1 Department of Epidemiology, Center for Human Growth and Development, and Institute for Social Research, University of Michigan, 109 Observatory Street, Ann Arbor, MI 48109-2029, USA.
2 Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, UK.
The Health of Nations. Why Inequality is Harmful to Your Health. Kawachi I, Kennedy BP. New York: The New Press, 2002, pp. 232 (HB), $25.95. ISBN: 1 565 84582 X.
Writing a book titled The Health of Nations1 is surely a daunting and ambitious task considering it is only one consonant removed from the popular title of Adam Smiths famous Wealth of Nations.2 Nevertheless, Harvard social epidemiologists Ichiro Kawachi and Bruce Kennedy revel in the challenge and have managed to integrate a vast amount of information in an attempt to help us better understand why social inequality in its various forms can be damaging to health, happiness, and the quality of human existence. This book is primarily about the goals of economic development and how we should evaluate its successes and failures. In this sense the authors are onto something fundamentally important. Kawachi and Kennedy question whether Americans are happier or healthier as a result of all their accumulation and consumption of goods and services. They answer no. More snappily, they suggest that chasing the American Dream can be hazardous to your well-being (ref. 1, p. 37), and that striving after fame and fortune should come with a government health warning (ref. 1, p. 37
While the book focuses on the US, the authors are aware of the implications for other nations, and lament that, Unfortunately, the American brand of turbocapitalism seems to be rapidly catching on in the rest of the world (ref. 1, p. 190). It will be up to readers to judge the extent to which the US malaise described in the book is relevant to other countries with different political, historical, and cultural traditions. Nevertheless, while everyone knows America is different, there is still enough in this book to be of interest to an international audience.
The book is broad in scope and the authors paint an expansive landscape of the ills that characterize contemporary America, discussing increases in income inequality, working hours, and the inexorable rise of ever more voracious consumer culture in chapters such as, Economic Goals and the Permanent Problem of the Human Race; Prosperity and Happiness; Keeping up with the [Dow] Joneses; and The Social Costs of Consumption. In their chapter, Stepping on the Hedonic Treadmill, Kawachi and Kennedy write powerfully about the effects of longer working hours and the need for dual incomes on the quality of family life. They write:
The "global care chain" is complete when a mothers love for her children becomes commodified, and the resulting "emotional surplus value" is passed on from (a) an older daughter from a poor family in a poor country, who cares for her siblings while (b) her mother works as a nanny caring for the children of an immigrant nanny, who, in turn, (c) works as a substitute mother for the child of a family in a rich country. (ref. 1, p. 129)
They argue that the US is immersed in a culture of competitive consumption where the good life is no longer defined by a finite set of material conditions for decent living. Instead we are somehow driven to consume goods and services that are aimed at increasing our relative standing in the community. We have become obsessed with positional competition. Not only does this positional competitionfor goods we really do not neednot deliver us health and happiness, it has negative externalities for the environment and the quality of urban and rural life. They entertainingly illustrate the issue of positional goods with the story of the French philosopher Denis Diderot, who recalled how, when he obtained a grand new scarlet dressing gown, became slowly dissatisfied with the other contingencies of his daily life, although they had previously seemed perfectly satisfactory.
Readers familiar with Kawachi and Kennedys work on social capital and income inequality will recognize the links they make between rising economic inequality and perceptions of relative disadvantage. In their view, such perceptions of relative social position help drive positional competition and have negative impacts on peoples sense of self worth, and the quality of their social relationships. But, while negative self-perceptions and deteriorating social capital are themes in this book, the most dominant message is that the greatest sources of inequality are structural in nature, and the authors endorse greater investments in improving housing, work environments, urban sprawl, pollution control, education, legal frameworks, and developing a more transparent and accountable politics.
