much, much more than we did in 1970, and how did we do that? We put more family members to work outside the home, we put children to work, we borrowed against home equity, we borrowed against credit cards that led to the crash in 2008.
Things were better in 1970 on a lot of indicators, not just hourly wage. We were happier as a society then. Everything sort of fits together if you’re willing to look at indicators reflecting progress or its lack in large societies.
Given our current political environment in the US, austerity is a huge buzzword and there’s so much obstruction, and attempts to deconstruct our existing social safety net. Do you see a future for turning this around in politics or has the US too far gone?
Everything goes in cycles. Things get better, things get worse; the economy grows, it contracts. I think we’re in the midst of a social movement. And as somebody who was in a social movement in the 1960s, we were not aware of it then. We had this utopian vision, there was opposition to the invasion of Vietnam, inner cities were burning, there was the Civil Rights Movement, the Democracy trials in Chicago, and our voting rates were the highest that they’ve ever been in society for Presidential elections.
As a result of that popular force, a whole bunch of things happened that were actually beneficial, and people often don’t recognize the political tendencies of both parties to produce legislation that benefited the public. Medicare in 1966, the social welfare system.
In 1969, Richard Nixon proposed a guaranteed income for all American families. That was his Family Assistance Act that was announced in August 1969. The newspaper and TV and editorial comment was 94% in favor. Imagine a Republican President proposing a tranche of income for every American family. And we thought it was a great idea. Today, if anybody proposed that they’d be a laughing stock. I just can’t imagine that.
So, our values were different then. Having been around then, I think that was pretty true. We cared for one another. There was a sense of the power of people, a sense of people massing together, pushing for their ideas. These days, that’s beginning again, but it’s really struggling. Somewhere in the last four or five years, we’ve had an awareness.
The Occupy Movement gave us recognition of what the numbers 1% and 99% mean. There was an immigrant march that was not reported much in this country, but it was huge. The million people in Paris demonstrating against terrorism. It’s not just happening in the United States, I think it’s happening in a lot of places.
What did the highest paid person make in 2013 in the United States? The answer is $400,000 an hour and most of us find that hard to believe, but it’s true. That’s gotta come down. We’re going to see the maximum wage fall in the next decade or so.
They just released a study that the top 1% will own the top half of the wealth. It seems like the momentum is on the side of the 1%.
I can wear two hats: one hat I wear, it was crafted by Thomas Piketty and Capital in the 21st Century. I use his material all the time. r is greater than g, so equality is going to grow. At the same time, something is happening in this country and elsewhere in the world that wants to do something about it. Piketty’s solutions are global transparency for income wealth and inheritance. He calls them utopian solutions, but I think that’s what we should be debating or discussing.
People are uncomfortable with the inequality in this country. On the one hand and on the other hand, the poor seem to think that someday before they die they’re going to strike the big one. You just have to go into a 7-11 and watch who buys lottery tickets: poor people are just betting on winning the big one.
I agree that inequality is bound to increase. I’m kind of a doomsday person, but I’m impressed with the fact that inequality is declining in Latin America. It’s the only place in the world where it is. And the capacity of people to mobilize mostly outside of the United States is hopeful.
Do you have any thoughts on President Obama’s recent proposals that seemed aimed at addressing social injustice?
There’s only two countries without a paid maternity leave and we’re one and Papua New Guinea is the other. He has at least stated that the basic problem in this country is inequality.
We need to do what’s necessary in early life when all this stuff is programmed or we pay the price later: obesity or heart attacks or horrible cancers, all that stuff. Back in October in the New York Times was an article on birth weight and standardized test scores.
The study took all the births in Florida over about 15 years where they recorded their birth weight and they followed these kids on grades three to eight and looked at standardized test scores. What they found was a striking socioeconomic gradient, always poorer people do more poorly. In this case, it was birth weight and standardized test scores. The birth weights went from 2 to 12 pounds, but [America has] the most low birth weights of pretty much all rich countries and preterm deliveries, that’s another issue. The higher your birth weight, the better you did on standardized test scores, peaking at around 9.5, 10 pounds.
