1.

WHEN A LOUSE infected with Rickettsia prowazekii lands on a human body and bites, the clock begins to tick. The bacterium passes from the louse into the bloodstream of its human host, rapidly invading the cells that line the insides of blood vessels. The vessels then start to leak. High fevers develop, a rash erupts, and organ systems may eventually fail. A case of epidemic typhus has emerged, possibly with lethal consequences. With the bite of another louse on that same human, the bacterium gains a new lease on life, and the terrible cycle begins anew.

Altogether missing from this brief description of the development and transmission of typhus, however, is the complex socioenvironmental milieu that fostered these developments in the first place. Crowded housing and unhygienic conditions, for instance, enable the louse to thrive and spread; they’re the reason typhus torments strained armies on the march, fleeing refugees, and marginalized populations more generally. Indeed, long before the pathogenesis of Rickettsia prowazekii was elucidated, typhus was recognized as a disease of poverty and misfortune.

The terrible typhus epidemic that broke out in the winter of 1847 in the poor, Polish-speaking German province of Upper Silesia was no exception. And, because of the observations of one man, it was the signature epidemic that would profoundly shape later thinking about the interplay between political economy and the production of human disease. The man was a physician named Rudolf Virchow, a young pathologist who had risen rapidly in the Berlin academic medical establishment.[1] Appalled by the government’s sluggish response to the epidemic, he wrote to his father in February 1848: “The suffering in Silesia is such a disgrace to the government that all the fine talk about it is worth nothing.” Itching to visit, he wrote of his “keen desire to see it close” and declared the epidemic “very interesting from the medical point of view.” His wish was soon granted — the Prussian authorities assigned him to the region to investigate.

In his subsequent report on the epidemic, Virchow seems to have gone well beyond his mandate. Not only did he famously connect the epidemic to the social and economic conditions of the marginalized Silesian population (subject to poor housing, education, and nutrition), but he also connected it to the political superstructure that had produced such conditions. He blasted the rapacious “landlord proprietors,” and the atrociously inadequate response by the government bureaucracy: “For there can now no longer be any doubt,” he wrote, “that such an epidemic dissemination of typhus had only been possible under the wretched conditions of life that poverty and lack of culture had created in Upper Silesia.” Going beyond his predecessors, he argued that the necessary antidote was unavoidably political: indeed, nothing less than a political revolution, by way of a “doctrine […] [of] Free and unlimited democracy,” was needed to prevent more such epidemics.[2]

As it happened, Europe was already ablaze with political unrest by way of the Revolutions of 1848. Virchow soon skipped out of Silesia and mounted a barricade in Berlin. But his report on the epidemic would become a foundational text for the messy and heterogeneous discipline known as “social medicine.” (“Nowhere does human disease occur as ‘pure nature,’” as the historian George Rosen wrote of the field in his 1947 essay “What is Social Medicine? A Genetic Analysis of the Concept.” “[I]t is ever mediated and modified by social activity and the cultural environment which such activity creates.”)

Virchow, of course, was not the first to comment on the social origins of disease. He just as obviously wasn’t the last.[3] (“Social medicine” would take a variety of odd twists and turns in subsequent decades; for instance, at one point, some of its adherents even embraced eugenics.) Recently, “social epidemiologists,” as they are now called, have with ever more quantitative sophistication explored the “social determinants of health,” demonstrating how such factors as income, wealth, social position, gender, and race generate inequalities in health. One of Virchow’s heirs is University of Michigan sociologist and health researcher James S. House, whose new book, Beyond Obamacare: Life, Death, and Social Policy (2015), tackles head-on the problem of health inequality in America.

 

2.

Discussions of health and health care in America are apt to begin with an acknowledgment of America’s relative inferiority — we spend much more on healthcare than other developed nations but live neither as long nor as well. Early in his book, however, House makes the important point that this relative inferiority is a recent development. In the 1950s, for instance, the United States was by and large performing the same as, if not better than, its European peers with respect to the major metrics of health for most groups, including life expectancy at birth, life expectancy at age 65, and the infant mortality rate.[4]

In the case of each of these basic measures of population health, the US subsequently experienced a startling relative decline. Despite a rapid escalation in healthcare expenditures relative to other high-income nations, at some point during the 1970s and 1980s the US slid into a relative — and for some subpopulations absolute — decline in health status. As he notes, women have lost several years of life expectancy — ranging from one to more than six years, depending on the point of comparison — relative to other high-income nations. In certain areas of the country and in certain subcategories, female life expectancy has actually fallen in absolute terms. More recently, maternal mortality has increased in absolute terms.