The book is intended for popular as well as academic audiences as suggested in the personalized subtitleWhy Inequality is Harmful to Your Health. It is in some ways similar in style to Robert Putnams Bowling Alone3it is highly readable and full of interesting facts about contemporary US society, including how baseball teams with greater pay inequality between the players have worse team performances over the season. But in spite of its title, this book does not argue a detailed case for the importance of inequality for population health, per se. It is about describing general social consequences of adopting more rabid versions of market capitalism. In fact, health does not even get a mention until Chapter 3 on page41fully one-fifth of the way through the book. One reason for this might be that the basic argumentthat inequality decreases quality of lifedoes not require data on health. Indeed, quantity of life may well be a relatively trivial contributor to overall quality of life in rich countries at the beginning of the 21st century. From this perspective, links drawn between inequality and population health are perhaps one of the weaker strands of the general argument advanced in this book.
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Is population health collapsing? |
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Figure 1 shows declining US all-cause mortality rates for both men and women from 1968 to 1998. The Figure also shows the sharp rise in income inequalityits steepest increase since the Depression.5 Of course, the trouble is that 30-year trends in all-cause mortality and income inequality run in opposite directions. Figure 2
shows declining all-cause mortality rates over the last 30 years, for both blacks and whites in the US, at the same time that trends in voter participation6,7a marker of social capital3were also declining. Also note that decreases in voter participation were steeper among whites than blacks. These Figures clearly demonstrate that overall mortality has continued to decline in the US, at the same time as markers of the sorts of social malaise, described by Kawachi and Kennedy in terms of inequality and social capital, have worsened. These are problematic observations for those who see a direct causal link between social capital and population health.8,9 The inequality is bad for your health argumentwhich we endorse in general termshas to be able to explain such seemingly discrepant findings. One answer is to better understand time-lags and long-term trends, but such discussions are fairly rare in the health inequalities literature,10 although useful contributions are beginning to appear.11,12
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Expanding the explanatory framework for the determinants of population health |
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These issues await further investigation, but in the meantime, it is also relevant to raise one more thorny issue for those of us interested in the social determinants of population health. What do we actually mean by population healthespecially in regard to the issues raised in The Health of Nations and their implications for the sorts of social conditions most conducive to better quantity and quality of life? How do we judge a population to be healthy? We normally use measures like all-cause mortality, life expectancy, or disability- or quality-adjusted life years. These are useful summary measures, but they also mask heterogeneity. In future investigations into the social determinants of population health, we think that the practice of examining overall indicators can be complemented by unpacking population health, because different types of health outcomes have different determinants.15
In developed nations, there have been large declines in many infectious diseases, stomach cancer, stroke, and heart disease, while non-Hodgkins lymphoma, diabetes, obesity, depression, and suicide among the young have increased. It is likely that some population health outcomes, such as suicide, homicide, and violence, are sensitive to current social conditions, while others, such as stomach cancer and haemorrhagic stroke may be sensitive to social conditions in the past.16 What sorts of population health outcomes are likely to be affected by the social conditions described by Kawachi and Kennedy and within what time-frames are they likely to be effected? It is perhaps easier to imagine how such conditions could influence rates of depression, violence, self-rated health, or through behavioural responses affect obesity and diabetes, and understanding the short and long-term effects on these sorts of outcomes is precisely why Kawachi and Kennedys book is important. But would we predict that these social conditions will cause a reversal in the large declines in rates of heart disease or stroke that have been seen since the 1960s? Will we see a return of stomach cancer to its levels in the 1950s when it was the single largest cause of cancer mortality in most industrial nations?
Shkolnikov, McKee, and Leon17 have convincingly shown how the tumultuous political, economic, and social conditions in post-Soviet Russiasurely, at least as powerful as the social turmoil in the US described in The Health of Nationshad profound effects on rates of accidents, violence, and heart disease. This was largely through binge consumption of alcohol bought on by job losses, desperation, and hopelessness. In stark contrast, there was no effect on trajectories of declining rates of rheumatic heart disease, stomach cancer, or increasing rates of breast cancereach of these outcomes simply continued their historical trajectories unabated. To understand the determinants of population health, it seems we will need to understand the determinants of the historical trajectories of the specific outcomes that comprise total population health. That will mean including an outcome-specific life course approach that attempts to integrate knowledge of disease causation across individual and population levels, and how these play out in succeeding birth cohorts over time.
