Socioeconomics, Culture and Public Health

Mosby Court housing project.

by James A. Bacon

The average life expectancy in the affluent West End of Richmond is 83 years. The comparable number for residents of Gilpin Court, a public housing project in the east side of the city, is about 60 years. How do we explain that discrepancy?

The conventional wisdom attributes the health gap to socioeconomic differences — Social Determinants of Health, in academic lingo — and there is no denying the close relationship between income, education and health. The better educated you are and the higher your income, the longer you are likely to live. Affluent Virginians are far more likely to have health care insurance, which ensures better access to health care, less likely to be exposed to environmental hazards, and more likely to hang out with other people who influence them to exercise, control their weight and embrace other healthy behaviors.

But is that the whole story? An article this morning in the Times-Dispatch, slugged “Where you live determines how long you live,” explores health disparities in the Richmond region. The reporting draws heavily upon the 2012 report on health equity by the state Office of Minority Equity and Health Equity (OMEHE),  which mapped the disparity in health “opportunities” region by zip code. The report uses a Health Opportunity Index that encompasses factors such as education, exposure to pollutants, affordability of transportation and housing, job participation, racial diversity, material deprivation and other factors.

Trouble is, by imposing a socioeconomic framework on the problem, policy makers bias themselves toward a socioeconomic analysis and wind up recommending socioeconomic solutions. Thus, in the words of Michael O. Royster, until recently the director of OMEHE, to fix health disparities we need to increase job opportunities for the poor, improve educational outcomes, reduce exposure to air toxins and generally “develop policies, programs, and practices within organizations and communities that support racial, economic and gender equality.”

Royce goes so far as to suggest that African-Americans are more likely to report (24.6%) experiences of perceived racial discrimination than whites (5.7%) or Hispanics, and that those who perceive themselves victims of racial discrimination also are more likely to report poor health. Perceived racial discrimination, he says, is associated with hypertension, substance abuse, depression and and psychological distress.

In other words, the onus is on society to improve health outcomes for minorities. The solution is more government.

While inequitable access to health resources undoubtedly is a contributor to the longevity gap, in my view, any approach that fails to address the disproportionate tendency for poor people of all races to smoke, drink too much, overeat, get insufficient exercise, use illegal drugs, engage in unsafe sex and  physically assault one another with guns, knives and cudgels — in other words, that fails to grapple with the culture of poverty — is missing the boat.

As I noted in a previous blog post, “Murders, Accidents and Public Health,” tobacco use, unhealthy diet, physical inactivity and problem drinking are associated with 40% of all deaths in the United States. Moreover, among African-Americans, a significant portion of the longevity gap can be explained by the dramatically disproportionate number of young males who are murdered.

Click for more legible image.

For an example of how culture affects health care outcomes, consider this: Hispanics in Virginia rank lower than African-Americans in educational attainment, only a little higher in average income, and considerably lower in medical insurance coverage, yet they rank far lower in the incidence of low birth-weight births. Indeed, between 1999 and 2009, according to Royce’s own statistics, Hispanics have consistently ranked lower than whites in the incidence of low birth-weight. What accounts for the difference? Can you say, culture?

A fundamental problem that Royce acknowledges only glancingly is the prevalence of social isolation and the poverty of social connections between family, friends and neighbors in poor neighborhoods. We’re talking about family breakdown and, other than the church and outside not-for-profit groups, the near total absence of civil society. If you’re looking for underlying causes, the social isolation America’s poor is huge.

Royce strays perilously close to acknowledging the role of culture when he notes, “Immigrant groups, on average, have better health status than native born Americans. Unfortunately, this health advantage deteriorates the longer immigrants remain in the United States. Health outcomes of children of immigrants and successive generations more closely mirror the health of native-born Americans.” Perhaps one thing that immigrants bring with them, and later lose, is strong family ties. Again, can you say, culture?

If our interest is to actually help poor people live healthier lives — as opposed to perpetuating the dogma that only an activist state can redress social ills — then we need to adopt a very different way of looking at poverty.

9 Responses to Socioeconomics, Culture and Public Health

  1. re: ” to smoke, drink too much, overeat, get insufficient exercise, use illegal drugs, engage in unsafe sex and physically assault one another with guns, knives and cudgels”

    do you have zip code data for that?

    do you think the rich do not drink too much or are too fat or use legal drugs similar to illegal drugs or engage in unsafe sec or murder each other?

    there may well be some differences but methinks your prejudice is showing.

    good health care is how you get informed about unhealthy habits, eh?

    ya think?

    re: the answer is more govt.

    was that why this country decided to go to public schools when we already had private schools? What would those “poor” zip codes look like if we did not have public schools and we only had private schools?

    I just think things are a lot less simple than your perceptions.

