That social factors strongly influence health and life expectancy is well established news. Indeed, the classic finding in this regard is that life expectancy in the United States and Britain, for instance, rose dramatically at the end of the nineteenth century. This is generally attributed to social factors--better housing, water treatment, working conditions, and nutrition--because effective medical interventions came much later (surgery did not become safe until the turn of the century, penicillin was not manufactured in large quantities until World War II, chronic dialysis did not become available until the early 1960s, resuscitation was first reported in 1960, and the intensive care unit did not become a fixture in hospitals until the late 1960s). Reinforcing this link between social factors and health outcomes are numerous studies both in the United States and abroad of the causes for the substantial and persistent decline in cardiovascular mortality since the 1960s. They show that about half of the decline is due to "social factors," such as smoking cessation and changes in diet, while 40 percent or so of the decline is attributable to direct medical interventions, such as better control of blood pressure, cardiac surgery, and cardiac care units.
The real issue is what to do about this information. How should the understanding that social factors have a profound and significant impact on health outcomes and inequalities affect research and social policies? Daniels, Kennedy, and Kawachi suggest that we should stop concentrating on health care and look "upstream." Our attention should be focused on improving access to basic education, level of material deprivation, a healthy workplace environment, and equality of political participation. While Daniels and colleagues (strangely) single out bioethicists for chastisement, their admonition to stop worrying about exotic new technologies, the doctor-patient relationship, the performance of managed care, and even the fair allocation of health care resources seems directed to everyone--health policy experts, health care administrators, politicians, and the general public. Their advice: if you care about improving the health of the country, stop obsessing about "increasing access to medical care" and campaign for social justice. This is what Michael Marmot and others once called "the extreme version of the upstream focus [in which] action to reduce inequalities in health should therefore focus on the causes of social inequalities." It is strange to hear this call at the very moment expanding access to medical care has again surfaced in the national debate since the 1993 Clinton debacle.
Who could disagree that we should focus more attention on social justice? Even if they had absolutely no impact on health, narrowing income inequality in the United States, improving the educational system, and reforming the political process to reduce the influence of money and enhance popular participation are independently worthy goals that demand our attention. However, linking them to health outcomes--making improving health an important reason and motivation to advocate social justice--will likely be ineffectual. It may well be counter-productive, at least in the United States.
First, it is highly unlikely that Americans are going to be roused to support improvements in social justice because such changes will (or, more accurately, may) lead to improvements in health outcomes. Those of us dedicated to a more just society find the American publics toleration of gross--and growing--inequalities in income and political power puzzling and frustrating. Yet this is the reality in which changes will have to be fashioned. While Americans do not seem interested in lower taxes at the moment, neither are they clamoring for higher marginal tax rates on the rich; while they want campaign finance reform, it is hardly a burning issue that will determine more than a handful of votes. The one issue of social justice that inflames Americans is education. And this is not because it will lead to better health outcomes, but to economic advancement; people worry that the educational system is failing many kids, including their own, and thereby locking them out of good jobs in the future.
As politically salient as health care is, it hardly seems as if the American public, at least, is likely to be persuaded to support higher marginal tax rates, campaign finance reform, or a host of other things because these changes may narrow health inequalities or even improve their own health. Somehow "Support higher taxes on the rich, live longer" or "Ban soft money, improve your health" are unlikely to be persuasive or plausible to the public.
If we want to reduce health inequalities and to improve health outcomes, following Daniels and colleagues by focusing "upstream" and getting bioethicists, health policy experts, and the public discussion to focus on income inequality is likely to be even more frustrating than focusing directly on health care has been for the last thirty years. And this is probably not limited to the United States. Aversion to redistribution and income equality may be more extreme in the United States than elsewhere, but throughout the developed world the embrace is of more, rather than less, socioeconomic inequality. Health care is unlikely to be the horse to carry social justice measures over the finish line.
Linking health improvement too closely to social justice could actually backfire. In the United States, health care programs have won broad support for many years. This is not only true for funding of the National Institutes of Health, but also for support of Medicare and other health programs. This is in part because health care is viewed as something that benefits everyone in society; health programs are not viewed as special interest programs or as programs for the poor, racial minorities, or other groups. As Rashi Fein has pointed out, the difference in support of Medicaid and Medicare is closely linked to one being viewed as a "poor persons" program and the other being a general program that also happens to benefit the poor. Whether we like it or not, it is precisely because health care is viewed as key to equal opportunity, without overtly or intentionally redistributing income, that it garners such strong public support. This is an essential foundation piece for any chance of forging a majority to support some version of universal health coverage in the United States.
Convincing the American public to look "upstream" and making general redistributive efforts key to improving health is unlikely to further the former and could well undermine the latter; resistance to redistribution is likely to be stronger than endorsement of expanded health access. Indeed, the more Americans are told how much re-distribution Daniels, Kennedy, and Kawachi contemplate to secure health improvements--income inequalities less "than those observed in even the most industrialized countries," early childhood interventions that "go beyond the best models of such interventions we see in European efforts," etc.--the more dismissive they are likely to be of gazing "upstream."
So what should be done about these data? One objective is to determine the effect of narrowing income inequality on the health of the "best off." While it is strange to worry about the best off, if narrowing income inequality improves overall health by raising the low end, but somehow decreases the health of the rich, they are likely to resist. There is no reason to think this will occur. Indeed, Medicare shows the opposite; it produced general improvements in health delivery that benefited the well-off. But demonstrating a "trickle up" for the health of the well-off would undercut at least this element of opposition to social justice.
Another lesson is to design health interventions that take into account thedifferential impact on the lower socioeconomic groups. Smoking cessation targeted at minorities, universal prenatal care that ensures the poor are covered, and opposing development and coverage of services that only the rich will have access to all utilize the knowledge gained while sustaining support for health.
Finally, bioethicists, health policy experts, and others should keep the focus on universal access and the just allocation of health care resources. Most Americans are dissatisfied with the current health care system; what is needed is an alternative a majority can endorse. While this may not have the same total impact on improving health outcomes as substantial income redistribution, health care services still account for 25 to 40 percent of improvements in health outcomes. This is substantial, worth securing for everyone, and will enhance social justice. And it is part of the current public discussion.
Admonishing caution in shifting the perspective of bioethicists, health policy experts, and the public "upstream" should be construed as neither an argument against greater efforts at social justice nor a dismissal of the importance of the social determinants of health, but as a warning not to forsake attention to greater access to health care.