Survival of the richest

[Stephen Bezruchka]

Some people in the US of A are starting to stir, as evidence in this
alumni magazine piece brought to my attention by our department chair.
STephen

***
Survival of the Richest :  Looking at how social factors affect human
health offers proof of conventional wisdom--and some more surprising
insights into disease and prevention.
University of Chicago Magazine April 2003
http://magazine.uchicago.edu/0304/features/survival.html
By John Easton  Art by Allen Carroll

"Them that's got shall get," goes the old Billie Holiday song, challenging
the accepted notion of the United States as an exceptionally mobile
society. "Them that's not," the lyrics continue, "shall lose. So the
Bible"--plus, it appears, mountains of demographic data--"said, and it
still is news." Also still news is a growing recognition of the
connections between "getting" and "losing" and health and disease and the
relentless discovery of ways in which deprivation, of any sort, can impair
well-being.

Extreme poverty has long been associated with reduced lifespan, but now
studies are revealing that not just the very poor--the malnourished or the
homeless--but people in each socioeconomic category have worse health than
those a notch above them. Similar links between resources and risk have
been found in every modern industrial society, human societies throughout
history, and even among nonhuman primates and other social animals.

Many of these ideas can be traced to a few pioneers, among them Alvin R.
Tarlov, MD'56. Three decades ago Tarlov--chair of Chicago's department of
medicine from 1968 to 1985 and now executive director of the Texas Program
for Society and Health, a consortium based at Rice University--began to
study how health is affected by social factors.

Such study of social determinants has been slow to take off, however,
because the topic is inherently so wide ranging. Doctors don't often chat
with economists, who seldom work with sociologists, who rarely seek out
lawyers. So Tarlov protege Mark Siegler, MD'67, a physician with a
penchant for ethics, and his Chicago colleague Richard Epstein, a lawyer
with a taste for economics, pulled together a conference this past
November at the Law School--"Social Determinants of Health and Disease:
Recognizing the Contributions of Dr. Alvin R. Tarlov."

Practitioners of the social-determinants approach vary widely but agree
that those concerned with public health should no longer focus simply on
biology, on germs and genes, but should shift more attention to such
variables as financial resources and social status, cognitive skills and
educational background, racial attitudes and ethnic practices, personal
behavior and lifestyle, even a person's neighborhood and friends.

A key factor in the growth of modern industrialized societies is also a
fundamental component of good health: "physiological capital," or the
accumulation of health resources. In 1750, noted Robert W. Fogel, a
Chicago Nobel laureate who applies the tools of economics to historical
problems, one-fifth of the English population was kept out of the labor
force because of poor health, largely chronic malnutrition. These
down-and-outs were smaller, frailer, sicker, and died younger than working
people. Since about 1800, however, increased access to food has meant a
dramatic improvement in public health--from 1750 to 1975 the average
Englishman's body size increased by nearly 50 percent--and a more capable
workforce.

Particularly important were the improved well-being and nutrition of
pregnant women. Well-fed moms gave birth to bigger, healthier children.
This initial investment, Fogel explained, "reduced the rate of
depreciation," meaning that newborns who acquired more health resources
early in life could fight off the diseases of old age longer. The result
was a kind of "biological but not genetic evolution," survival not quite
of the fattest but of those with a sufficient nest egg of calories.

One good measure of this progress is the decline in infant mortality. In
1800 some 17 percent of English children died in infancy and a whopping 79
percent of the children born to poor mothers weighed less than five
pounds. Today England's infant mortality has fallen to less than 1
percent, and fewer than 8 percent of newborns weigh under five pounds.

While some may explain these health-status improvements by citing better
medical care, Fogel attributed them to better nutrition and an improved
environment. Physician intervention could "slow the rate of depreciation
of physiological capital," he admitted, but the real gains in public
health came from better diets, access to clean water, and better
sanitation, which have delayed the onset of the chronic diseases of aging
by five to ten years. As for exact figures on the salutary role of the
environment versus health care, Fogel was "in the middle of applying for a
grant" to determine precisely that.

