Social Policy is Health Policy: Addressing the “Causes of the Causes” of Health Disparities
Although the U.S. boasts the most advanced medical technologies in the world, hundreds of thousands die each year from preventable diseases like stroke and lung cancer. Health disparities between the poor and the rich are starker than in any other high-income country. In this article, Dr. Rita Hamad discusses why a focus on prevention in healthcare settings is not enough. Rather, social and economic policies that address the “causes of the causes” of health disparities are more likely to improve population health.
When it comes to health in the United States, we as a society excel at treating individuals after they have fallen off of the proverbial cliff, yet we fail to invest serious resources to keep them from tumbling off the precipice in the first place. Our nation’s top medical centers boast the most advanced medical technologies in the world, yet hundreds of thousands die each year from preventable diseases like stroke and lung cancer, at much higher rates than in other high-income countries. Moreover, the distribution of illness in our society is highly unequal: a child born to poor parents is more likely to be unhealthy throughout her life and die early compared with a child born to wealthier parents, despite the pride that we take in providing “equal opportunities” to all. As I will argue here, improving population health and reducing these disparities depends critically on expanding our current biomedical model of disease to a broader perspective that also includes the social and economic determinants of health.
While there is a growing emphasis among health policymakers on preventing common diseases before they develop, existing measures still fall short of this broader perspective. For example, Dr. Vivek Murthy, the U.S. Surgeon General, has recently been traveling throughout the country speaking to local groups and universities about his vision of health. A few weeks ago, I heard him speak at Stanford, where he described the three factors that he sees are the “fundamental causes” of many health problems in this country: highlighting these challenges of (1) nutrition, (2) physical activity, and (3) psychological wellbeing, he hopes to shift the dialogue around health to include an emphasis on prevention. If we can change people’s diets, increase physical activity at the population level, and improve mental health, he asserts, the burden of disease will be significantly reduced.
As a family physician, I admire Dr. Murthy’s focus on prevention, which is the principal goal of primary care providers. As a social epidemiologist, however, I bemoan the fact that this plan continues to focus on a narrow conceptualization of health that ignores the broader social and economic forces at play. The problem is not only that ingrained habits like diet and exercise are hard to change, as anyone who has tried to influence these “lifestyle factors” would attest. Rather, decades of research have demonstrated that the sickest individuals in our society are also the most socioeconomically deprived. Being poor in this country is virtually synonymous with being less healthy. Individuals of lower socioeconomic status are more likely to suffer from almost every illness, including a higher burden of infant mortality, more chronic diseases like diabetes and heart disease, and increased cancer rates. Some – including perhaps Dr. Murthy – would attribute this to poor lifestyle choices among low-income individuals, and would suggest redoubling our efforts to promote healthier eating and regular exercise.
Yet leading researchers in economics, epidemiology, and biology are uncovering a more profound cause of these health disparities. Recent studies demonstrate that exposure to chronic stressors changes an individual’s biology – increasing inflammatory responses, shortening the telomeres that protect our DNA, and causing long-lasting changes in brain physiology.1,2 These transformations begin early in life among children born into families of lower socioeconomic status.3 Other work suggests that the stress of poverty consumes an individual’s mental “bandwidth,” leaving less cognitive resources for other tasks and leading to risky health behaviors.4 These researchers have demonstrated in a compelling fashion that increased disease and disability among the poor is not a choice, it is a consequence of the stress of poverty itself. Of course, low-income families are also less able to purchase healthcare and medications for themselves and their children, they are more likely to live in inexpensive poor-quality housing, and they have less access to nutritious food.5 But the research on the body’s response to the stress of poverty demonstrates that it’s not just about subsidizing one service or another; there is something fundamental about the stress of poverty and inequality that affects a person’s biology.
Understanding the roots of health disparities in this way leads to vastly different implications for how to improve health in the U.S. This research suggests that health is not likely to improve very much if doctors continue to hammer educational messages into their patients, or if public health officials invest more resources in awareness campaigns. This is because the underlying causes of disease go deeper than health behaviors and healthcare access. With this in mind, I would replace Dr. Murthy’s three-pronged focus on nutrition, physical activity, and mental health with a trifecta that includes poverty, educational attainment, and housing. In social epidemiology, these are known as the “causes of the causes” of disease, because their influences are long-lasting and underlie a vast assortment of health conditions.6
A growing body of research has begun to demonstrate that a range of social and economic policies have the potential to influence health outcomes substantially, often as an unintended consequence.7 For example, my own work shows that expansions in the earned income tax credit – the largest U.S. poverty alleviation program that provides a tax rebate to poor working families – have resulted in improvements in child health outcomes.8 Other studies demonstrate that the growth of compulsory schooling across the U.S. during the 20th century increased educational attainment, which led to lower mortality rates and improvements in cognitive outcomes in old age.9,10 Community development has also been identified as a major contributor to health outcomes, and collaborative organizations such as the Build Healthy Places Network have begun to promote creative policies and programs that address health by tackling issues such as housing, neighborhood quality, transportation, and schools.11 Build Healthy Places fosters connections between policymakers, practitioners, and investors, while synthesizing relevant research findings on the potential health effects of a broad range of community interventions.
This last example not only illustrates the critical importance of cross-sectoral approaches for improving population health, it also provides an example of how health policies and programs can expand beyond the biomedical model to target the social and economic drivers of health. For those interested in reducing the burden of disease, it is no longer an option to restrict our attention to the medical sector, given its limited capacity for targeting the roots of health disparities. Rather, the realization that social policy is health policy will enable the development of more innovative and effective interventions that address the causes of the causes of disease.
- McEwen B, Seeman T. Protective and Damaging Effects of Mediators of Stress: Elaborating and Testing the Concepts of Allostasis and Allostatic Load. Ann N Y Acad Sci. 1999; 896(1): 30-47.
- Shalev I, Entringer S, Wadhwa PD, et al. Stress and telomere biology: A lifespan perspective. Psychoneuroendocrinology. 2013; 38(9): 1835-42.
- Needham BL, Fernandez JR, Lin J, et al. Socioeconomic status and cell aging in children. Soc Sci Med. 2012; 74(12): 1948-51.
- Mani A, Mullainathan S, Shafir E, et al. Poverty Impedes Cognitive Function. Science. 2013; 341(6149): 976-80.
- Adler NE, Newman K. Socioeconomic Disparities in Health: Pathways And Policies. Health Aff. 2002; 21(2): 60-76.
- Joffe JM. Looking for the causes of the causes. J Prim Prev. 1996; 17(1): 201-7.
- Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet. 2008; 372(9650): 1661-9.
- Hamad R, Rehkopf DH. Poverty and Child Development: A Longitudinal Study of the Impact of the Earned Income Tax Credit. American Journal of Epidemiology (in press).
- Glymour MM, Kawachi I, Jencks CS, et al. Does childhood schooling affect old age memory or mental status? Using state schooling laws as natural experiments. J Epidemiol Community Health. 2008; 62(6): 532-7.
- Lleras-Muney A. The Relationship between Education and Adult Mortality in the United States. The Review of Economic Studies. 2005; 72(1):189-221.
- Building Healthy Places Network. http://buildhealthyplaces.org (2015, accessed 22 November 2015).