If we think of what’s happening to early life in this country, there’s a segment of the population that does very well, but we have so much low birth weight, so many preterm deliveries, so many kids — 23% of kids in this country growing up in poverty, it’s not good. School boards are struggling with No Child Left Behind and Race for the Top and all these ways of trying to get money to improve the quality of their education and, by and large, most of it’s not working.
So we’re focusing on firing teachers who don’t produce good test scores, but a lot of kids in this country can’t learn in the school system that we have. That may not be a bad thing because we focus so much on education, but we spent most of our history as hunter gatherers and we had no schools then and people were remarkably adapted to surviving in that environment. But with today’s environment, we tend to think that education of poor people will be the way for them to succeed. But I don’t think that they have the capacity to function in our school environment without changing a lot of things.
So what do we need to change? We could have Nixon’s guaranteed income. We could try and support parenting instead of outsourcing it. Kids are no longer raised by parents, they’re raised in a haphazard mix of environments that are not good for their health. We have to change the circumstances that impact early life and given the innergenerational programming that occurs, we have to wait a few generations to see results. We’re not that patient as a society.
Are there things that individuals who may not have access to all the determinants of health that they can do to reduce or mitigate or counteract the effects of those health issues that arise from inequality?
Yes, but it’s not the usual advice.
[Editor’s note: at this point in the interview, Dr. Bezruchka mentions Dr. Raphael’s “10 Tips for Better Health,” which immediately rang a bell because it was once on the Wikipedia page for the social determinants of health. It’s not any more. But the inimitable Michelle Allison captured the entry, plus I related the list in the post I wrote about the SDH back in 2012. So it wasn’t until this moment in the interview when I realized that the guy I just interviewed an hour before was the author of this great list. It’s well worth revisiting in its entirety:
The traditional 10 Tips for Better Health
- Don’t smoke. If you can, stop. If you can’t, cut down.
- Follow a balanced diet with plenty of fruit and vegetables.
- Keep physically active.
- Manage stress by, for example, talking things through and making time to relax.
- If you drink alcohol, do so in moderation.
- Cover up in the sun, and protect children from sunburn.
- Practice safer sex.
- Take up cancer-screening opportunities.
- Be safe on the roads: follow the Highway Code.
- Learn the First Aid ABCs: airways, breathing, circulation.
The social determinants 10 Tips for Better Health
- Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
- Don’t have poor parents.
- Own a car.
- Don’t work in a stressful, low-paid manual job.
- Don’t live in damp, low-quality housing.
- Be able to afford to go on a foreign holiday and sunbathe.
- Practice not losing your job and don’t become unemployed.
- Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
- Don’t live next to a busy major road or near a polluting factory.
- Learn how to fill in the complex housing benefit/asylum application forms before you become homeless and destitute.
We now return to Dr. Bezruchka.]
So what can an individual do? Let me give you an example based on my own personal experience. I think the way I do because I have a background as a mathematician and everything has to make logical sense. If I want to prove a theorem, I have an axiom and deductions and I work logically. As an ER doc, I never saw a Latino patient in the ER. I saw a whole bunch of people standing around a stretcher and one of them was the Latino patient and the rest were their family and friends there to support them.
Meanwhile, next to them is a White guy moaning alone. Latinos in the United States have better health outcomes than non-Latino Whites. Whenever I talked about the social economic gradients, poor people tend to have poorer health (when I say better health, I mean as measured by mortality indicators: life expectancy, mortality and that kind of stuff). Yet they’re poor, by and large. Latinos tend to be poor.
So there’s something that I just described about the social nature of Latino society that buffers the adverse effects of being poor. Having friends’ support is stronger than not smoking or exercising or eating the usual kind of things that we think are bad for you, but not having friends is worse. What individuals can do is seek out friendship and social support in whatever ways they can.
This year I had about five groups looking at things like CrossFit, Pure Barre, swing dancing. LARPing, a whole host of these groups that are near the university that they’re observing, participating, and interviewing people in. A common thing that they found was that people are attracted to these various activities because of the sense of community and social togetherness that they found there.
The way that I interpret this, because I think this has changed so much, social media has individualized us tremendously. You walk down the street and most people have a handheld device and they’re constantly interacting with it. This is a real problem. Mothers aren’t mothering their infants. They’re checking Facebook or so on. This is changing the nature of parenting to what extent it’s already been eroded and it’s too soon to tell what effect it’s having. Certain kinds of people (not the poor because they’re working too hard, too many jobs, no time), those of means, are seeking out community because they recognize some benefit from that.