Yet it isn't only the impoverished whose health is affected by
socioeconomic status. While Fogel has focused on the English poor, Sir
Michael Marmot, director of the Whitehall I and II studies of civil
servants, researches the British middle class. These long-term
studies--the first, which began in 1967 and followed participants for 25
years, and Whitehall II, which began in 1985 and is still under way--have
shown, said Marmot, head of epidemiology and public health at University
College, London, that the social gradient in health extends from the
bottom to the top of society. Among civil servants, "none of whom is
poor," the first study found that the least well off had mortality rates
nearly eight times as high as the wealthiest. More important, there was a
significant gap between each step in the hierarchy. In other words, "The
problem is not confined to the high risk at the bottom."

Nor is the problem purely economic. In the United States, Marmot added, 77
percent of whites live to at least age 65, but only 61 percent of blacks
live that long. Even more revealing, 65 percent of poor whites live to 65
but only 30 percent of poor blacks do.

What causes such discrepancies? Is it access to health care? No, Marmot
said. Is it genetics--do better genes lead to better health and higher
socioeconomic status? No. Is it primarily income, which is closely tied to
education? Again, no, Marmot answered. On an international scale U.S.
blacks are far from poor, yet their life expectancy is comparable to the
residents of Kazakhstan, where income is measured in goats. More
significant than actual income is relative deprivation--where one lies in
the local hierarchy, a notion that applies not simply to finances but also
to power and independence at work, levels of social participation,
education, and early life experiences, all of which can influence
behaviors, such as smoking and drinking, that have a health impact.
"Control over life," he said, "and opportunities to participate fully in
society are powerful determinants of health."

Yet despair, emphasized Marmot, "is not warranted. Health for everyone can
improve." Lifespan and well-being for all social classes rose dramatically
during the 20th century, and the "gap between rich and poor, between top
and bottom, can change. The slope of the social gradient in mortality is
not fixed."

Where you find yourself in the social hierarchy may not be as important as
who's there with you. Arguing for the need to integrate sexuality into
considerations of social factors affecting health and medicine was Chicago
sociologist Edward O. Laumann, the world's authority on sexual practices.
His large-scale surveys of sexual behavior in the United States, and more
recently around the world, have found high rates of sexual dysfunction in
all 32 countries studied, with about 40 percent of women and 30 percent of
men acknowledging sexual problems. "Is that a medical problem?" he asked.
"Or is it inherent in the nature of sexual expression? Are there too many
other things vying for our attention?"

In contrast sexually transmitted diseases are a crucial part of human
health status and can only be understood in a sociocultural context. At
first glance, Laumann said, it appears that STDs, like many health
problems, are concentrated among the disadvantaged, with the highest
documented rates found among inner-city African Americans. But that could
be a function of reporting: the poor go to public clinics that notify the
authorities, while the wealthy choose private physicians who are more
discreet.

Indeed, Laumann's recent research in China found just the opposite. The
sexual revolution that swept the United States in the 1960s has had
different effects behind the Great Wall. More than 80 percent of Chinese
women, and 60 percent of men, have had only one sexual partner. Although
few poor women catch sexually transmitted diseases, 38 percent of the
wealthiest Chinese women have had chlamydia. What makes this infection so
elitist? It turns out that the use of prostitutes is more socially
acceptable in China, but costly. So wealthy men visit commercial sex
workers, then bring the disease home to their wives.

Cutting across economic lines are social isolation and loneliness, factors
that Chicago psychologist John T. Cacioppo called key determinants of
health. In all age groups, he has found, loneliness predicts mortality,
with increased rates of cardiovascular disease, stroke, and cancer
occurring in those who are socially isolated. Efforts to intervene, such
as providing short-term social supports for people recovering from a heart
attack, have been "mostly unsuccessful," largely because "we don't
understand the process" that creates such isolation: "There's no
particular pathophysiology."