“How the wealthiest and most powerful nation in the world,” he writes, “and also by far the greatest spender on health care and insurance, could experience declining relative and perhaps even absolute levels of population health constitutes a very profound paradox.” Though he labels the trend an enigma, he in fact spends much of the remainder of the book making nonenigmatic connections, pace Virchow, to relevant socioeconomic developments. And one central development, as both his own research and that of others reveals, is growing health inequality in America.

 

3.

The story of health inequality is not a new one. In 1828, in what was one of the first uses of quantitative analysis in the study of occupational health, the French physician Louis-René Villermé observed differences in mortality among workers admitted to Parisian hospitals.[5] Death rates were lowest among the more skilled workers (butchers and carpenters) and highest among the least skilled (porters). A crucial element of the contemporary notion of health inequality, however, is not simply that poverty or particular occupations are injurious to health, but that there is a continuous gradient in health as we descend the socioeconomic scale.

This has been demonstrated, time and time again, with great statistical clarity. The famous Whitehall studies, led by the great epidemiologist Michael Marmot, investigated the relation between the level of employment of British civil servants and their health and death. The 10-year follow-up to the original study, begun in the late 1960s, found an approximate threefold disparity in mortality when comparing those in the highest “grade” with those in the lowest. Crucially, however, as the investigators’ 1984 paper in the journal The Lancet put it, these men all had “stable, sedentary jobs,” and so these differences couldn’t be explained by exposures to dangerous chemicals in the workplace (or, for that matter, to the hazards of unemployment or poverty). Nor could the mortality differential be fully explained by also taking into account such factors as age or smoking, or even blood pressure or cholesterol. In addition, differential access to healthcare couldn’t be the cause: Britain had established its universal National Health Service soon after World War II.

And so it became clear that even relatively minor social gradients (i.e., among different grades of male civil servants in a single affluent country) translated into marked inequalities in life and death. A great amount of subsequent research has confirmed this correlation between social and health status. House describes his own research in this area in the “Americans’ Changing Lives” (ACL) study, which began in 1986 as a study of the social determinants of health throughout life. Some 3,617 participants were enrolled and periodically followed over the ensuing decades, including as recently as early 2012. “The strongest predictors by far,” he notes of this cohort, “of successful health maintenance […] and effective functioning over the life course were two indicators of socioeconomic position: education and income.” The magnitude of these socioeconomic differences was enormous. Between the highest and lowest socioeconomic groups, he notes 25- to 30-year differences “in the rate of aging in terms of functional limitation.” Indeed, the risk of death associated with either low education or income exceeded that of any other individual health risk, including smoking.

Generally speaking, as House notes, racial factors are also very important. Being of African-American heritage confers worse health metrics in multiple domains, with much of the difference explained by differences in socioeconomic status. This is not to say that racism doesn’t cause poor health, but merely that it does so (in part) through socioeconomic pathways.[6] House argues that we should think about the social determinants of health using the now popular sociological framework of intersectionality, with economic, racial, and gender “axes” together playing a role in the production of health and disease. Indeed, the fact that the socioeconomically advantaged are as healthy as the residents of our peer nations helps buttress the point that, in America, there are indeed two interrelated inequalities at play — one of wealth and income, and the other of health. Emmanuel Saez and Thomas Piketty have outlined the quantitative contours of the former with great clarity, but the latter has received far less attention in the public sphere. And yet, shouldn’t it be the contrary? Isn’t health more fundamental? As the ancient Greek poet Ariphron wrote (overstating the case a bit):

If there be any joy in wealth or in children, or in that kingly rule that maketh men like to Gods, or in the desires we hunt with the secret nets of Aphrodite, or if there be any other delight or diversion sent of Heaven unto man, ’tis with thy aid, blessed Health […].[7] 

 

4.

