Delivery of Care

Medical care is not health, and it is not a health care system

An excerpt from the upcoming book, The Health Care Revolt, by Dr. Michael Fine, talking about why we have a market extracting wealth, and not a health care delivery system investing in health

Image courtesy of PM Press.

The cover of the new book by Dr. Michael Fine, Health Care Revolt, which will be published on Sept. 1 by PM Press.

By Dr. Michael Fine
Posted 8/6/18
Most of the money spent by the health care delivery system has very little to do with promoting health or in changing public health outcomes. Dr. Michael Fine has written an insightful book about how we got ourselves into what he calls a market of wealth extraction, the ways in which we can get ourselves out of the current mess.
How do neighborhood health stations and health equity zones, focused on place-based health and building a culture of health, become part of the conversation about the future of health care in Rhode Island? What health systems or health insurers would be willing to dramatically lower the salaries and compensation paid to executives as a way to hold down rising medical costs and drug costs? When will polling in Rhode Island ask questions about health care in advance of the 2018 election, which continues to poll nationally as the number one concern of voters in the 2018 campaign? How does creating a single-payer insurance system address the problems with what Fine calls the wealth extraction market?
Dr. Michael Fine is going to be running as an independent candidate for the R.I. State Senate, seeking to replace former Republican state Sen. Nick Kettle, who resigned earlier this year after being accused of allegedly extorting sex from a page.
Fine said that more than 30 residents had met with him at his home in Scituate to urge him to run, and after listening to them, decided to run. Fine said that he was awaiting official confirmation from the R.I. Board of Elections that he had gather enough signatures to earn a place on the ballot. Fine said that he had gather more than 130 signatures, more than the 100 signatures required.

Editors Note: In my first interview with Dr. Michael Fine in March of 2011 who was the newly appointed director of the R.I. Department of Health, I asked what seemed a straightforward question about what Fine saw as the future direction of the health care delivery system in Rhode Island.

Fine replied in a blunt, direct fashion, correcting me, saying that Rhode Island did not have a health care delivery system; what the state had was a market built on wealth extraction.

Surprised by the candid response, I asked Fine to repeat what he said, to be sure I had heard him correctly; he did so, again, with emphasis.

When my story ran in The Providence Business News, a colleague at that time, Megan Hall at Rhode Island Public Radio, wrote a column about the iconoclastic content about what Fine had said.

Some seven years later, Fine has written a new book, Health Care Revolt, that explores in depth those issues he had first raised in the 2011 interview, with a comprehensive look not only at what we are doing wrong but offering some cogent ideas what can be done in response, and in doing so, provide the seeds to restore and preserve American democracy.

The abridged excerpt is long read, a deep dive, but it captures so much of what doesn’t get talked about in the news coverage about health. It is exactly the kind of story that needs to be shared if we want to change the narrative on health care in Rhode Island and the nation. It may take you two cups of coffee.

PROVIDENCE – The town of Roseto, Pennsylvania, first came to notice in [the 1960s by epidemiologists] because the people who lived there were not having heart attacks and dying of heart disease in a period when heart disease was the most significant cause of premature death in the U.S.

Citizens of Roseto had a vastly lower incidence of heart disease than did people who lived in neighboring towns, the state of Pennsylvania, or the nation as a whole, despite the fact the people who lived in Roseto ate a diet that was no better than the places to which it was compared and didn’t exercise more.

Instead, Roseto had something more powerful: a connected and engaged community and family-focused population of people who lived together in one place and intended to keep doing that.

Roseto is a little town of 1,600 in the hills of northeast Pennsylvania that had been shaped by a culture of community cohesion and family solidarity. It was settled in 1882 by a group of Italian immigrants who all came from Roseto Val Forte, a town in the province of Foggia in southern Italy, and its culture was shaped by a dedicated and sophisticated parish priest named Father Pasquale de Nisco, who functioned as confessor, de facto mayor, community organizer, and moral authority for Roseto’s people.

