Cracking the Health Code

by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership

If you watched one of the major networks in the past week – CNN, MSNBC, Fox News – you would think that the only newsworthy thing that happened was the arrival of the royal baby in England. Even here in the United States, a country that rejected British rule over 237 years ago, hysteria over the birth of Prince William and Kate Middleton’s son reached a fevered pitch.

Unfortunately lost in all of the hullabaloo surrounding the royal birth announcement were far more interesting and important stories, including several that have important public health and policy implications. For example, the US National Research Council and the Institute of Medicine released the results of a long awaited study that compared the overall health of Americans with their counterparts in 16 other affluent countries. The results were shocking.

Despite spending nearly twice as much on health care as countries like Australia, Canada, Great Britain and Japan, the US consistently ranks at the bottom in terms of public health outcomes. American men ranked last in terms of life expectancy, while American women ranked next to last. Americans also have higher rates of premature birth and infant mortality, teen pregnancy, sexually transmitted diseases, heart disease, lung disease, obesity and diabetes, traffic injuries and homicides. In many of these measures, the US faired no better than some impoverished countries in Asia and South America.

The main reason for this disparity seems obvious: compared with other affluent countries, far too many people in the US lack health insurance or face other financial barriers that prevent them from seeking care. There is also a lack of primary care providers in the US, so even those Americans who do have insurance often wait until they are very sick to seek treatment, usually from specialists who provide care at a substantial premium.

Of course, several of the reforms included in the Affordable Care Act are designed to address these problems. When these reforms kick in over the next two years (assuming that Republicans fail in their repeated attempts to repeal them), more people will have insurance. Reimbursement rates for primary care physicians will also increase, hopefully luring more doctors to specialize in preventative care. Finally, both the Affordable Care Act and the American Recovery and Reinvestment Act (the so-called stimulus package) provide nearly $250 million to increase the number of doctors, nurse practitioners and physician assistants trained in primary care.

Given this, we should expect the currently poor status of health in our country to improve dramatically, right? In ten to fifteen years, America should no longer rank at the bottom of the list of affluent countries with respect to public health outcomes like life expectancy, infant mortality and teen pregnancy, right? Sadly, this probably won’t be the case. The problem of poor health in the US is not just a question of limited access to care. Rather, the problem goes much deeper than that. It is rooted in the fundamental structure of American society.

What too many academics, clinicians, policy makers and politicians fail to appreciate are the structural determinants of health. The social and economic conditions that surround us on a day-to-day basis have as much of an impact on health as whether or not we see a doctor on a regular basis. Consider, for instance, the recent results of a twenty-year study of so-called ‘crack babies’.

During the crack cocaine epidemic of the 1980s, an estimated 150,000 to 200,000 children per year were born to cocaine-using mothers. The babies exposed to cocaine in utero were more likely to be born prematurely, be of low birth weight, exhibit delays in cognitive development, or be diagnosed with an attention deficit disorder. The crack epidemic, it was feared, would result in a generation of children with severe behavioral or cognitive problems.

That fear, however, was unfounded. For the past two decades, a team of researchers has been following these children carefully, tracking every aspect of their cognitive and physical development using a battery of psychological, educational and clinical tests. These researchers found was that there were no significant mental and physical differences between babies born to crack-addicted mothers and those who were not. However, children who were raised in poor inner-city neighborhoods were more likely to lag behind their wealthy suburban peers in both mental and physical development. Poverty, the researchers concluded, was “a more powerful influence on the [health] outcome of inner-city children than gestational exposure to cocaine.”

Compared with other affluent and considerably more healthy countries like Australia, Canada and Finland, the US has higher rates of childhood poverty, greater income inequity and less social mobility. All of these affect public health, more so than access to medical care. Until we address the social and economic problems that affect our health, America will remain the sick cousin of the developed world.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on July 24, 2013. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]