Assuming then the interconnection of these twin inequalities, the timing of the pivot — when inequality stopped declining and began climbing — may well have occurred around the same time for both health and wealth.

Consider, for instance, a study published in 2008 by Nancy Krieger and colleagues that examined changes in health inequalities between the years 1960 and 2002. As expected, they found an overall decline in premature mortality (i.e., deaths under age 65) throughout the country for the period as a whole. But, critically, something changed at the period’s midpoint. From 1966 to 1980, when comparing counties with differing levels of income, the researchers found that socioeconomic disparities in premature mortality decreased, especially for people of color. However, after 1980, the pattern reversed: socioeconomic disparities in premature mortality (together with infant deaths) started to widen (or stagnate, depending on the specific metric used). In other words, the differential in premature mortality between poor and rich counties at first narrowed before swelling — with the transitional “inflection point” located in the early 1980s. These unequal declines in death equated to an estimated “excess fraction of 4.9 million lives cut short.”

Other studies have similarly shown that the economic gradient in health and death has been widening in recent decades. A 1993 study in The New England Journal of Medicine found that the difference in mortality between individuals with high versus low income (or high versus low education) was substantially larger in 1986 than it was in 1960. A 2012 study also found that inequalities in life expectancy (measured by educational attainment) increased between 1990 and 2008. Indeed, in 2008, the life expectancy of both whites and blacks with less than a high school education was about as low as that of the general population some 50 years earlier. And a 2009 study in the Journal of Health Economics found that in comparing the years 1993–1997 with 1998–2003, the differential in life expectancy between individuals in the bottom fifth of lifetime earnings (as compared to those in the top fifth) rose almost 30 percent among men and approximately doubled among women. Indeed, individuals in the bottom fifth for lifetime earnings experienced no improvement in life expectancy at all.

The emerging picture, therefore, is not simply that poverty kills, which is true. Nor is it simply that there is a continuous gradient of health by income or education, which is also true. Both of these dynamics have presumably been at work, at least to some extent, in stratified human societies throughout history. The salient point is that within the past few decades, there seems to be a historic widening in the prospects for healthy living between those at the top of the economic pyramid and those below. Societal gains in both health and wealth are confined to those at the top, causing metrics of population health to experience a relative overall deterioration.

 

5.

Understanding how, and why, this is all happening is complex and requires turning from the medical literature to history. The 1970s — the decade identified by House as marking the beginning of a relative decline in American health — was, to use the title of an important book by the historian Judith Stein, a “pivotal decade” in the story of American inequality. During what Stein calls the “Age of Compression” (the post–World War II period, ending in 1973), strong economic growth coincided with a decline in economic inequality (and, as we’ve seen, a likely decline in health inequality). But, as she describes, a “fire bell in the night” arrived in the year 1971, when the country experienced its first trade deficit since the 19th century; subsequently, over the course of the decade, recurrent oil crises bred inflation, productivity fell, and wages stagnated. This economic turmoil opened a window of opportunity and served as the launching pad for a new “neoliberal” era characterized by the rollback of organized labor, the rise of finance, the decline of manufacturing, a systematic attack on the welfare state, and, as Stein calls it, a new “Age of Inequality.”

That these changes would have ramifications for health is not particularly surprising. The authors of the 2008 study on falling and rising health inequalities, for instance, speculated that some of the political changes of this era might explain the relative rise of inequality with respect to premature mortality after 1980:

These societal changes could conceivably have had an impact on premature mortality rates for many causes of death, as a consequence of policies that reduced federal responsibility and funds for public health and antipoverty programs (in part via “block grants”), froze the minimum wage, disproportionately decreased taxes on the wealthy (resulting in their growing concentration of wealth), and restricted affirmative action.

Many researchers believe that inequality itself may translate into poor health, but, significantly, not only in the more obvious ways. As discussed earlier with the Whitehall studies, health inequality among socioeconomic groups cannot be fully explained by differences in certain health behaviors (e.g., smoking), nor in exposure to particular environmental or occupational hazards. Inequality and poverty seem in themselves to confer additional toxic effects on human physiology by way of unremitting psychological stress.

