Sunday, September 12, 2010

Social Determinants, Personal Responsibility, and Health System Outcomes

Whole Foods, Inc., CEO John Mackey has been both an outspoken critic of the Obama administration's health reform plan and an advocate for “personal accountability” suggesting that people’s health behaviors – including such things as smoking, poor diet, obesity, and lack of exercise -- account for much of their health risk, and thus people should be held responsible for the poor choices that they make, receiving fewer health benefits if they have not taken the steps to maintain their own health. He has recently made this argument in an op-ed piece in the Wall St. Journal, “The Whole Foods alternative to Obamacare” (August 11, 2010). Subtitled “Eight things we can do to improve health care without adding to the deficit”, Mackey runs through a list of proposals that feature inequity, maintaining and increasing the health and wealth of those who already have the most of it; that would create enormous increases in insurance company profit, would not meet the health needs of those who have needs, and would end up costing a fortune. The “controls” are all on services that would benefit people, the “freedom” is all for corporations to continue to have unfettered access to excessive profit.

All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments,” he writes. Of course, his definition of “socialized” includes the health systems of every single developed country in the world outside the US, whether they have a National Health Service (e.g., UK), single-payer insurance (e.g., Canada) or a mixed system that includes private insurers that are regulated (e.g., Switzerland, Germany). What is unsaid by Mackey is that the system he proposes (much like the current one in the US) does not eliminate lines for everyone but rations by wealth and insurance status. CEOs like him do not have to wait in lines, but the further down the socioeconomic ladder you are, the longer the line becomes, until, at the end, unlike in those other countries, there are tens of millions of people who can’t get on the line at all. Unsurprisingly, these proposals are likely to resonate with and please the readers of the Wall St. Journal’s editorial pages. The US health system is not only incredibly expensive (not because it covers everyone, which it doesn’t, but because of the huge profits taken out of the system by Mackey’s fellow CEOs) and unfair, but it performs poorly on virtually all dimensions (see the Commonwealth Fund’s 2010 report, “Mirror, Mirror on the Wall”, with results summarized in the attached figure).

More insidiously, however, some of these arguments can appeal to many others, who see sense in expecting people to take “responsibility” for their health and act in healthful ways: “Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.” Eat nutritious food, exercise, don’t smoke or take illegal drugs or drink to excess, etc. This is good advice, and all of us should try to take it. I’m sure that it is advice that many of the employees of Whole Foods – the ones who are young and healthy – appreciate, because it validates what they do, and see – the “outcome” is that they are young and healthy. It is possible that there are other Whole Foods employees, not young and healthy but older and/or with chronic disease – who many not find his advice, or the company’s health plan, to be of such great value. His essay may be a call to action for those who, given some combination of youth, genetic luck, good health, and socioeconomic opportunity, are still not doing all they can.

But health behaviors – and the health care system – are not the only determinants of health. Indeed, the Determinants of Health model from Healthy People 2010 (see figure) make clear that there are m any factors that impact health, most of which are ignored by Mackey and his ilk. They are also not all going to be addressed by health system reform, whether that in the current “Obama” plan or even in a more extensive change, advocated by people like me and the Physicians for a National Health Program to be more like the other, much higher performing systems in other countries. That system change is necessary, but not, in itself, sufficient. The environment, both physical and socio-economic, have tremendous impact. In addition, issues not specifically on this model, such as the impact of race (racism, not perhaps overt but in terms of the impact of “perception of race” on those of color). These are the Social Determinants of Health, and have been written about extensively, in a literature that is either unknown to or rejected by Mackey and his friends. Perhaps the clearest exposition of the Social Determinants is by Camara Phyllis Jones, MD, MPH, PhD, of the Centers for Disease Control and Prevention (CDC), who has written extensively on this topic. However, she has also developed a cartoon depicting how the social determinants of health intersect with the health care system as well as how the different levels of the health care system (primary, secondary, tertiary prevention, and treatment) interact with each other. Her slide show, “Social Determinants of Health and Equity, the Impacts of Racism on Health” is available on line and contains these cartoons. They demonstrate, through the use of a cliff analogy, the role of these different factors. Although very useful for teaching children, their clarity is also of great value for teaching health professionals. And they might even be understood by CEOs.

With Dr. Jones’ permission, Neal Palafox, MD, of the University of Hawaii, produced slides based on her model, one of which is reproduced here. It represents health risk as a cliff. If someone falls off, we can provide medical care (the ambulance); however this is variably available for people (access to care). If we can identify diseases and treat them before they require expensive care, this is secondary prevention (the net also represents “safety net” health services). Better yet, we can provide primary prevention – keep people from falling off the cliff (the fence). Some of this is achieved through the individual behavior changes like those advocated by Mackey. The social determinants, however, which he ignores, are represented by the distance that people are from the edge of the cliff; some folks are at greater risk. As Dr. Jones also develops in her slides, many of those same people are those who have less protection by the fence, or the net, or for whom, when they do get sick (fall off the cliff) the ambulance is not there, or even “going in the wrong direction”.