Father de Nisco built Roseto into a place where families stayed together and people took care of one another, where what mattered were relationships, not income or social prominence.

In 1961, a physician in a nearby town noticed that people in Roseto weren’t dying of heart disease, and his chance comment to a colleague about that fact triggered a huge epidemiological investigation.

Scientists came to see for themselves. They studied death certificates. They tested the water and tracked people’s diets and physical activity. They got people to fill out questionnaires. And they found that the people of Roseto were only half as likely to die of heart disease as were people in surrounding communities. And what’s more, those scientists found that the reduced risk of heart disease wasn’t the result of genetics or diet or the mineral content of the local water or physician skill or the presence of obesity, diabetes, or high blood pressure, or even infectious disease.

The scientific evidence suggested that social cohesion – the impact that living in a close, connected community – was preventing heart disease.

Just when small towns in the U.S. were falling apart, just when extended families were breaking apart, just when the nuclear family itself was beginning to disintegrate, Roseto suggested that family and community mattered for health, that family and community might help prevent heart disease.

This hypothesis was validated in the second half of the study, from 1965 to 1985, when the social cohesion of Roseto started to fall apart. As pressure from consumerism disrupted the social cohesion of Roseto, the rate of heart disease and heart disease death in Roseto rose to the same level as the surrounding communities and the nation as a whole.

Mountains of evidence tell the same story
Since the Roseto study, we’ve developed mountains of evidence that is more sophisticated statistically, and this evidence tells the same story over and over again: social cohesion matters for health.

Our healthiest places are those where people stick together enough to educate their children and protect the environment, where housing is safe and few people are homeless, where fewer people drink or smoke or do drugs.

We can design whatever health care system we want. We can build hospitals or not; train health professionals or not. Have copays or not. Use the market or not. But as we think about what works, we need to remember that we must build and strengthen communities if we are to be effective in improving the health of Americans, so building and strengthening communities needs to become the focus of our health care enterprise.

It is just easier for Americans to be healthy if we live in communities where people know one another and can take care of their own.

The health care market
The first intellectual problem that underlies the failure of our health care market to make the U.S. a healthier nation is that Americans don’t share a clear understanding of what health is, so we don’t know what we are trying to achieve by spending all this money – which gives everyone license to spend money on everything.

The second intellectual problem underlying the failure of our health care market to make us healthier is a certain fuzziness about cause and effect in health and health care – confusion about what we can or should do to create healthier people and a healthier population.

The third intellectual problem is that the measures we use to understand what we mean by the health of individuals and the health of the population don’t accurately reflect what we mean by health at the end of the day.

Health is a broad but vague concept like love or justice. Health serves as a goal that can motivate the population to act, but health as an idea can just as easily be exploited and manipulated by people with something to sell. That’s because every person defines health differently for him or herself. Most of us think about health as one part the ability to function as a member of a family or community, one part freedom from pain, and one part the ability to live a long time, with each of us mixing the proportion of those concepts together in different ways.

What we talk about when we talk about public health
When we talk about public health, on the other hand, we are referring to two separate and distinct concepts. One concept is the common-sense perception of social or environmental conditions that impact the health of individuals.

A crowded slum or a contaminated public water supply, for example, is said to be bad for the public’s health. But public health also refers to a set of measurable overall characteristics of the population that allow us to compare different places. We measure and discuss life expectancy, for example, when we compare Japan to China, or infant mortality, when we compare New York to Utah, or when we compare the social condition and experience of African Americans and Latinos to Americans of European descent.

Life expectancy, infant mortality, years of potential life lost, the likelihood that a particular disease or condition will develop in different proportions of the population of a place – which epidemiologists, who are really population health scientists, call the incidence and prevalence of that disease or condition – these are some of the measures we use to understand and think about how social organization and the environment impact the people who live in different places.

[It is worth noting that many important impacts of social organization cannot currently be measured, so they slip under our analytic and intellectual radar. We lack good measures of social trust at the community level, of community engagement or involvement, and of the happiness, comfort, and joy of people living in a place.

