Tuesday, April 2, 2013

Did You Know That Oppression is Bad for Your Health? Guest Essayist Dr. Daniel Goldberg Offers Up Some Wisdom on the Causes of Racial Health Inequities in the United States


I am lucky to have such a nice group of folks who volunteer to write guest posts here on We Are Respectable Negroes. One can indeed be judged by the company they keep. I do believe this rule holds in both the "real" and "virtual" realms.

Proverbial wisdom suggests that "whatever does not kill you, makes you stronger." Dr. Daniel Goldberg, a man of many professional talents and abilities--and so very humble by the way--argues otherwise in the first part of a three installment series with which he has blessed all of us here at WARN.

Daniel is cool folks who has commented here on We Are Respectable Negroes since its inception several years ago. He has also offered great advice and suggestions to me offline as well. He is also good people. That is one of my highest complements.

Given how our conversations here at We Are Respectable Negroes often deal with intersecting concepts such as race, poverty, the Common Good, gun culture, nihilism, social inequality, life chances, and social capital, Dr. Goldberg's series is timely and welcome. I do think that you will enjoy it, as well as learn much from David's work as demonstrated by the following essay.

****

Thanks much to Chauncey for the space.  I’m Daniel S. Goldberg; you can find out more than you or anyone else needs and wants to know at my academic web page.  But briefly, I’m an attorney, an intellectual historian, and a public health ethicist.  I’m a peculiar academic creature, but I work quite a bit on issues of health inequities, the social determinants of health, and justice in terms of what I call the usual suspects (class, race, gender, etc.)

This series of posts (three in total) is about health inequities, and especially racial health inequities.  It is about the causes and potential solutions for such health inequities.  It is about structural violence, oppression, and the political economy of health.  Health inequities – to be carefully distinguished from health care inequities (see below) – are vast and they are growing.  

These trends tend to adhere at almost any level: hyperlocal, local, county, state, region, nation, and globe.  The concept known as the social gradient of health refers to the general fact that the gradient of health correlates strongly with social strata, most notably, race and class (which are themselves obviously dependent variables in some crucial sense).  The statistics are just overwhelming (see, e.g., the CDC’s special 2011 M&M Report, or the County Health Rankings, just updated for 2013, or any one of a host of other sources).   

So, we’ve got a problem.  These posts reflect my personal views on the nature of the problem, and on the most promising pathways to ameliorating them.  Such amelioration consists both of improved overall health and compressed health inequities.  These posts are about health.  These posts are not about health care.

Why am I less interested in discussing health care and access to it? Most people interested in social justice tend to see such access as a core issue.  I understand this perspective, and to some extent even agree with it.  But I am less interested in health care because the epidemiologic evidence overwhelmingly suggests that the prime determinants of health and its devastatingly unequal distribution in human populations are the social and economic conditions in which we live, work and play.  And there is relatively little dispute that access to acute care services are only a minor determinant of health.

These assertions may sound bizarre to the good readers of WARN.  Such is understandable; there is excellent evidence that Americans tend to understand health as a function of health care.  That is, we generally believe that those who tend to be healthy are healthy because they have access to health care; those who lack access to health care tend to be unhealthy.  But the dirty little secret, which is no secret at all among epidemiologists and public health professionals, is that the evidence that medical services are significant determinants of population health outcomes is extraordinarily weak.  

This is a blog post, so I cannot really go into all of the details as to why.  But I’ll give just a few basic starting points for those who are interested in checking my math (and I discuss all of this in more detail in some of my academic work, much of which can be downloaded from my web site).

Start by googling Thomas McKeown.  McKeown was a professor of social medicine at the University of Birmingham, and was a trained physician and demographer.  Beginning in 1955, and continuing through the late 1970s, he and his colleagues developed the McKeown Thesis, which contended that the single largest recorded gain in life expectancy in the Western world had almost nothing to do either with organized medicine or with public health.  McKeown et al. showed that the doubling in life expectancy in England between 1600 and 1940 (an unfathomable increase in such a short time) had almost entirely completed its course before we got the first effective chemotherapeutics (the sulfa drugs in the 1930s).  

All of the major 19th c. killers were in substantial decline well before we got the first really effective medicines for said killers.

The McKeown Thesis is controversial, since it also contended that organized public health activities had similarly little effect.  Most scholars today think McKeown was wrong on this latter point.  But they think he was correct about medicine.  And the evidence is equally strong in the U.S.

Unconvinced? Ok, try the Whitehall Studies, some of the most important epidemiologic studies of the last half-century.  The follow-up from Whitehall II is still going on (or very recently concluded, I think).  The Whitehall Studies are a longitudinal cohort study of British civil servants, with extremely good data collected across decades of time with excellent capacity to control for confounders.  

For our purposes here, Whitehall helps because the subjects are all British civil servants, which means they all had access to basic health care.  So if we find a stark social gradient among the subjects, it is hard to figure that access to health care is a significant determinant of morbidity and mortality.  And, in fact, that is exactly what we find in Whitehall  (There is a crucially important debate going on to the present regarding the extent to which risky health behaviors play an important role in explaining the inequalities observed.  Such is the subject of a future post because it implicates strong concerns of disadvantage, victim-blaming/shaming, and stigma).

Finally, if you’re still not on board the It’s-Mostly-Not-Medical-Services train, just go ahead and read the final report of the World Health Organization’s Commission on Social Determinants of Health (2008) (entitled Closing the Gap: Health Equity through Action on the Social Determinants of Health), where they lay almost all of this out.  

As with any good academic debate, there remains disagreement, with some debate regarding the true contribution of medical services over the last half-century ongoing.  But I am comfortable suggesting that the broad consensus is that the quantum of said contribution is relatively small, causing probably no more than 10-15% of gains in life expectancy across a population (and some think even less).

So, if we want to do something about the crushing inequities that Black and Brown communities experience in the U.S., we need to move way, way beyond health care.  I am not opposed to expanding access to health care services; far from it – of course we should do so.  But, as I have argued, we should not confuse the moral claim (that we ought to expand access to basic health care) with the counterfactual claim that in so doing we would substantially improve population health and raise up the health status of the most materially deprived.  The evidence supporting the latter claim is weak.

Having been born on another continent, and having spent some time in other places on the planet (mostly the global North), I can report anecdotally that the general attitude towards American perspectives on health is mostly genial head-scratching, in a sort of ‘What the eff are you people DOING over there? You are STILL working on getting people access to health care? We more or less accomplished that many decades ago, and are on to more important things.’

Which things? If it ain’t health care services and health care disparities that are most likely to ameliorate the – let me say it again – devastating health inequities that racial and ethnic minorities experience in this country every day, then what would? What should we do?

To answer this question, we need to understand the root causes of such health inequities.  And my sense of what those root causes are is forthcoming in part II of the series.

12 comments:

grumpy rumblings said...

Great essay! I teach some of these topics in one of my classes. There's also a really good documentary called "Unnatural Causes" that covers the research in depth for folks who want to know more.

chauncey devega said...

I will have to check that out. I am so appreciative that Daniel took the time to share his work with us.

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Daniel Goldberg said...

Thanks, grumpy. I actually teach Unnatural Causes all the time; I'm fortunate to know the producer, Larry Adelman, as well. (Sidenote: If you like UC, there's a new documentary coming out, not quite a sequel, but not unrelated either. It is entitled "The Raising of America," and it is about the signal importance of early childhood development in producing health over the life span; deeply related to inequities, too).

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