In his ACL study, as House describes, those with lower levels of education and income had “psychosocial risk factors” — such as social isolation or an accumulation of “negative life events” — ranging from one and a half to nearly five times higher than those who were better off. Such chronic psychosocial stressors can undermine multiple organ systems and processes. Economic inequality in itself produces psychological stress, as Richard Wilkinson and Kate Pickett describe in their bestselling book entitled The Spirit Level: Why Greater Equality Makes Societies Stronger, which in turn unleashes a cascade of physiological perturbations. “The psyche affects the neural system and in turn the immune system — when we’re stressed or depressed or feeling hostile, we are,” they argue, “far more likely to develop a host of bodily ills, including heart disease, infections and more rapid ageing.”[8] The science of how this happens is now better understood. In a 2010 review of the evolution of health inequalities research in the United States, for example, Nancy Adler and Judith Stewart of the University of California cite studies demonstrating that chronically elevated stress is associated with a wide variety of markers of poor health, including elevated blood pressure, fat accumulation in blood vessels, and shrinkage of brain cells.

In my specialty — pulmonary medicine — research in recent decades has similarly fueled our understanding of the complex interplay among our socioeconomic position, our environment, and our health. It has been known for some time, for instance, that those with lower income or education have lower lung function. One plausible contributing factor (among many) for that finding relates to the fact that the quality of air we breathe is affected by the relative status of our neighborhood, as recently shown in one study of metropolitan areas in the United States. However, apart from different levels of pollution exposure, it is also possible that those with low incomes may additionally have increased susceptibility to air pollution, which may (in part) result from the biological effects of chronic stress. For instance, high levels of household stress have been shown to augment the harmful effect of air pollution on lung function and the incidence of asthma among Californian children. Work with laboratory animals has shed some light on how this might come about. In one study, the effect of air pollution on rats depended on whether the animal was exposed to “social stress” (created by dropping the creature into the cage of an aggressive peer). Though both stress and pollution alone had biological effects, the combination of the two resulted in higher levels of inflammation and immune activation, and a unique breathing pattern.

There is also some work, as Adler and Stewart note, suggesting that psychosocial stress — and possibly low socioeconomic status itself — may have damaging effects on the very health of our genes. “Telomeres,” the pieces of DNA that “cap” the ends of our chromosomes, protect genetic material from degrading. They shorten with aging, and shortened telomeres have been connected with a variety of diseases. Psychosocial stress most likely expedites the shortening of these genetic structures, hastening the process of aging itself. These types of pathways — and many more — mediate the link between societal and health inequality.

Virchow’s lessons thus become all the more relevant as these pathways between politics and disease become more concrete, if still opaque in their details. For Virchow, the cascade began with the political economy of Prussia. Now, almost two centuries later, his essential framework still manifestly holds. Indeed, the physiological connections between political economy and health are surfacing in ever more explicit fashion in multiple domains of research.

 

6.

More pragmatically, though, what can be done? And what role does our healthcare system play in all of this? House’s book is titled “Beyond Obamacare” because, in his view, however important Obama’s signature healthcare legislation may be, the Affordable Care Act — or basically any healthcare reform — will ultimately have only a small impact on these health inequalities, and therefore on our overall health and health expenditures. Those of us who are “socioeconomically advantaged” are “already approaching the biological limits” of our health and longevity (this is something of an overstatement, but never mind). The task ahead is rather to target social inequalities in health, which could — and here House is being optimistic — “not only improve health and reduce spending for health care and insurance but also add value to our economy and society through a more productive labor force and greater overall societal well-being.” He calls this a “demand-side,” as opposed to a “supply-side,” approach to health policy; in other words, we need to lessen demand for healthcare by improving population health through “nonhealth” policies, instead of simply increasing its supply.

Some of House’s good ideas are mixed up with muddled ones. He makes the reasonable point that medical care itself has only a limited impact on health. This point was most famously made, as he acknowledges, by the English scholar Thomas McKeown, who studied the historic decline in tuberculosis in the 19th and 20th centuries. McKeown found that this decline actually predated the introduction of effective anti-tuberculosis antibiotics. He attributed it to improved social conditions. Other research, House argues, has supported the overall story that the great bulk of the improvement in human life expectancy during the 20th century stems from some combination of public health policy and of political and economic progress.