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The influence of life course processes at the individual and population levels |
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Second, the authors treat the continuous gradient between social position and health as a mystery, the only solution to which is a consideration that psychosocial factors are the primary cause. Here they walk a familiar path in modern health inequalities research.28 For example, in regard to the Whitehall study, it has been argued that a gradient in mortality among civil servants who are not poor argues for the importance of psychosocial factors linked to position in the hierarchy (ref. 29, p. 1127). The existence of a socioeconomic gradient in heart disease mortality amongst predominantly middle-class groupssuch as Whitehall civil servantshas been widely cited as evidence that psychosocial factors, generated by internalization of position within social hierarchies, must be important, since there is a little or no material deprivation in adulthood amongst these groups. This lack of adult material deprivation, combined with the apparent inability of conventional risk factors to account for the gradient,30 has lead to a widespread impression that psychosocial factors, therefore, must play an important causal role.
Psychosocial factors may well be part of the picture, but we should carefully examine the evidence in favour of a psychosocial contribution and consider plausible alternative hypotheses. Firstly, recent evidence suggests that the apparently low explanatory power of conventional risk factors in regard to heart disease is based on little evidence and has been over-sold.31 Secondly, the socioeconomic gradient in cardiovascular disease (CVD) amongst middle-class adults could also be generated by the cumulative effects of deprivation in childhood and across the life course. Such cumulative effects over the life course could plausibly generate a finely graded association between adult socioeconomic indicators and CVD.32 Disadvantaged childhood social circumstances will have been almost entirely absent amongst the most consistently privileged social groups (e.g. top-grade civil servants in Whitehall), but will have been experienced by a proportion of other middle-class groups in less-favoured adulthood social locations, even though they are just below the very top levels in the social hierarchy. This hypothesis is supported by the Glasgow University students study, where childhood social circumstances strongly influenced CVD mortalityeven amongst a relatively homogeneously affluent (in adulthood) population of those who were fortunate enough to attend university in the late 1940s in Scotland (Figure 4).33
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Strengthening the evidence base for the importance of psychosocial factors in influencing population health |
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Over-generalizing the importance of psychosocial factors for health in the interests of popular consumption may not be the best long-term strategy. Kawachi and Kennedys Harvard colleaguesocial capital researcher Robert Putnamprobably lessened his credibility among public health professionals when he wrote that:
The bottom line from this multitude of studies: As a rough rule of thumb, if you belong to no groups but decide to join one, you cut your risk of dying over the next year in half. If you smoke and belong to no groups, its a toss up statistically whether you should stop smoking or start joining. These findings are in some ways heartening: its easier to join a group than to lose weight, exercise regularly, or quit smoking. (ref. 3, p. 331)
This is a naïve distortion of the epidemiological evidence and if readers take it to heart, potentially damaging to population health.38 And this is a pity, because Putnam, like Kawachi and Kennedy, is an impressive scholar who has important things to say. It is hard to imagine how putting the most positive interpretation on the evidenceeven to the point of ignoring contrary findingswill ultimately help strengthen the case that psychosocial factors are indeed important determinants of some dimensions of population health.
