by Kirsten Hartil
“Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care.”
At least according to Article 25 of The United Nations Universal Declaration of Human Rights, so why does the United States, one of the wealthiest countries in the world, have some of the poorest health outcomes compared to other high income countries?
My previous blog, adapted from the Institute of Medicine (IOM) report U.S. Health in International Perspective: Shorter Lives, Poorer Health, described how the U.S. compares in causes of mortality and years of life lost with other high income and OECD countries. Here, as outlined in the report, I explore some of the social determinants of health that may explain this. Social determinants of health, as opposed to biological determinants (biology and genetics), describe the conditions in which people are born, grow, live, work and age, including the physical, built and social environment (urban or rural, social networks, transportation, food options, recreational facilities, and safety/violence). They reflect public health and medical care systems, health behaviors (diet, exercise, smoking, unsafe sex practices, failure to use seatbelts and helmets, drunk driving, gun ownership), socioeconomic factors (education, income, wealth, ethnicity), environmental factors and policies, and social values. The panel determined how these social determinants compare in the U.S. and the other wealthy countries and whether such differences could contribute to the health disadvantage.
Health care systems and access to them are different between the U.S. and other peer countries. The report highlights the lack of universal health care (near or near-universal access to health care is offered by the 16 other peer countries), the highly fragmented health system, limited public health and primary care resources and high rates of uninsured and underinsured. However, since most people only access health care when already sick, the report concludes that the health care system determines health outcomes only in combination with other determinants of health.
Health behaviors, such as diet, physical inactivity and tobacco use were identified as the actual leading causes of death and years of life lost in the U.S. in 2000. Other actual causes of death, included motor vehicle crashes (due to alcohol or failure to wear seatbelts), incidents involving firearms, sexual behaviors, and illicit use of drugs. These behaviors contribute to the nine domains in which the U.S. has a health disadvantage: adverse birth outcomes; adolescent pregnancy and sexually transmitted infections; HIV/ AIDS; drug related mortality; injuries and homicides; obesity and diabetes; heart disease; chronic lung disease and disability.
Behaviors alone do not explain the health disadvantage faced by Americans compared with those living in peer countries. Even after selecting Americans with healthy behaviors, i.e. those without a history of tobacco use, drinking or obesity, or those who are white, medically insured, college educated or in upper income groups, Americans still appear to have worse health compared to their peers, suggesting other factors also account for the health disadvantage. The report noted that advertising and marketing of tobacco, alcohol and unhealthy food, exposure to violence and stress and sexualized content in television, film and music also contribute to unhealthy behavior.
Poverty is a major confounder for poor health outcomes but has the most serious impact on children as outlined in the WHO Commission on Social Determinants of Health 2008 report: Closing the gap in a generation.
The effects of poverty on child health and development are well known and were documented by Dr. Bernard Dreyer during his 2012 American Pediatrics Society address. They include: increased infant mortality; health and developmental problems; increased frequency and severity of chronic diseases such as asthma; food insecurity; increased accidental injury (and mortality) and increased obesity and its complications. In addition, children growing up in poverty are more likely to drop out of high school, less likely to graduate from college and since education correlates with future income and health, perpetuating “the cycle of poverty.”
Often, for people living in or near poverty their social and built environment contributes to their poor health outcomes. Low-income neighborhoods have been called “food deserts” because of their lack of access to healthy affordable food while encouraging the consumption of unhealthy food. They can discourage exercise (due to lack of resources or fear for safety). In addition, low paid employees are often not entitled to paid sick leave (a bill to mandate paid sick leave in NYC was recently vetoed by Mayor Bloomberg) or lack insurance limiting their access to health care.
In the U.S., one in five children lives below the federal poverty level (FPL). This rate of child poverty is second only to Romania (Figure 2). Minorities suffer the worst with more than one in three African-American and Hispanic children living below the FPL. In Bronx County, 41% of children under age 18 are living in poverty with 78% of children enrolled in public schools being eligible for free lunch.
The ‘social safety net,’ government funded programs that provide free or subsidized food, medical care, child care, elder care, education, housing, public transportation, employment and recreational services, are designed to improve social and health outcomes for individuals living in or near poverty and to the otherwise disadvantaged. Despite having the second highest median household income compared to the other high income countries, U.S. spending on social services is lower than all countries except Ireland, Korea, Mexico, New Zealand and the Slovak Republic and the U.S. ranks 31 out of 34 OECD countries in terms of income inequality. The sequester, a package of automatic Federal spending cuts, and proposals put forward in the reauthorization of the Farm Bill (defeated June 20 in the House of Representatives http://www.nyccah.org/federalfarmbillfailure), will further reduce Federal spending on programs such as WIC (a nutrition program that serves low-income women and children), SNAP and Low Income Home Energy Assistance Program, Head Start (the federal preschool program for low-income families) and housing assistance and is unlikely to reduce the burden that poverty places on the U.S. health disadvantage.
What can be done?
Continuing to invest in public health is one solution. A major goal of public health is improving health by encouraging healthy behaviors through a combination of public awareness and policy initiatives. As mortality by communicable and infectious diseases have decreased in the developed world, health behaviors are now recognized as the leading contributor to the global burden of disease. The Top 10 Public Health Achievements of the 20th Century, which include vaccinations, the control of infectious diseases, family planning, motor-vehicle safety and the recognition of tobacco as a health hazard, have contributed greatly to increased life expectancy.
However implementation, particularly of public health policies, is easier said than done. For example, public health and legislative efforts to cap the size of soda portions by the Department of Health (DoH) in NYC (because of their association with increased risk of obesity), met with considerable blow-back, in part a result of lobbying efforts by the American Beverage Association, but also from advocacy groups such as the NAACP and the Hispanic Federation. NAACP President, Ben Jealous, explained on “UP with Chris Hayes” that the ban would disproportionally impact minorities and small business (although, as covered on NY1, data published by Columbia University’s Mailman School of Public Health appears to dispute this). However, as the IOM report highlights, the American value of individual freedom and the right to choose, whether it be what size of soda to drink, whether to use tobacco or to own a firearm, also contributes to some of the resistance which meets legislative attempts to modify behavior. Therefore, initiatives such as the NYC Green Carts and Shop Healthy that promote rather than legislate healthy behavior may be more successful.
Promoting healthy behaviors also depends largely on health departments partnering with community, cultural and faith based organizations. In the Bronx, community organizations such as Bronx Knows (an HIV testing initiative in partnership with the DoH), Teen Advocates (a Planned Parenthood of NYC program that uses peer educators to provide information to young adults), and coalitions such as Bronx Health Reach (established to eliminate racial and ethnic health disparities), are incredibly effective at reaching out and empowering their local communities. In fact, Dr. Tom Farley, commissioner of the NYC DoH, announced on June 28th that The Bronx Knows and Brooklyn Knows have conducted 1.4 million HIV tests since 2008 and linked 78% of those newly diagnosed to care. Some of this may explain why, although the Bronx ranked bottom (or near bottom) out of 62 counties in all other health outcomes, it ranked 47th in health behaviors in the RWJF County Health Rankings.