The suicide rate and the incidence and prevalence of drug and alcohol addiction gives us some measure of the despair or unhappiness of individuals who live in a certain place, but we don’t measure the success of those communities at helping community members build meaningful lives. Sometimes what we measure impacts what we do, even when what we measure isn’t that important, and so it is helpful to be mindful about what is not measured, so we don’t forget to attend to it.]

In an earlier book, James Peters and I proposed a practical definition of individual health to guide public policy, and that’s the definition I’ll fall back on here.

Health, we argued, is the equal ability of individuals to function in family and community at any point in the life cycle and to actively participate in the democratic process. And public health is a set of measures that allows us to compare the environmental conditions and social organization of places.

In that book, we didn’t articulate the purpose of medical services or of what passes for a health care system in a community or a place. It is that purpose I hope to explicate here.

Definitions aside, it is important to understand what matters, which programs and processes help people achieve the goals that we measure when we talk and think about the health of individuals and places.

Such an analysis helps us understand the extent to which our public spending on goods and services is effective at achieving the goals we intend to achieve. How good is what we buy with public money at improving health as we understand it? What can or should we buy to improve the health of the population, and what can or should we buy to improve that health most efficiently and effectively?

What does $3 trillion a year buy us?
We now spend about $3 trillion a year on goods and services intended to improve health. Of that spending, 30 to 40 percent goes to hospitals and 20 percent to doctors – mostly to specialists.

Drug purchases account for another 20 percent, and 20 percent is spent on things like equipment and supplies – for example, breathing machines and crutches and those cool little scooters people drive along the sides of streets that are so effectively advertised on TV.

But here’s the hard news. Very little of what we buy matters much for health, or at least, matters much when it comes to reducing infant mortality, increasing life expectancy, reducing years of potential life lost, or creating community, happiness, and joy – however difficult it is to measure or meaningfully discuss those goals.

Vaccines and vaccinations matter for life expectancy. Medicines probably helps people with diabetes, heart disease, high blood pressure, HIV, and hepatitis C live longer.

Seeing the doctor right away when you are pregnant reduces the likelihood that you will lose your pregnancy, although about one-third of all pregnancies are not carried to term, even in 2017, despite all our fancy technologies.

Having ambulances, doctors, and hospitals available when a natural disaster strikes probably reduces the loss of life and the extent of disability from injury, but natural disasters occur infrequently, so this impact on the population as a whole is hard to detect statistically.

But there is no clear evidence that any of the rest of it matters – the doctors, the hospitals, the breathing machines, and even the cool little scooters driving alongside streets – at least from a public health perspective [even though many of those services provide comfort and perhaps even a few extra years of life to individuals who become ill].

We don’t know if the number and location of hospital beds has any impact at all on the longevity or function of the population. But there is good evidence that too many hospital beds is associated with greatly increased cost and some adverse health impacts, because hospitals work hard to fill their empty beds leading them to do too much to people who weren’t really sick.

On the other hand, there is some evidence that the number, location, and organization of maternity services do impact infant mortality, though that number, location, and organization is not the strongest predictor of infant mortality by any means.

Other factors – early prenatal care, nutrition, time off from work, and other social supports – have a much greater impact and cost a whole lot less.

The same is true of doctors. There is good evidence that the number and location of primary care doctors [family physicians, internists, and pediatricians] is associated with less infant mortality, longer life expectancy, fewer deaths from heart disease and cancer, and lower costs.

But the number and location of other specialists is associated with shorter life expectancy and higher costs. Two-thirds of the doctors in the U.S. are specialists, which is one of the ways in which we are different from other countries – many of which have medical communities that are half to two-thirds generalist physicians.

But no one knows how generalists impact public health. Yes, having more primary care doctors means more people will be screened for preventable diseases – something primary care doctors do adequately but not brilliantly.