There is no doubt much truth to this picture. The social determinants of health may well trump the scalpel and the salve. But it’s not a static or straightforward story. Rather, the determinants depend to a great extent on the disease in question and the population in question. For instance, spending the entire gross national product on lung cancer surgery, chemotherapy, and research would have less impact on lung cancer deaths than simply banning cigarette production. For a variety of other disease processes (ranging from pneumonia to trauma), medical care yields critical, if complementary, benefits. Everyone is likely in agreement here.

“Society” may be unreasonably optimistic about the limitless potential of medical care, but House errs in suggesting that this misguided optimism is an important cause of our excessive medical spending. “[A] near-religious faith in the benefits of health care,” he states, “has led us to devote almost 20 percent of our gross domestic product (GDP) to it and to recoil from almost any suggestion that we reduce our access to and utilization of care, whether via ‘death panels’ or limitations on access to medical specialists.” House is wrong. Faith in — or more precisely overuse of — medical care is not the source of our high healthcare expenditures. On the contrary, my argument here is that our high healthcare expenditures — very much like the underlying health inequalities themselves (or, for that matter, typhus epidemics) — can be traced to politics. Indeed, as many commentators have noticed, the primary cause of exorbitant American healthcare spending lies not with patients demanding (or physicians providing) too much healthcare, but instead with the enormous inefficiencies inherent in a fragmented system dominated by the political prerogatives of the healthcare industry. For instance, it was the lobbying power of the pharmaceutical industry that ensured that the federal government be prohibited from negotiating drug prices (as other nations do). Our healthcare spending has nothing to do with a peculiar American belief in the power of the pill, but instead with the peculiar path of healthcare reform in this country, one that has become dominated by powerful corporate interests. Another round of healthcare reform and the creation of a single-payer national health insurance program could, by contrast, powerfully control the rising costs of healthcare, though this isn’t what House means by going “Beyond Obamacare.” In other words, the very same “neoliberal” political dynamics that nurtured the rise of health inequality in America simultaneously sculpted the confines of the healthcare reform debate.

In point of fact, despite all of the literature discussed in this essay, it is actually not clear that improving health through “nonhealth policies” (i.e., social spending and public health measures) would in itself reduce healthcare expenditures in the manner House argues. In the healthcare arena, as has been noted for some time, supply can create its own demand (to use the common formulation of Say’s Law): at least to some extent, hospital beds fill themselves, and physicians fill their schedules with patient visits. We may indeed need more “supply-side” interventions — for instance, greater planning and control over where and when healthcare infrastructure is created — in order to control healthcare spending, even if the public’s health were to markedly improve.

But what are the “demand-side” interventions that House thinks we might employ to lessen health disparities? Some of his examples, such as income support policies or investment in education, are eminently reasonable. But again, though educational attainment has been strongly tied to health inequalities in various studies, it’s far from certain that more societal spending on higher education would translate into reduced aggregate healthcare expenditure in the real world. But this is something of a quibble: House is correct in emphasizing that ameliorating socioeconomic disparities themselves is the “sine qua non for reducing all health disparities and improving population health” (and he is also correct in emphasizing that racial inequalities require some additional measures).

Yet he is unrealistic with how we might accomplish this. He argues that various education programs, income support programs (the Earned Income Tax Credit, food stamps, Social Security Income), and macroeconomic policies (the “dual goal of promoting low inflation and full employment”) were “developed with bipartisan support,” and that “[o]ther policies can be developed for these same purposes, also with bipartisan sources and support.” There are many problems here. For instance, in addition to low inflation and employment, House proposes economically indexed taxes on unhealthy consumables. Whatever the merits of that idea, in his discussion of macroeconomic policy and health, House doesn’t acknowledge that the orthogonal goals of minimizing inflation and maximizing employment often serve different interests. Central banks are frequently criticized for representing the interests of economic elites over workers when they pursue, with myopic vigor, the latter over the former. This is what Joseph Stiglitz refers to as the “distributional consequences of monetary policy.” Macroeonomic policy — like health policy — is intrinsically political.[9] It can be wielded to either worsen or ameliorate economic inequality, and thus health inequality.

