Wealth Divides Health

How long will you live? At face value, this seems like a strange question, for how can you predict how long your lifespan will be? However, your lifespan (and a multitude of other health outcomes) are highly related to socioeconomic status and household income. Below, I provide a graph indicating race- and ethnicity-adjusted life expectancy for 40 year olds by household income from 2001 to 2014. (1)

Several findings from this study stand out upon first glance. The life expectancy margin from the richest 1% to poorest 1% of individuals was 14.6 years for men and 10.1 for women. Additionally, life expectancy disparities are increasing and vary based on geographical areas. This geographic disparity makes sense since most neighborhoods are inhabited by households in relatively similar income percentiles. In this article, I hope to explore a 2010 WHO Report titled “A Conceptual Framework For Action on the Social Determinants of Health.” (2) How might researchers create a framework to describe social determinants of health and how might this affect policy and intervention efficacy?

In my article titled “A Can of Worms. Is Education Health?,” I define Social Determinants of Health (SDoH) as non-medical factors that affect healthcare outcomes. (3) This definition is intentionally vague as researchers continue to identify various factors that affect health including education, income, food security, and transportation access. You might also think of Social Determinants of Health via the Symptom-Stage Model which I present in my previous article. (4) In this framework, SDoH may be found in the first few stages (1-3…) of the model and SDoH inequities create cascading effects that result in various health issues down the line.

The WHO has created the following framework to understand SDoH.

Upon closer inspection, this framework has many similarities to the Symptom-Stage Model. Socioeconomic and political issues (Structural Determinants) affect Intermediate Determinants (SDoH) which then impact health and well-being. However, via this model, the WHO claims that the health impacts which are the result of SDoH widen the existing disparities that caused the health issue in the first place. Furthermore, while we recognize living conditions, access to resources, etc. as Social Determinants of Health, the WHO defines Structural Determinants as societal systems that give rise to disparities in the first place. These include culture, governance, and policies (including labor market, housing, land, and education).

What researchers have begun to recognize and what I have argued in many of my prior articles is that the health system plays a relatively minor role in overall health. In this graphic, the WHO places health systems (hospitals, clinics, etc.) at the end of the line, in a sense mitigating the impacts of SDoH. However, we see that Structural and Social Determinants impact health and well-being in many ways untreated by conventional medicine. Legislators MUST find strategies to tackle structural and social determinants to improve health parity.

I define health policy as legislation proposed or enacted at the local, regional, state, or federal level to keep individuals and communities healthy and improve well-being. In my previous article centered around the Symptom-Stage Model, I argued that the most effective health policies will treat an issue at its earliest stage (in this case, structural or social determinants). However, I hope to add a second dimension to this argument.

If two policymakers were to look at the life expectancy disparity, they might have different policy recommendations. Of course, this may be a result of the policymakers having different stakeholders, but each policymaker might hope to target a different subset of the population with this legislation. Below I include a WHO framework for health policy levels/dimensions.

Policies might be targeted towards specific individuals (micro), specific communities (mesa), the general public (macro), or the environment/global population. I pose that the level used to build health policy affects the efficacy of the policy itself. For example, at the macro-level, legislators may reduce exposure to health-damaging factors whereas at the micro-level, legislators may reduce the consequences of social, economic, and health-related disparity. It appears as if this comparison reflects the Symptom-Stage Model, where large-scale measures that affect the most people target early stage issues and small-scale/micro-level measures address the issue’s outcome.

The WHO identifies specific “arguments” to describe policy interventions at different levels. These arguments are essentially frames that policymakers can refer to when crafting legislation at that specific level. In this article, I hope to focus on the neo-material macro, and neo-material micro arguments that influence macro- and micro-level policy respectively. The neo-material argument is the idea that political and economic structures create income disparities that affect health and several other “resource” inequities from health to social welfare. (5) One neo-material macro life expectancy argument may be that income inequality results in decreased investment in social and environmental resources for lower-income individuals, widening health disparities. One neo-material micro life expectancy argument may be that income inequality means fewer economic resources for lower-income individuals, limiting their ability to prevent, treat, and cure disease.

As I conclude this article, I hope to provide a few examples of policy interventions for this income inequality issue.

At the macro level, legislators ask exposure-related questions: How can we implement policies to reduce people’s exposure to factors that may harm their health and wellbeing?

• A universal policy (affecting everyone) might involve improving access to clean water and developing safe working environments.

• A selective policy (affecting target individuals) might involve subsidizing housing, cooking fuels, and waste management systems.

At the micro level, legislators ask ameliorative questions: How can we implement policies that reduce the effects of poor health?

• A universal policy might involve healthcare financing and management for impoverished patients or those affected by chronic debilitating illness.

• A selective policy might involve support or medical reimbursement for those patients specifically.

When looking to solve a particular issue, we must first identify what population we want to target and at what level we hope to implement policy. As researchers continue to explore the various Structural and Social Determinants of Health while examining ways in which health policy affects different populations, perhaps we may provide our elected officials with evidence-informed methods to draft effective legislation. While I hope this article provides you with a greater understanding of multilayered health policy frameworks, I also believe that we must use the available research to hold our legislators responsible; we must advocate for health policy that addresses Structural and Social Determinants of Health and that reduce the gaps between individuals of different socioeconomic status.