Yes, primary care doctors provide more vaccinations, again adequately but not brilliantly, as they, in partnership with school nurses and legislation that requires vaccination for school, make sure more than 80 percent of American kids are adequately vaccinated. [A much smaller proportion of the adult population is adequately vaccinated, despite our having lots of primary care doctors for adults.]

The impact of primary care
Some of us think that the impact of primary care in the health care market we have now comes from protecting the public from the rest of the health care system. When you go to see your family doctor for a headache, she or he is likely to know your family and your personal situation and stresses. He or she will ask you about how you are sleeping and will check on your neck and back – which is where most headaches actually come from – and will figure out a way to treat your headache effectively in one visit.

When you go to the emergency department for a headache, you’ll see doctors who don’t know you or your family and community, and they’ll give you a CT Scan and an MRI and perhaps a spinal tap because they’re worried about all the terrible things they see commonly but occur rarely and are devastating causes of headaches, like brain tumors and aneurysms.

You’ll also generate a $5,000 to $10,000 bill and leave with instructions to get a neurology consultation, which may lead to more tests and procedures, most of which are likely unnecessary, and all of which carry a small statistical risk.

Multiply that small statistical risk by all the people who go to the emergency room with a headache, and you get the increased risk of injury and death caused by the medical services marketplace in the U.S.

The British Medical Journal recently estimated that we have something like 250,000 deaths yearly in the U.S. that result from medical errors and the overuse of medical services – and that doesn’t include injuries. The costs associated with all these unnecessary medical services are astronomical.

What primary care doctors do probably doesn’t affirmatively improve the public health much. But primary care doctors are valuable because people who use primary care don’t use the specialty and hospital care, which is dangerous when not necessary.

And yet that specialty and hospital care consumes about 50 to 60 percent of our health care spending, or about $1.8 trillion a year. So having lots of primary care doctors matters a little for health, but mostly because they protect people from the rest of a health care market out of control.

Most of us think no more than 10 percent of public health outcomes are due to medical services – the services that consume $3 trillion a year. The 10 percent estimate is a wild guess, widely believed but based on no real evidence. No one knows the real number, but I’d be surprised if medical services are even that effective, despite consuming 18 percent of the gross national product.

Remember that public health outcomes are only indicators that we are able to measure to help us compare the social organization and environmental conditions in different places – life expectancy, infant mortality, and the like – and don’t reflect our ability to function in community, our happiness, comfort, or joy, or our ability to participate in the democratic process, which is what most of us really mean by health.

What matters
If only 10 percent or less of public health outcomes are a function of medical care [which consumes $3 trillion a year], what produces the other 90 percent of the public’s health? If medical care doesn’t matter much for public health outcomes, what does matter? And what would happen if we spent our money on those things that matter, instead of what doesn’t seem to matter much?

Sanitation matters. Clean water, the proper disposal of waste, and the safety of food matter a lot. We started to understand food and water safety in the mid-1800s with the work of Rudolf Virchow, John Snow, and others. They used epidemiology – the classic analytic tool of public health – to help track down patterns of infectious diseases like cholera and found the sources of that infection in contaminated water and food, which led us to create safe public water systems and develop standards for food safety, so, beginning in about 1900, we were able to prevent illness and death from many infectious diseases.

Sanitation in health care itself matters. Basic hand hygiene and the use of sterile procedures in operating rooms and by people like dentists and acupuncturists, people giving shots, and even by tattoo artists matters. Procedures that help secure the safety of the blood supply also matter, because a safe blood supply prevents medical services from doing affirmative harm, even when we can’t prove they do measurable good.

Infection control by departments of health matters. Infectious diseases are naturally occurring phenomena that change and evolve over time and take advantage of the proximity of human beings to one another to spread. Outbreaks of infectious disease can be controlled by good public health practice: by identifying people who harbor diseases and treating or isolating them and their contracts.

Good public health practice saves lives. New diseases like Ebola and Zika will emerge and threaten the population every few years, and a healthy society is one that is prepared to use good public health practice to contain, control, and prevent those diseases with new vaccines and environmental controls.