Given the gravity and impact of the SDH, how should we view individual health behaviors in the context of the SDH?
I think they’re a good idea. I exercise, I don’t eat too much, I’ve tried being in environments where I’m forced to work naturally. If I can’t, that’s harder and harder. I’ve had some health issues, so I’ve lost some capacity, but on Saturday I’m going up and making a 2,000 foot ascent with a former student of mine and I tend to do that on a weekly basis.
It used to be that my office hours were undertaking this hike with students. And we would talk mostly on the way down. I’m fortunate living in Seattle because I can drive a half an hour and have this 2,000 foot ascent. There’s no way I’d tell somebody to just give up the individual factors that we know are good for health, it’s just that they’re not as important as working together to try and change society.
I try to arrange for people to do that in whatever way they can. In my course, the students have to take the ideas out of the class and present them to an audience that they organize. And that gives them some confidence that they have ideas that others don’t know about and they can inform and have discussions on them.
Trying to talk about these ideas is the most important — the most important thing we need to do at this point. The Institute of Medicine came out with its report in 2013: “US Health In International Perspective: Shorter Lives, Poorer Health.” The most important document they’ve ever come out with. They had 500 pages of basically the same stuff I’ve been talking about for 20 years. It just legitimizes it with their imprimatur.
When [the IoM document] came to what to do, the first thing was “Inform the public.” Inform the public that our health status is that of a middle-income country at best; that we’re good at dying young … not a thing that most Americans want to even consider.
The second thing was look at what healthier countries are doing that might be of use here. We have to see that Sweden, for example, spends more government money in the first year of life than in any subsequent year. If you look at where we spend our government money, it’s on people my age and older, Social Security and all that stuff.
If we look at early life, it’s once they get into school, age 5 or 6. That’s where we start to spend money, when you get your real bang for the buck in your first or two of life. I make this statement that roughly half of our health as adults are programmed in the first thousand days after conception.
What sort of investments would you recommend making in that first year of life?
I would have paid maternity leave on very generous standards. If we want people to parent, give them time to do that. Sweden mandates a year’s maternity leave with full pay. The mothers take the whole year, the fathers take 12 weeks. In the second year, it’s optional, but at 80%. Now, who pays your salary while you’re off work? It’s not the business you work for, it’s the government. Te percent of the [gross domestic product] that the Swedish government spends is about 50%. Ours is about 30%. So they have a lot of money because they have high tax rates and people accept that to spend it on early life.
Antenatal leave: life is stressful and a pregnant mother being stressed is not good for the health of her children. Lots of studies demonstrate that. Pretty well all other rich countries give you paid time off work if you’re pregnant up to about 18 weeks. We have five states in this country that give you four weeks paid maternity leave and they all show better health outcomes.
Spending money on early life, both in terms of supporting parents by giving them paid time off, by raising the minimum wage, by having a generous welfare system. The word welfare is a putdown here, but in Sweden it’s not. It’s what people are owed because it’s good for them. When Bill Clinton said we’re ending welfare as we know it and Reagan spoke of welfare queens, that was a real disservice to the 20-plus percent of people who are poor. And there’s a lot of poor people who don’t avail themselves in this country of what welfare there is because it’s shameful.
One thing you said earlier that caught my ear, but did you say that if you had to pick one, personal behaviors versus advocating for social equality, you would recommend social equality?
Absolutely. There’s evidence on eudaimonic well-being, which is a form of well-being or happiness in which you look for your own self-actualization and focus on helping others. They looked at biomarkers of people with eudaimonic well-being in contrast to hedonic well-being. Biomarkers are better in those who seem to have this sense of purpose in life is to help others.
I’ve heard this proposal before, that focusing on reducing inequality is a better bang-for-your-buck than individual health behaviors, which seems so counter-intuitive to what we’re taught.
The way the world is organized right now with corporations having most of the power, for climate change and sustainability and a whole host of issues, the political structure of the world has to change for human survivorship. How that will happen and what it will be like, if you look back 200 years ago, there’s no way you could predict that we’d end up in this neo-liberal nirvana of corporate greed being glorified.