Nor are there obvious differences between the lonely and the non-lonely.
They look the same. Their personalities are similar. They face the same
difficulties in life. But lonely people, Cacioppo's research has found,
don't cope as well with stressful events; they tend to withdraw rather
than confront problems, perhaps because they have fewer opportunities to
share their successes and frustrations or conspire with colleagues. Hit
harder by stress, as they age the lonely develop more peripheral
resistance--a sort of vascular teeth clenching--which reduces cardiac
output, increasing the demands on the heart. They also have higher levels
of the hormones associated with chronic stress. And they complain about
sleeping poorly, a problem confirmed by studies reporting more
microawakenings among lonely sleepers. An estimated 31 million people,
most 65 or older, will be living alone by the year 2020. Cacioppo urged,
"We need to find ways to support these people".

Sociologist Robert J. Sampson, who recently left the University to take a
post at Harvard, pushed the scope out beyond the individual to look at the
health-related effects of neighborhoods. Since the 1920s poor, inner-city
neighborhoods have been known as "hot spots" for unhealthy statistics:
higher rates of violent crimes, child abuse, infant mortality, suicide,
and accidental injuries. Clustering people by class, race, and health,
Sampson noted, "is a robust and apparently increasing occurrence."

But Sampson and colleagues have begun to uncover factors that can improve
the health of even poor city neighborhoods. The Project on Human
Development in Chicago Neighborhoods is a massive effort to assess
community ecologies, a process the researchers have dubbed "ecometrics."
The project team began by dividing the city into 343 neighborhood
clusters, each relatively homogenous in racial or ethnic mix,
socioeconomic status, population density, and family structure. Then the
researchers interviewed 8,782 residents and 2,900 business,
law-enforcement, educational, religious, political, and
community-organization leaders. They also videotaped 28,000
"micro-community environments" (such as street blocks) looking for health
risks such as garbage in the streets, public intoxication, or unsafe
housing.

They found several traits linked to better community health. Most
important is what sociologists call "collective efficacy"--residents'
willingness to work together to solve a neighborhood problem. How eager,
the researchers asked, are community members to step in if children are
skipping school and hanging out on a streetcorner, or spray-painting
graffiti on buildings? It turns out that higher levels of collective
efficacy are associated with lower rates of current and future violence:
"Social ties create the capacity for informal social control." Just being
next to a neighborhood with high collective efficacy, Sampson said, "is
one of the best predictors of lower homicide" rates.

That statistic bolsters his overarching contention that "community-level
prevention that attempts to change social environments" may prove an
effective complement to traditional thinking about disease and its
"individual and disease-specific approach."

One health factor that traditionally lands squarely in the lap of the
individual sinner is obesity. What was once decried as a personal
weakness, however, has become a national trend, perhaps "the greatest
change in an important variable across the entire population that the
nation has ever seen," according to Arthur H. Rubenstein, dean of the
University of Pennsylvania's medical school, who recited well-known but
alarming statistics on obesity. Forty years ago, being fat was a bit odd,
something to be teased about. In 1960 only one in four adults was
overweight and about one in nine considered obese, with a body mass index
(BMI) of 30 or more. (Normal BMI is 18 to 24, overweight is 25 to 29.)
Today two in three adults are overweight, and nearly one in three is
obese. Still more troubling is the emergence of obesity at younger ages.
In 1970, for example, less than 5 percent of teenaged boys were obese; now
more than 15 percent are. Although the waistline explosion has hit every
societal level, it has had the greatest impact on those with lower
socioeconomic status and on disadvantaged ethnicities, such as Mexican and
African Americans. Half of all adult black women are now obese, Rubenstein
pointed out, many of them morbio favor freedom. Regulation is the realm of
lawyers, and "when push comes to shove lawyers are the most powerful and
the most dangerous" people on earth. He traced the history of
public-health legislation from its early days, when it sought only to
contain communicable diseases and ensure proper sanitation, to the
emergence of a more inclusive, modern version--dominant after 1937--that
covers "any and all matters that relate to the distribution of health care
and health-care services."