Sanitation and control of infectious disease, broadly defined, were put into practice in the years around and just after 1900 and had much to do with the doubling of the expected life span between 1900 and 2000. Everyone benefited when we put these measures in place.

That’s the good news. The bad news is that these measures now exist. With the exception of a [relatively] small additional investment in our public health infrastructure that would help us better combat infectious disease, more public or private spending on sanitation will not yield much more public health improvement as measured by life expectancy and infant mortality.

Safe and healthy housing and a clean environment matter. Our industrial history created a world in which people were crowded together and exposed to a variety of environmental poisons that wrecked our lungs and gave too many of us cancer.

Crowded housing created the conditions in which many people were exposed to and contracted tuberculosis. Social compression – the effective isolation of lots of poor people and those with disabilities into places with few social services – gives way to violence and drug and alcohol use.

The lead-based paints used in urban environments left a legacy of contaminated dust and soil that still sickens our children today.

We can make some progress improving public health indicators like life expectancy, infant mortality, and health disparities by race by building new housing and by renovating and cleaning those old industrial sites. Investment in housing is money well spent.

Not smoking matters. Cigarette smoking and other tobacco use is the leading preventable cause of potential years of life lost in our population. We need to end it forever, and any money we spend doing that will be money well spent.

Drug and alcohol use matters. Drug overdose is the leading cause of death among people 18 to 64. Someone makes a profit – legally or illegally – every time anyone picks up a shot glass or takes a toke or does a hit. Drug and alcohol addiction is a complex social challenge. Only 10 percent of us are susceptible to addiction, which means the other 90 percent of us are able to enjoy some moderate use without a high risk of developing dependence.

The challenge of our public policy is to allow some use and some profit but to work together to prevent the addiction that sometimes results from casual use and to treat the addiction – itself a disease – when it emerges in some of the individuals who consume. Prevention of widespread use and addiction is a critical public health priority, and treatment of people with a substance use disorder is and ought to be a central public health priority.

Food and nutrition matters a lot. We have created epidemics by allowing the mass marketing of meat that raises cholesterol and industrial food products and sugar-sweetened beverages that cause obesity, and then high blood pressure, heart disease, stroke, and diabetes, which itself leads to kidney failure, heart disease, and blindness.

Much of the food sold in our supermarkets and bodegas and fast-food restaurants is toxic, and that we allow it to be sold at all suggests there is a bankruptcy in our public process. Knowing that, we ought to stop subsidizing dangerous goop and start subsidizing and promoting fresh fruit and vegetables. Imagine a world in which apples and carrots are promoted the way Oreos and Cheetos and Coke are promoted now.

How might we approach stopping the epidemic of obesity and diabetes? First, we ought to tax the hell out of industrial food-like products that are mass marketed and that too many people eat too much of.

Industrial food-like products include anything that comes wrapped in a flavor sealed pouch, anything sold in a fast-food joint, and anything artificially sweetened. That’s potato chips and most breakfast cereal, nachos, Lunchables, McDonald’s burgers, and french fries in all their incarnations – basically anything that isn’t fresh fruits and vegetables, including soda and most fruit juices.

All that goop is directly harmful, because industrial food science is very good at making it taste so good that we keep coming back for more. They’ve proven, though billions of dollars of profits, that we can’t eat just one. So we need to tax the goop and use the tax dollars to build local agriculture, public transportation, and community centers.

Local agriculture is a powerful source of local jobs and local farming is recession-proof, because people need to eat regardless of the state of the national and world economy.

In little Rhode Island, which has a population of one million, we produce only about 1 percent of what we consume. If we produced 10 percent of what we consume, we’d add 4,000 jobs, and these are jobs that require people to stand and walk, instead of sitting at a desk.

Right now in the U.S., all our food is produced industrially by fewer than 3 percent of the population [a hundred years ago it was 80 percent]. In a very real sense diabetes is a disease caused by industrialization that we have given ourselves.

