Dear Peter

Policymakers, consciously sometimes, other times not, and economics are major determinants of health outcomes. Stated succinctly - and there is extensive evidence to support this - the greater the level of income and wealth inequality - the higher the level of health inequalities. Google The Spiirt Level for more info. Best. Paul

Yes policy has everything to do with the health of nations, an excellent point Paul, thanks for your input!

Dear Peter,

You are quite right about Individualist vs. Collectivist social identities. In collectivist societies, freedom and responsibility are defined by group leaders. In such cases, freedom is relative because the individual has to act within the lines drawn for him/her by others. National affluence and economic prosperity almost invariably lead to a better understanding of freedom, which in turn, helps the individual to be  more responsible. The point of fact is that the present events happening around us provide us with clear evidence regarding the societies that are optimally healthier because the members can always find a chance for expressing their ideas and beliefs. What I want to get at is that suppression and limitation of public and individual freedoms can make the society unhealthy.

Best regards,

R. Biria

Thank you Reza Biria for your wonderful answer.  But I am curious, should there be laws in place to limit the freedoms of the super-rich say that people cannot make more than five billion dollars personal accumulated wealth?  Should there be 'rules of limitation" with respect to what we can make in terms of our wages?? A free society means one that is responsible to everyone is that not true?  How ought we to move forward on that platform ideologically speaking to preserve rights for both individuals and collectives in ways that are balanced.

Freedom has never been absolute.  We are social beings and the very nature of society limits individual freedom.  Historically, some of those limits have been intended to control free-riders, those who would enjoy the benefits of a society without making any contribution.

A major challenge in every society is our conflicted human nature that creates tension between the forces of civilization and barbarism.  As Artistotle noted, when given the choice, people tend to do the wrong thing rather than the right thing.  Healthy societies have found ways to suppress the forces of barbarism, usually through education and through the passage of and strict enforcement of laws.   The goal, again drawing on Aristotle, is to encourage virtuous behavior until it becomes a matter of habit.

Societies become unhealthy when groups form who are dedicated to barbarism.   Gangs and dictators are two simple examples.  The uber-rich who control “democratic” societies are a more complex one, for the manifestation of their barbarism is not as obvious as what we find among gangs and dictators.  The violation of laws by the uber-rich—and the politicians who are beholden to them—are every bit as damaging to civilization as the acts of gangs and dictators.  One might argue that they are more damaging, for their actions and inactions serve to undermine the concepts of law and fair play that differentiate civilization from barbarism.

Consider:  In the US, it is illegal to use insider information related to business transactions to make money.  Members of Congress, however, have exempted themselves.  The President of the United States vows upon taking office to uphold and enforced the laws of the United States, and there are various laws concerning immigration that are designed to control our borders.  Nevertheless, every president since Ronald Reagan has refused, either implicitly (Bush I and II, Clinton) or explicitly (Obama), to enforce the law.

There is always a trickle-down effect, especially when radical populism is on the rise, because barbarism so easily assumes the mantel of “individual freedom.”  Thus, police stop using their turn signals when changing lanes, and they begin rolling through intersections, ignoring stop signs, and they ignore everyday drivers who do the same.  The individual cop tells him- or herself that “there are more important things to do.”  Even though the law  (in California, at least) states that whenever a dog owner takes the dog outside it must be on a leash, people ignore the law.  The accumulated result is a nation of cheats and scofflaws as barbarism takes control.

Reliable epidemiological evidence consistently shows that morbidity and mortality rates are considerably higher in the most unequal societies, such as the USA, where policy makers allow sick people to die because these, our brothers, our sisters, cannot afford preventable treatment. Paul

Reliable epidemiological evidence consistently shows that morbidity and mortality rates are considerably higher in the most unequal societies, such as the USA, where policy makers allow sick people to die because these, our brothers, our sisters, cannot afford preventable treatment. Paul

Reliable epidemiological evidence consistently shows that morbidity and mortality rates are considerably higher in the most unequal societies, such as the USA, where policy makers allow sick people to die because these, our brothers, our sisters, cannot afford preventable treatment. Paul

Sorry for duplication. RG is playing up, technically speaking.