Such broad and meddlesome definitions of public health "will in all
likelihood be conducive to the ill-health of the very individual it seeks
to protect," Epstein argued, citing several examples of regulatory failure
(cases that protected the powerful and hurt the vulnerable, such as a
quarantine affecting a specific ethnic group, or mandatory
vaccination--with the option for the wealthy of buying their way out, thus
posing a risk to others) traceable to equal parts venality and
incompetence. Legislatures, he said, have "every incentive to get it
wrong, and they will succeed."

Wake Forest law professor Mark Hall offered his own example of government
overzealousness. When his "germophobic" 14-year-old daughter was nipped by
her new puppy she felt anxious enough to phone their veterinarian and ask
about rabies. Although the dog had already received his shots, the vet was
legally obliged to notify the local health department, setting in motion a
process that culminated in a playful and perfectly healthy puppy being
quarantined for three months.

Hall was troubled by the notion of siccing that same process on obesity,
for example, by classifying overeating as a public-health problem. Once
you identify a cause, such as cheap and tasty fast food, he said, then
action becomes necessary. "Public-health law confers tremendous authority
on government officials," Hall said, "allowing measures that are justified
only in situations of extreme emergency." That makes sense in the battle
against a pathogen like cholera or rabies, or even against a harmful
behavior like smoking perhaps, but not for an "ecological problem" such as
obesity, which is immersed in social, economic, cultural, and political
considerations. At least one member of Congress has already begun to
discuss launching a war on fat, said Hall, a new battle of the bulge. This
is not "a rhetoric of prudence, balance, and restraint."

So far the legal community agrees but has left room to change its mind. In
January a judge dismissed a potential class-action suit blaming the
McDonald's Corporation for obesity in teenagers. The decision to dismiss
was guided by the principle that "legal consequences should not attach to
the consumption of hamburgers" unless consumers are unaware of the dangers
of eating such food. If a person knows that eating copious orders of
supersized McDonald's products is unhealthy and may result in weight gain,
"it's not the place of the law to protect them from their own excesses."

The real challenge confronting any attempt--whether legal, educational, or
biomedical--to alter the social gradient of health was perhaps best
summarized nearly 50 years ago by socialite Babe Paley, who was born rich,
grew up thin, and married two rich, thin men.  "You can't be too rich,"
she supposedly said, "or too thin." Paley's key insight was to connect the
two. Marmot's pioneering Whitehall study, for instance, showed the
correlation between socioeconomic status and lifespan, but it also
revealed that low status was associated with obesity, smoking, less
leisure-time physical activity, higher blood pressure, shorter height, and
coronary heart disease.

A glance at the conference speakers and taller-and-thinner-than-average
audience revealed many of the same connections. While not exactly rich by
Paley's standards, they all had advanced degrees from elite institutions
and the enhanced career paths that follow. Most had a BMI within spitting
distance of 25. No one deserted the lectures to smoke. Most, if not all,
reside in neighborhoods of high, even obsessive, collective efficacy,
primarily Hyde Park, and all were deeply concerned about matters of public
health. They were uniformly numbered among the "them that's got," and they
were go-getters.

They apparently have the added advantage of being persuasive. Three months
after the Chicago conference the president of the American Association for
the Advancement of Science opened that organization's annual meeting in
Denver with a plea for more socially focused research, specifically citing
Marmot's Whitehall Studies. Floyd Bloom, chair of neuropharmacology at the
Scripps Research Institute and former editor-in-chief of Science, author
of more than 600 papers and the text The Biochemical Basis of
Neuropharmacology--in short as hard-core a molecular biologist as they
come--kicked off the meeting by telling his audience that genomic-based
health care, though often described as a miracle on the horizon, is likely
to be expensive and require many more years of research before new options
are available to patients. "The puzzles of better health promotion and
disease prevention may be approached more rapidly and effectively through
intensified social-science research," he concluded, "rather than by
awaiting the expected evolution of gene-based explanations and
interventions based on future genetic discoveries." No longer a new kid on
the block, the social-determinants field has finally been blessed and is
coming into its own.