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The Roseto EffectWhat are the lessons for population health? |
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First, the Roseto Effect is built on a somewhat shaky epidemiological edifice. Figure 4 is based on data presented by Egolf et al.,41 and shows the age-adjusted rates of death due to myocardial infarction (MI) in Roseto and its comparison community Bangor, from 1935 to 1984. The Roseto Effect is evident in the lower rates for men and women in comparison to Bangor between the mid 1930s and 1950s, and the subsequent increase in mortality from MI between 19551964 and 19651974, which was attributed to the coincident breakdown of social integration in Roseto.42,43 It is important to note that these effects are limited to MI. In the study that first reported on Roseto,42 there were no differences between these communities in rates of hypertensive or arterosclerotic heart disease death (without evidence of MI) a sub-category of heart disease potentially related to pathological processes influencing MI. Subsequent studies also showed no differences in congestive heart failure.41 Figure 5
is adapted from the data presented by Egolf et al.,41 and shows the age-specific male death rates for MI. The Figure shows that, in the earlier period from 1955 to 1964, there were identical MI rates in Roseto and Bangor for the youngest and oldest men aged 3544 and >65. That means the age-adjusted Roseto Effect was driven by changes in MI mortality for men aged 4554 and 5564 years. While the rates in these age groups were low in Roseto from 1955 to 1964, they were based on only one and two deaths respectively. In 19651974 they were based on six and nine deaths respectively. The Roseto Effect for women was based on even smaller numbers. This does not mean the Roseto Effect was not real, but the very small numbers of deaths, combined with the lack of differences for other categories of heart disease, should perhaps warrant circumspect interpretation.
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Furthermore, even though standard risk factors such as blood cholesterol did not differ between Roseto and Bangor,51 we now know that such cross-sectional assessments are prone to error.31 Like the apparent French Paradoxof low heart disease rates despite high saturated fat intake and cholesterol levelsit turns out that it may not be so paradoxical after all, if saturated fat intake 30 years ago is assessed, at the time that the current elderly CHD patients began laying down their atheroma in earnest.52 Thus, we think intergenerational processes affecting the life course risk factor profiles of successive generations combined with long-term levels in the prevalence of known CHD risk factors in the population like smoking and high-fat diet from the 1920s to 1960s, are at least a plausible alternative explanation for what was observed in Roseto.
Finally, it is instructive to read how some of the original investigators interpreted their findings. According to Bruhn and Wolf:
The data obtained over a span of twenty years in the Italian-American community of Roseto, when compared with those of neighboring communities, strongly suggest that cultural characteristicsthe qualities of social organizationaffect in some way individual susceptibility to myocardial infarction and sudden death. The implication is that an emotionally supportive social environment is protective and that, by contrast, the absence of family and community support and the lack of a well-defined role in society are risk factors. (ref. 43, p. 134)
This is the usual message that has been extracted from the Roseto studies and used to support the positive role of psychosocial factors, like social capital, on health. But the authors last phrase also hints at the potentially ambiguous nature of strong social ties. It reflects rather more conservative views in regard to the traditional roles of families, religion, and local social institutions as desirableand health protectiveforms of social capital. Elsewhere in the same book, Bruhn and Wolf state that by the early 1960s the signs of community disintegration were already evident:
A few action seekers had begun to appear among Rosetans, mainly among the middle-class mobiles.... They entertained, travelled, and joined clubs outside the community in search of new experiences and opportunities.... Many of these middle-class mobiles and action seekers actually identified themselves as outsiders in Roseto. Nevertheless, they continued to live there although maladapted to the social order.... Our study found such individuals at high risk for the development of myocardial infarction ... (ref. 43, p. 122)
The cited evidence that they are at higher MI risk is two case studies describing details of their stressful, socially unconnected, and frustrating lives. Oh, and the authors also mention that one smoked two, and the other three, packs of cigarettes each day for 20 years before they died, but this was not interpreted as being as aetiologically important as the fact that they had apparently sought non-traditional club memberships and new experiences outside the traditional community. This Roseto story about the importance of traditional values, is certainly not the one promoted in the Health of Nations, but it echoes contemporary concerns about the potential for less-progressive deployments of the concept of social capital.38,53,54 Given what we have presented above, how much weight should we attribute to the Roseto effect as strong evidence for the role of community ties in improving population health?
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Conclusion |
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Acknowledgments |
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References |
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