Paul, not sure where you got your data, nor is it clear what your basis of comparison is.  If we look at the WHO data, we find that between 1990 and 2011, the under-5 mortality rate in the USA is 8%.  Should we compare that figure to, say, India, which has an  under-5 mortality rate of 61% or to Canada, with a rate 6%.

If the focus is on economic status, Canada might be a better basis of comparison.  If the focus is on social inequality, however, wouldn't India be a better basis of comparison?  In this case, the US performs well.

Also, if we consider the Emergency Medical Treatment and Active Labor Act, which requires hospital emergency departments to provide free treatment to medical indigents, on what basis do you claim that "policy makers allow sick people to die"?

Hello James. The data is primarily based on the research published in The Spirit Level by Richard Wilkinson and Kate Pickett (2009,I believe). I can provide lots of other sources too.

In 2014, the same authors took stock of more recent developments in a respected UK newspaper, The Guardian. They noted, among many other things, that In the aftermath of the financial crash, about 80% of Britons now think the income gap is far too large.

That message has been echoed by world leaders, notably, President Obama and Pope Francis. By the way, I believe that Wilkinson and Pickett are expert advisers to the UN, WHO, OECD, EU and ILO.

As they perused the data, it became patently clear that, in addition to health and violence, problems  more common at the bottom of the social hierarchy are more common in more unequal societies . This includes rates of drug addiction, obesity,  imprisonment, and unfair life chances for poorer children.

It is pertinent to add that the renowned Harvard academic, Professor Ichiro Kawachi,  describes inequality as a social pollutant. It is also relevant to note that the health and social problems that Wilkinson and Pickett investigated are between twice and 10 times as common in more unequal societies.

With regard to policymakers in America "allowing" poor and very sick people to die because of the lack of affordable health care, there is ample evidence of this. One example is the the huge opposition to ObamaCare - a very modest first step towards affordable healthcare - among a majority of Republican senators, if I am not mistaken. Best, Paul

I

Hello James. The data is primarily based on the research published in The Spirit Level by Richard Wilkinson and Kate Pickett (2009,I believe). I can provide lots of other sources too.

In 2014, the same authors took stock of more recent developments in a respected UK newspaper, The Guardian. They noted, among many other things, that In the aftermath of the financial crash, about 80% of Britons now think the income gap is far too large.

That message has been echoed by world leaders, notably, President Obama and Pope Francis. By the way, I believe that Wilkinson and Pickett are expert advisers to the UN, WHO, OECD, EU and ILO.

As they perused the data, it became patently clear that, in addition to health and violence, problems  more common at the bottom of the social hierarchy are more common in more unequal societies . This includes rates of drug addiction, obesity,  imprisonment, and unfair life chances for poorer children.

It is pertinent to add that the renowned Harvard academic, Professor Ichiro Kawachi,  describes inequality as a social pollutant. It is also relevant to note that the health and social problems that Wilkinson and Pickett investigated are between twice and 10 times as common in more unequal societies.

With regard to policymakers in America "allowing" poor and very sick people to die because of the lack of affordable health care, there is ample evidence of this. One example is the the huge opposition to ObamaCare - a very modest first step towards affordable healthcare - among a majority of Republican senators, if I am not mistaken. Best, Paul

I

 Paul, I took a quick look at the Wilkinson book.  Thanks for the reference.  By way of disclaimer, I wasn't able to read the entire book, but I skimmed parts of it, and it doesn't really seem to be about health in the medical sense, which is how I understood your previous post.  Instead, it appears to be a political tract advocating a shift away from advanced capitalism along the lines of Baudrillard's argument (though not referenced in the text) that advanced capitalism is based on inequality.  As such, I cannot give it the credence I give WHO reports that as far as I can tell do not support many of Wilkinson's claims.