But the European social democracies seem to be capitalist in many ways, and yet the people feel like the government should be there to support them. When you speak of health, there’s a whole bunch of factors you could look at. I look mostly at mortality because it’s hard to fake a death. There’s a study on dental health. Your mouth is really a mirror of the rest of your body, and a study looking at political organization in countries and their dental health, and they show that the Scandinavian social democracies produced healthy teeth.
Is that a function of access to dental services or education on dental health? What is it attributable to?
We all want to say “Oh you brush your teeth twice a day, you see a dentist and you paint fluorides on and all that stuff.” I think it’s the psychosocial feeling you get living in a society where you feel less exploited.In Japan, they have twice the rate of men smoking that we do and yet their health status is phenomenally better than ours. And there are studies showing that the adverse health effects of smoking in Japan are less than you would predict by looking at a country like the United States.
So what is it that makes Japan be able to smoke and get away with it? Yes, smokers in Japan have worse health than non-smokers, but the difference isn’t as big. The life expectancy hit is not as big. Social factors, I think, can mitigate the adverse affects of bad behaviors. I illustrate that when I speak by asking the question: “Do you ever see a lone Japanese tourist here?” I then say “Do you ever see a lone American tourist” and everybody nods. Yeah, all the time.
They do things together. They have this concept in Japanese society called social harmony or Wa. That togetherness can make up for an awful lot of bad behaviors or factors like that. I think the dental health thing in social democracies relates to the sense of being that people feel there that they don’t here. We can see this actually in studies of stress responses.
In other words, you physiologically stress people experimentally in Lithuania and Sweden, separated by a not very big body of water. The Swedish people can mount a real high stress response with a rapid decay to this experimental procedure. The people in Lithuania have a much slower rise in the stress response, smaller peak, takes a long time to decay. It’s emblematic of the idea that the society you live in has a huge impact on your health and well-being. It’s not what you do that matters as much.
Is it fair to say that the #BlackLivesMatter movement that’s happening around Michael Brown and Eric Garner, is that a health movement as well?
Yes. Race compounds the effects of inequality and social status. It’s programmed in early life.
The first studies were done in the 1930s and they’ve been repeated many times and they all find the same thing: black children are programmed from an early life to feel bad about themselves. Society reinforces that every step of the way. The awareness that this is creating and the discussion in the media is very healthy, but I think trying to change most people’s attitudes toward races is like the epigenetic program: it’s going to take a long time. I think the racial prejudices are programmed in early life and they are reinforced by society and so they have to start with the right programming in early childhood and reinforce that. That’s a real tough one.
How does a person look at the SDH, the effects of income disparity and social inequality, how do you look at the enormity of the institutions that uphold that inequality and not succumb to feelings of futility and immutable fate in terms of your own personal health or long-term objectives in trying to achieve greater equality? How do you recommend someone interested in fighting that not feeling so overwhelmed by what they’re up against?
My advice to people is to understand what’s going on. That’s not easy. What can you do? I think it’s hard to do stuff you don’t have skills at, so do something you have some skills for. It’s hard to do something you don’t enjoy, so do something you enjoy that uses your skills. And don’t expect to be paid for it — that is, if we’re going to do something about improving our health status, about decreasing inequality, it’s hard to get a job with that in mind.
And so, as a doctor I was privileged to be able to have another source of income. I eventually got out of doing clinical medicine because this was much more satisfying. I got into a situation where I could try and influence others on more than an individual basis with a patient. If they understand these non-individual medical factors are really what matter, they have to find ways of engaging others in using their skills.
In my courses, I try to give [students] ways of doing that. You’ve got to get comfortable talking about these ideas. You can practice around dinner time when you get a marketing call from some company trying to sell you something, especially the ones that say this call is being recorded for quality assurance purposes because they won’t hang up.
So you can practice what you’re trying to say. That’s what I do sometimes. That’s kind of cheap, but still, we have to gain the facilities to talk about this. You find it different in other societies. At the benefit of being in other countries where you can talk about these ideas. So develop some skills at doing stuff that you enjoy doing.