Even more problematically, coming on the heels of a three-decade period in which “bipartisanship” has done more to increase disparities in income than reduce them, I’m skeptical of the political road that House lays before us.[10] As Mike Davis notes in his analytic history, Prisoners of the American Dream, the neoliberal assault of Reaganomics actually began in the final years of the 1970s, when Congress was dominated by Democrats. Emphasizing “bipartisan” policy solutions to health inequality comes across as a strained effort to find a technocratic solution to what is essentially a political problem. House suggests that at some point a conducive “political stream” will arrive and make possible his evidence-based “policy stream.” In this instance, however, the streams of politics and policy cannot so simply be disentangled. Although House mentions Virchow in a number of instances throughout his book, it seems that he has missed one of Virchow’s most important lessons: addressing the social determinants of health requires active and conscious political change.

Following the temporary success of the Revolution of 1848, Virchow’s political involvement did not wane. He was the cofounder of the journal Medical Reform, and in his writings for the journal, he emphasized both the importance of what we would call universal healthcare — all have “equal right to [a] healthful existence,” he wrote — together with the social and economic roots of disease.[11] “Typhus would not have grown to epidemic proportions in upper Silesia,” he reflected in an 1848 address, “if the population had not been bodily and mentally neglected, and the devastation caused by cholera would be quite negligible if the disease claimed no more victims among the working classes than among the well-to-do.”[12] This is basically what social epidemiology continues to tell us today; and, yet, Virchow went further still by recognizing that it was the political structure of Prussia that maintained this unjust status quo. For this reason, he joined the barricades.

Similarly, today, there can be little doubt that any serious effort to tackle the profound health inequalities that House has so clearly exposed will be, by necessity, partisan and political. Health inequality and economic inequality are mutually symbiotic injustices, each feeding and reinforcing the complicated dynamics of the other — a particularly malign manifestation of the intertwined caduceus snakes. Trying to roll back health inequality without directly confronting economic inequality is a Sisyphean pursuit. Progress requires embracing political struggle — in the manner of Virchow — head-on.

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[1] For details on Virchow, I rely in this essay on Erwin Heinz Ackerknecht, Rudolf. Virchow: Doctor, Statesman, Anthropologist (Madison: University of Wisconsin Press, 1953).

[2] Rudolf Virchow, Collected Essays on Public Health and Epidemiology, trans. L.J. Rather, vol. 1 (Canton, MA: Science History Publications, U.S.A., 1985), 205-319. Quotes on pages 215, 310, and 315.

[3] Dorothy Porter and Roy Porter, “What Was Social Medicine? An Historiographical Essay,” Journal of Historical Sociology 1, no. 1 (1988).

[4] He notes the one “slight exception” of male life expectancy at birth.

[5] William Coleman, Death Is a Social Disease: Public Health and Political Economy in Early Industrial France (Madison: University of Wisconsin Press, 1982), 168.

[6] A point emphasized by Ichiro Kawachi, Norman Daniels, and Dean E. Robinson, “Health Disparities by Race and Class: Why Both Matter,” Health Affairs 24, no. 2 (2005).

[7] Quoted in Henry E. Sigerist, Medicine and Human Welfare (New Haven: Yale university press, 1941), 56.

[8] In their book, Wilkinson and Pickett also describe how economic inequality drives worse health outcomes in essentially all major domains, ranging from violence to obesity to drug use.

[9] Joseph E. Stiglitz, The Price of Inequality (New York: W. W. Norton & Company, 2013), 288-331. Quote on page 304.

[10] In an endnote, House acknowledges that the problems he outlines arose during decades of bipartisan power sharing, but I believe he draws the wrong conclusion from this history.

[11] Virchow, Collected Essays on Public Health and Epidemiology, Volume 1, 16.

[12] Ibid., 117.

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A.W. Gaffney is a physician and a writer with a focus on healthcare policy and politics.