I feel compelled to push back, however, when it comes to your statement that opposition to the Affordable Care Act is an example of policymakers allowing poor and very sick people to die because of lack of affordable health care.  As I indicated previously, in the US we have legislation, created and passed by policymakers, that requires hospitals and trauma centers to treat the medically indigent.  I would argue that the issues are more complex than you suggest.  The higher mortality rate among the poor, for example, is related to several lifestyle factors as well as to a sad reality:  many fail to obtain regular check ups (which could allow for interventions before a condition becomes critical) even when they can obtain medical exams from free clinics.  Then there is also the issue of the black-on-black crime.  According to FBI data, black-on-black murders account for nearly half of all homicides nationwide, even though African-Americans make up only about 13% of the population.

I also would suggest that the real issue for those opposed to the Affordable Care Act is similar to the recently implemented Common Core State Standards Initiative in education.  They see it as another instance of the federal government interfering in people's lives, requiring people to pay for health insurance even if they don't want health insurance (which some young people have argued they do not need).  The comparison with Common Core is interesting because American schools did fairly well under local control.  Under federal control, performance has declined or, at best, stayed the same, depending on the subject.  Perhaps opponents of Affordable Care can't help but feel anxious that health care, like education, will degrade under its mandate.  And then there is the cost issue.  

Dear James

Thank you for your edifying reply, which has taught me much. You are right of course, that the sources I quoted is value-laden, but the data are based on empirical research. Allow me to present key finding from a very respected US journal that was published this year.

Life expectancy increases continuously with income. At the age of 40 years, the gap in life expectancy between individuals in the top and bottom 1% of the income distribution in the United States is 15 years for men and 10 years for women.

For individuals in the bottom income quartile, life expectancy at the age of 40 years differs by approximately 4.5 years between the commuting zones with the highest and lowest life expectancies. Adjusting for race and ethnicity, life expectancy for individuals with low incomes is lowest in Nevada, Indiana, and Oklahoma and highest in California, New York, and Vermont.

Gaps in life expectancy by income increased between 2001 and 2014. Life expectancy did not change for individuals in the bottom 5% of the income distribution, whereas it increased by about 3 years for men and women in the top 5% of income distribution. These changes varied significantly across areas. The gap in life expectancy between the lowest and highest income quartiles decreased in some areas, such as areas within New Jersey and Alabama, but increased by more than 3 years in other areas, such as areas within Florida.

Correlational analysis of the differences in life expectancy across geographic areas did not provide strong support for 4 leading explanations for socioeconomic differences in longevity: differences in access to medical care (as measured by health insurance coverage and proxies for the quality and quantity of primary care), environmental differences (as measured by residential segregation), adverse effects of inequality (as measured by Gini indices), and labor market conditions (as measured by unemployment rates). Rather, most of the variation in life expectancy across areas was related to differences in health behaviors, including smoking, obesity, and exercise. Individuals in the lowest income quartile have more healthful behaviors and live longer in areas with more immigrants, higher home prices, and more college graduates.

I shall send you the source in a separate post. Best wishes Paul

JAMA April 26, 2016, Vol 315, No. 16 >

Paul, yes, there is no question that life expectancy increases with income.  As you noted, there appear to be multiple factors involved, and the poor lifestyle choices you listed are major contributing factors.  Because education level is correlated with income and lifestyle, I suppose it is another factor.  I've read that in California, the average education level of illegal immigrants from Mexico and Central America is 3rd grade, and reports indicate that as a group they are among the most unhealthy.  Thus, it appears that access to health care is only one factor in creating a healthy society.  

I would argue that politicians bear great responsibility in such an endeavor.  In my lifetime, however, I have not observed many US politicians dedicated to doing so.

James

Then we are on the same page, James.; well, a lot closer to being so, at least!  In 1948, the then Labour government launched the UK National Health Service (NHS). The first and foremost duty of an NHS nurse or doctor is to attend to the patient´s clinical need and well-being. This trumps everything, and it is enshrined in law. Even the Conservative and Labour politicians are generally united in the ethic.

Some years ago, I was watching an American documentary, and I witnesses an event that has moved me more than most things in life. A poor white American, badly hurt but conscious, was lying on the street. An African-American medic approached him. The man look up and said, "I cannot afford you, Sir". The medic replied, "No charge, buddy". I shall take that memory to my grave because it inspires me every day. Very best wishes, Paul