    • “do you think the rich do not drink too much or are too fat or use legal drugs similar to illegal drugs or engage in unsafe sec or murder each other?”.

      You have truly lost your mind here. Let’s just take your point about the rich murdering each other.

      Do you really contend that the murder rate in wealthy neighborhoods is the same as in poor neighborhoods?

      Really?

  2. Nope. It’s probably worse, much worse, in the poor zip codes but what about the rest of the panoply of bad habits?

    do you really think the poor are fatter or abuse ALL drugs – illegal or prescription or drink more?

    and do you think a person who gets regular medical care would at least hear from the medical professionals about obesity, diabetes, and other health affects from such habits and at least SOME of them heed the advice?

    The problem of being poor is that you don’t get to choose your zip code – you generally end up with others in the same condition and poor breeds crime – we know that.

    Was not that long ago that the govt realize that putting poor people in “projects” was a bad idea.

    What I object to is the simple-minded premise.

    the number one reason why most people die earlier is the lack of regular medical care.

    when you don’t go to a doctor regularly, diseases do not get caught in the early stages and treated. For instance, obesity that morphs in to diabetes… Most rich receive treatment for diabetes. Most poor die of cardiovascular complications that arise from long-term untreated diabetes.

    If you look at the poor in a given zip code – more might die from murder but on a larger scale – 10x, 100x, 1000x as many die from untreated medical conditions. when you stack up murder against the other causes of death – it’s minuscule

    Many of the poor are working poor, They work for low wage jobs that don’t offer health care or offer only minimal care.

    And the irony here is that taxpayers not only pay for their health care, they pay through the nose for it – but it’s primarily care for late-stage diseases via ERs or MedicAid rather than regular care.

    We live in a world of denial about this. We are virulently opposed to the idea of “giving free health care” to those who do not have it and we pretend that it’s because we are opposed to paying for it.

    We won’t pay for more cost-effective regular care – but we WILL pay for heroic and expensive late stage care.

    I DO NOT THINK that more govt is the only or the correct solution but I DO THINK that if we are already paying anyhow, why not do it cost-effectively as opposed to dreaming that we’ll just stop paying?

    you call the GA the Clown Show. Well, WE are the clown show when it comes to our attitudes about ” Socioeconomics, Culture and Public Health”. We ARE the ONLY country of all the industrialized countries – in the world – that have this problem.

  3. LarryG writes: “We won’t pay for more cost-effective regular care – but we WILL pay for heroic and expensive late stage care.”.

    However, considerable evidence exists to indicate that preventative medicine raises the overall cost of health care – regardless of what Mr. Obama may believe.

    “The evidence of hundreds of studies over the past four decades has consistently shown that most preventive interventions add more to medical spending than they save,” Russell concludes.

    http://www.washingtonpost.com/blogs/wonkblog/post/what-if-prevention-doesnt-save-money/2011/12/11/gIQAM60OnO_blog.html

    Time to look at the facts, LarryG.

  4. then why does Europe and Japan spend 1/2 what we do to cover everyone?

    they cover ALL of their people and pay 1/2 what we do AND they LIVE LONGER and have LESS INFANT DEATHS?

    how can that be if it costs more to cover more?

    let’s put this another way. What FACTS are we working off of?

    are we not working off of “what if” scenarios?

    the only other explanation that I’ve heard is that we, as a nation, are less healthy than all the other nations with universal health care.

    Now.. do you really believe that?

    • LarryG – the Japanese have some of the worst health care habits I have ever witnessed. They smoke like chimneys, drink like fish and work like dogs. I love hanging out with the Japanese but after a week I have to come home and rest!

      I don’t think their health care system makes a damn bit of a difference. I’d look a lot more closely at their diet and societal genetics than their government issued insurance cards.

      Life expectancy in the US and Denmark are almost identical. Why? Denmark has a full blown single payer governmental health insurance system. Meanwhile, people in France live almost three years longer than Americans or Danes. Why?

  5. DJ you guys kills me when it comes to the comparisons:

    United States 8,233
    Denmark 4,464
    France 3,978
    Japan 3,035

    http://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_(PPP)_per_capita

    Now you know. The other 3 countries have universal health care and pay 1/2 per capita for health care even though they too have “bad habits”.

    how do you explain this?

    how do you explain that every other country in the industrialized world:

    1. – has universal health care
    2. – pays 1/2 what we do for health care?

    how do you explain this for ALL these countries?
    what is the one common thread?

  6. I didn’t bring up the life expectancy issue, you did:

    “they cover ALL of their people and pay 1/2 what we do AND they LIVE LONGER and have LESS INFANT DEATHS?”.

  7. DJ – what performance metric would you use instead to measure the value of spending money on health care?

    what do you think we get for spending twice as much that other countries do not get for spending only 1/2 as much?

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