Health Break | Published January 31, 2005 | Written by Jeffrey A. Ratner, MD

What Makes A Population Healthy?

It is becoming clearer that at any given level of overall economic development for a country or region within a country, the populations of countries and regions with smaller gaps between rich and poor, in general, are healthier than the populations of countries and regions where the gap is larger.

These observations imply that the economic structure of a nation may be the most important determinate of the health of its people. To illustrate this, look at the health of people in the United States of America, measured by life expectancy. Fifty-five years ago, the U.S. was one of the healthiest countries in the world by this measure. Today, there are some 25 countries that are healthier than the U.S.

The U.S. has the highest infant mortality rate, the highest child poverty rate, the highest teen pregnancy rate, the highest child abuse death rate, and so on, among all rich countries. There are no indicators in which we excel, except in spending money on healthcare, for we spend half of the world’s total healthcare bill.

Think of it—for every dollar in the world spent on healthcare, 50 cents is spent here; yet, our citizens are less healthy.

Japan has the highest life expectancy of any country in the world, yet there are twice as many smokers per capita in Japan than in the U.S. To understand this phenomenon, we need to look at post-World War II Japan and the changes that occurred from 1945 to 1950, during the U.S. occupation: The first was demilitarization; the second was democratization, as U.S. policy-makers wrote the country’s constitution, providing for representative democracy, free universal education and the right of labor unions to organize and engage in collective bargaining; and the third “D” was decentralization, when the 11-family zaibatsu that ran the huge corporations controlling the country was broken up. The most successful land reform program in history was carried out. What this did was bring down the economic hierarchy and leveled the playing field. The resulting rise in health in Japan is the most profound ever observed on this planet.

So why do people with lower incomes get sick more? Is it because they smoke more (which they do)? Is it because they drink more (which they may do)? Is it because they use more heroin (which is true)? Is it because they eat more (which is true)? Is it because they don’t exercise as much (because they don’t)?

Studies have shown that even though these behaviors are considered bad for health, the excess smoking, drinking, heroin use and food consumption in conjunction with a lack of exercise, only explains about 10 percent of the reason that poorer people have poorer health. Learning this has been a revelation for me. I used to blame sick people for their behaviors that made them sick.

It is tempting to say that the reason lower income people get sick more is because they can’t afford healthcare. But, that isn’t the case. Consider the Hispanic population: They don’t access healthcare much, they tend to not have medical insurance and they tend not to go to the doctor. Yet, they tend to be much healthier than their non-Hispanic white counterparts.

The truth is that in the last 55 years we have drastically changed the rules of who gets what share of the pie in regard to healthcare. Relative poverty, living in a large gap society is the worst part of poverty.

In next week’s Health Break column, we will further examine this tragic phenomenon between economics, poverty and poor health.

Jeffrey A. Ratner, MD, specializes in Pulmonary and Internal Medicine and is in private practice in State College. He is currently Chief of Staff at Mount Nittany Medical Center.

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