And we need to tax, not subsidize, the production or corn, wheat, and sugar to cut off the problem at its source, because none of these crops are needed now to maintain the diet of a healthy population.

Public transportation and community institutions matter. Public transportation has two important impacts. First, you have to walk a little bit to and from the bus or the train, and that walking is good for you. Second, you see other people on the bus and the train, and that human contact is also good for you.

Americans forget that not so many years ago, we had community centers – YMCAs and Boys and Girls clubs. We had places to go and hang out after work or after school, places with a gym and a pool, in pretty much every community.

Kids would have a place to go and play ball after school and on weekends, and adults had places to spend time together, exercising or learning in adult education centers.

Yes, some community centers and many Ys still exist, but their social role has been supplanted by for-profit gyms and fitness centers. Many of those allow people who are motivated to stay fit, which is a good thing, but the for-profit nature of the enterprise means we have segregated our world into those who can afford the fancy gyms and those who can’t.

It would be better for us to build community centers for everyone, build exercise into our daily life, and use our resources to create other publicly funded places for us to be together – art museums, concert spaces, film archives, and public parks – than to allow ourselves to be so easily divided by income and culture.
Can I prove that taxing industrialized food products and using the money to subsidize local agriculture, build better public transportation, and making sure there is one community center for every community will reduce diabetes and save lives? Of course I can’t.

No well-standardized, double-blind crossover trial has ever been done to prove that, and none ever will be. Such a trial is too complex and too expensive. But no well-standardized, double-blind crossover trial has ever been done on our market-driven industrial food system either.

In fact, our demand for evidence-based decision-making in all our public processes is helping to drive our market culture, because evidence is controlled by market actors who can afford to obtain it and know how to ask research questions that are inherently biased.

One of the challenges in our public life is the challenge of using a certain amount of suggestive evidence mixed with a certain amount of common sense to make good decisions that benefit all of us. And we also have to use a certain amount of moral courage to not let ourselves be so easily picked apart by people with something to sell.

Physical activity matters. It’s the best defense against obesity, diabetes, high blood pressure, heart disease, and stroke. But we’ve engineered physical activity out of our lives. It is relatively easy to build physical activity into our cities and towns, using bike paths and well-engineered walking routes through pedestrian malls closed to car traffic, and easier still to create a social consensus exercise around using the stairs instead of elevators and having kids walk to school together, by having adults walk with them as a group in what’s called a walking school bus – but those things won’t happened unless we put our mind to them.

Let’s close all city centers to private cars during normal working hours; let’s start having all elevators run off a key card system, and then start charging all users for those keycards, as a way of providing an incentive to use the stairs.

Education matters – though indirectly. People who are more educated live longer, have less infant mortality, and make more money. Higher-income people live longer and have less infant mortality [although it’s interesting to note that poor people are nicer to one another – or at least contribute a higher proportion of their salaries to charity].

There’s nothing magic about education from a biological perspective. There is no change in the body or the immune system that results from taking three or five college courses. Educated people have just learned to make healthier choices. They chose healthy social connections. They learn why not to smoke and drink, and some of them even learn to avoid doctors and hospitals unless it is absolutely necessary.

We don’t know with certainty that investment in education will create a healthier population, because again, no one has ever done the well-designed, double-blind crossover trial to prove that education creates better public health outcomes. But the association between education and public health outcomes is so strong that an investment in public education seems wise, and because the fact that an educated population makes democracy more meaningful is more important than much of our spending on medical care.

Race matters for health, but again, indirectly. There are mountains of evidence showing African Americans and Latinos have poorer health outcomes than white Americans. Race as we measure it is a proxy measurement for racism, which, to paraphrase Ezra Pound, might be called a stupid suburban prejudice, but a prejudice that has bedeviled the lives of too many Americans in ways that are too numerous to count.

Race influences health though a number of mechanisms: through stress, poverty, education, and reduced access to medical care. It’s interesting that even though too much access to medical care has some association with adverse health outcomes in the population as a whole, improved access to primary care has been shown to reduce health disparities among the women and children of the African American population.