Most of the discussion of these issues are among those of us who are relatively privileged. We may not be wealthy CEOs like John Mackey, but we are educated, literate, and consumers of ideas. Most of us are at least middle-class; even those who may say “no, I don’t have money” are usually in that status temporarily (e.g., from being students), but have the values and self-efficacy that comes from our class, socioeconomic, and educational background. This group certainly includes all the politicians, pundits, academics and successful businesspeople – and medical students. It may be hard to believe, but the vast majority of people are not in that group. Check out income demographics: according to the US census, in 2000 only 12.29% of households – not individuals – had incomes over $100,000 a year, and only 2.37% over $200,000; 2008 estimates indicate household income >$100,000 is the top quintile, and the top 5% is >$180,000.

We absolutely need health reform, real reform, that will begin to move us in the direction of the high-performing health systems in other countries. We also need to encourage healthful behaviors. However, rather than penalizing others whose circumstances – genetic, socioeconomic, social, racial, physical – make that more difficult, we need to develop programs, that require, as Dr. Jones notes, “…collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture and environment.”

And we need to get started.


Jeoffry B. said...

I was drawn to your blog by the EQUAL e-list. I think this post and the slide show is smart and well intentioned but significantly out of date. Consider the following:

1. Since 2008 the USA has undergone a major economic meltdown.The public health community is largely unaware of the future impact of this on the fabric of life for all residents of the USA.
2.Not only has the (a) poverty level massively increased, but (b)large sectors of the safety net are being atrophied and (c)the security, services, and dreams of the middle class are being destroyed.Thus
(3)Social Justice is no longer an issue just for the poor and minorities.Since
(4) The distribution of family income (GINI Index)is more distorted in the USA than any time since 1929. At 42 this level is on par with Mexico, Jamaica and other third world countries.As a matter of fact, the CIA lists USA as about the 40th worst country in the world in this regard - and at a level of inequality which promotes social unrest!
(5) If you study the data in THE SPIRIT LEVEL by Wilkerson and Picket, you learn that levels of illness and most other parameters of social morbidity in developed countries and USA states are strongly related to income distribution INEQUALITY and not average income.

Thus my inference is that the analysis and data presented in this blog are constrained by past conventional policy and academic wisdom and not insightful of our contemporary unfolding catastrophy. Addressing health care and social justice now more than ever requires a paradigm that looks at politics at the broadest level.If you understand the implications of this analysis I invite readers of this blog to join in a discussion of how we can face this challenge and change the course of events.
(I have extensive PPT slides on domestic economic and health parameters I can share if I am contacted at

Bob Bowman said...

From 1997 t0 2005 the US MD medical students from parents making over $100,000 increased by 70% while students from parents making less than $40,000 decreased by 30 - 40% and middle income admissions decreased by 20%. The changes spanned race, ethnicity, and gender.

AAMC studies note that those most likely to gain admission are least likely to have awareness of lower income people. Changes in the past decade make this even more likely.

Changes also have included Asian and foreign born populations and physicians. This is a group of about 12% of the US population but this group claims about 40% of the physicians entering the US workforce.

White populations are now underrepresented with regard to new physicians entering the workforce, joining Hispanic, African American, lower income, middle income, and rural populations. Rural origin white males have declined the most from 25% entering the workforce to 2% over the past 50 years. Rural origin admissions have declined the most in counties dependent upon manufacturing and farming and counties left behind in social organization, income, population density, education, and physicians.

Rural origin admissions have declined most rapidly in states with 40 - 50% rural population - those most recently declining below a majority rural population - an indicator of political changes with an urban majority gaining control.

Those gaining admission in highest probability and increasing in admission are children of combinations of concentration: most urban, highest income, children of professionals and physicians. Those losing out are those least associated with concentrations.

Those gaining in entry to the US workforce from US or non-citizen origins are least likely to be found in family medicine, primary care, rural, and underserved careers - least basic health access contributions. Those being replaced in entry are those most likely to be found in basic health access careers.

Changes resulting in more narrow origin physicians least like normal Americans include substantial declines in income, education, and opportunity for lower and middle income Americans, testing to the test, narrow science focus, and legal actions.

Bob Bowman

Marly said...

What a great post! I wanted to add that Michael Pollan points out in his book, Omnivore's Dilemma, that right now our system encourages unhealthy food choices. Our government subsidizes corn which results in Twinkies that cost a lot less than buying a bag of apples. So I agree with you that it's not enough to say that people need to be more accountable for their health.

I also agree that it's easy to be lulled into this discussion of personal accountability as a way to assuage guilt over not providing more health services to those in need. It's as if we're saying, "We don't need to provide you with more health services, you just need to take better care of yourself. Now, go have a Twinkie."

Yes, I know, oversimplified. I guess that's the point.

However, as someone who is for reform in healthcare, I oftentimes find myself frustrated. What can I do? I've done the typical writing to my congressional representative, phone calls. I even started a blog focused on this topic. Short of resigning my life and setting up camp in DC, I find the topic of personal accountability tempting because it is something I can do right here and now.

This is a great discussion and I appreciate the opportunity to contribute to it! Marly

Total Pageviews