But primary care isn’t anywhere near powerful enough to outweigh the deleterious effect of racism on the health of individuals and has almost no effect on the health of African American men, who often bear the brunt of the public expressions of institutional racism and are too often hassled by police and selectively imprisoned, resulting in an epidemic of incarceration among black men, itself independently associated with poor health outcomes.

The challenge in our thinking about race and racism as markers for public health outcomes, however, is the problem of how to change the impact of race. There is no drug to treat the stupidity of people who perpetuate racist beliefs and practices.

And though social and economic reparations can help address the damage a history of racism has wreaked on generations of American families, there is no medical treatment to repair that damage per se, although we use health care to treat some of the biologic and social impacts of the harm racism has caused – more high blood pressure, diabetes, and stroke, more premature delivery and infant mortality, and many more victims of violence.

And there is a mountain of evidence showing that the victims of racism are not treated equally by our dysfunctional health care market, even now and despite improved access to health insurance.

We need to use our regulatory agencies to assure equal treatment. We need to make primary care and specialty care [primary care specifically] available to every person who has to live in a racist society and might be harmed by it, but health care itself won’t fix racism. Our society as a whole has to do that by owning our past, confronting the bias that exists in every one of us, and then changing our racist beliefs, practices, and institutions.

Poverty vs. income inequality

Some of our public health spending needs to be devoted to doing the kind of analysis that makes sure people are treated equally by our health care institutions and professionals. We need to keep a focus on the elimination of health disparities associated with race as part of every decision we make about public spending on health and medical services.

Income inequality is the intellectual bug-a-boo of our thinking about what matters for health. Lots of studies show that there is an association between income inequality and poor public health outcomes, although public health scientists are far from a consensus on this indictor and its association with health.

Some have suggested a biologic mechanism by which income inequality might create poor outcomes: people are more stressed where there is social distance between people of different income levels and stressed people fire up their adrenergic nervous system [the fight or flight reaction].

A chronically fired up fight or flight nervous, circulatory, and hormonal system causes hardening of the arteries, high blood pressure, and stroke. Places where there is a big divide between rich and poor have more social unrest, the argument goes, and that causes more stress.

In the U.S., we think more about poverty than we do about income inequality. Poor people don’t have access to fresh fruit and vegetables, so they rely on high-calorie, high-salt, and industrial food products for their nutrition, and consuming that kind of food causes diabetes, heart disease, and stroke.

Illness is also associated with more poverty. Poor people sometimes live in city neighborhoods near factories and mills or where factories and mills used to be, so they are exposed to old industrial pollutants and are much more likely to be lead poisoned.

So yes, there is a real association between poverty, income inequality, and public health outcomes. A number of previously discussed social factors associated with income inequality and poverty – education, housing, environment, food nutrition, physical activity, freedom from tobacco use, and effective prevention and treatment of drug and alcohol use and addiction – are predictors of poor health outcomes, and so our public spending on health ought to target these factors.

Reducing income inequality is a social good in its own right, because more equality creates more social peace, and social peace creates the conditions under which democracy is most vibrant, and vibrant democracy prevents social instability, and social instability, when it occurs, is bad for everyone’s health.

Peace is better than war. Justice is better than injustice. I don’t need to make reference to better public health outcomes to make those claims, and I keep hoping that my friends and colleagues who want to use income inequality to justify the need for social justice and democracy will realize that social justice and democracy are values that deserve our support in and of themselves.

What we measure, what we don't

As the discussion about Roseto, Pennsylvania, showed, social coherence – the extent to which people in a place get along and are willing to spend time together and work together to build a meaningful common life – appears to matter a lot for health, but like education, racism and income inequality, social coherence is an influencer, an intellectually slippery notion when viewed in the context of health. There aren’t clear measures of social coherence that everyone understands and agrees on the way we understand and agree on infant mortality or life expectancy.


The measures we try to use, measures like the number of voluntary associations per person or the extent to which we trust one another as measured by surveys, are all associated with better classic public health outcomes. Those measures tell us that places that have more social trust are associated with longer life expectancy, less infant mortality, and so on.

Part of the intellectual problem with the associations between social coherence and health is a lack of scientific consensus about the validity of the measures of social coherence, which are all self-defined. The definition of a voluntary association, for example, differs from person to person, and the meaning or intensity of the extent to which we trust someone is pretty subjective, try as we may to design survey instruments that are consistent and establish internal validity.

Mortality is hard and measurable – everyone can count the years you live and we all count years in the same way. But there is also the sense that social coherence is health, which is why the argument that social coherence matters for health appears circular.

If social coherence is a necessary condition for health, it is hard to say a necessary condition matters in the same way as we say a material condition matters. If we provide better sanitation and better food, we’ll get a healthier population.

But we can’t provide more social coherence in the same way. When we create a healthier population, we get more social coherence. When there is more social coherence, when we are getting along and spending more time together, the population’s health improves.

When the population’s health suffers illness, when there is an epidemic, a natural disaster, or an increase in substance abuse and drug overdose death, our ability to be together safely and comfortably is diminished, and social coherence suffers – the world becomes every man or woman for him or herself.

When our social coherence is fraying, we feel unsafe but not necessarily unwell. Cause and effect in regards to health and community is hard to establish, because health and community overlap, as necessary conditions for one another.

Still, from a public health perspective, if you gave me a choice between building a hospital or a library or school, I’d chose the library or school every time, at least until the moment there was an outbreak of a disease that hospitals help treat. And because libraries are much cheaper than hospitals, you can build 10 or 20 libraries for the cost of one new hospital building and serve hundreds more people every day.

That’s the tension that exists when we think about public spending, health, and medical care. Spending on medical care helps address our fear of the unknown, though it isn’t effective at all in improving the public’s health. Spending on social programs [sometimes] helps makes a more vibrant society if that spending is thoughtful and effective, and a vibrant society is more likely to make us healthier than will spending on medical care, particularly in our culture, where spending on medical care is more about someone else’s profit than it is about our common life.

The way to improve the health of the population is to maintain sanitation and improve nutrition, housing, and the design of the built environment. Better education, a focus on addressing the impacts of a history of racism, and a concerted effort to eliminate cigarette smoking, cleaning the environment and keeping it clean, and the prevention and treatment of drug and alcohol addiction will make individuals and the public healthier.

A health care system that can bring prevention to all Americans equally and that protects us from the overzealousness of some purveyors of medical care can make us healthier yet. Medical care provides treatment for and comfort to the sick. Sometimes. When it isn’t killing the well. Medical care isn’t health and it isn’t a health care system.

Peace matters. It isn’t possible to be healthy when people are killing one another. If we have learned nothing from seeing the devastation caused by war in Syria, Liberia, or Gaza, we should at least learn that. Looking at war-torn places should help us value the democracy we have, which, however imperfect, allows us to maintain a social fabric that doesn’t rely on violence to process our disagreements.

And democracy itself matters – perhaps even matters most. Democracy creates the social conditions that allow us to be at peace, at least domestically. Democracy channels our conflicts with one another into a forum that allows those conflicts to be resolved without violence, at least most of the time, so we are free to have relationships with one another. That we haven’t been able to translate our relative domestic tranquility into an ability to avoid conflict internationally is a central failure of our democracy and our culture.

Peace allows us to produce food and shelter and to create communities that allow relationships that can be sustained over time. Communities build housing and public transportation and protect the environment. We create health out of our relationships with one another, and then the health of the population circles back and makes democracy more robust.

A health care system exists in that matrix of conditions and influencers to promote our ability to be in relationship with one another, and so an effective health care system is one that focuses on the common good. Of all the material conditions and influencers that impact health, democracy matters most.

But the wealth extraction system that passes for health care in the U.S. is helping to destroy that democracy. So maybe it’s time to revolt.

Reprinted with permission of the author and PM Press.

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