The Poor Made Visible
reprinted from Michigan Today, Winter 2003
An interview with Professor George A. Kaplan
Professor and Chair, Department of Epidemiology,
School of Public Health, University of Michigan
This is a remarkable time in history in terms of both the interest in and funding of public health and science devoted to health. We have the 800-pound genome gorilla: People are reading every day that the health problems in society will be solved by information coming from the elaboration of what we know about the human genome. Everything from the rarest disease to problems of racism, people are now saying, can be solved by what we may learn about the genome. It gets pretty extreme.
In my lectures I quote a former head of the National Institute of Health saying it's not unreasonable to think that research on the human genome will lead to the end of disease and disability. I immediately follow up that quotation by showing figures on life expectancy in Eastern Europe over the last 20 years.
The life expectancy of a 14-year-old male in Hungary decreased by three and a half years. That's equivalent to the amount of life expectancy that would be gained if we eliminated cancer and heart disease. It's a huge amount. We know this was a time of tremendous social, political and economic turmoil in Hungary as it went from a planned economy to essentially a free market economy. It affected people at every level from what they could eat to how they felt about themselves. And it had tremendous impact on their health.
I contend that understanding the genetic aspects of health is only a very small part of the picture. What we need to do is build bridges between the biological and social sciences if we're to close the great health divide between the people in the mainstream and those who are marginalized.
My research is focused in two ways, elaborating what these health divides are and, second, trying to develop ways of understanding the forces that produce health disparities in the population, both the biological and the social forces. It's this intellectual integration of knowledge across multiple levels of study that I think is key today.
Take the question of whether or not societies that have a greater gap between rich and poor have poorer health. Comparisons between the United States and Canada are particularly interesting because in many respects we're the same and in some respects we're different. When we started this work, we found that if we arrayed the states, or metropolitan areas within the states, by the extent to which there are large income gaps between rich and poor, people in the states with smaller gaps have better health. Their death rates were lower, and almost every other indicator we looked at was better in those states.
When we did the same study in Canada, however, we found no relationship whatsoever between income disparity and health. We think that one of the reasons is that there is less racial and economic residential segregation in Canada, as well as greater regional planning. Racial and economic segregation are associated with greater adverse exposures and fewer resources with which to combat these exposures. Regional planning can help to reduce some of the unequal concentration of these exposures and resources.
Canadians set policies mainly at the provincial, that is regional, rather than local level. In Canada it would be much harder to have a Detroit-area residential pattern, where you have hypersegregation in the city and suburbs. When you leave Detroit's boundaries, you cross from the most heavily segregated area in the country with respect to Blacks to the most heavily segregated area with respect to Whites.
How does that happen? Local governments can lure jobs from one area to another. A wealthy locality can give all sorts of tax breaks and actually bleed jobs out of Detroit and into the surrounding areas. Political processes that allow for enormous differences in material being can get instituted. Where you have regional government you can't do that. This is an example of a policy determination that can have a big impact on kids and their eventual opportunities to have good health versus worse health.
We need to train people to get out of their disciplinary boxes from the research point of view and policy point of view to understand how all these things fit together.
The first thing we have to do is change two prevailing mindsets. The first is that the only way to improve health is to invest huge amounts of money in fundamental science, basic science. I'm not against that, but we have to understand its limitations. The second mindset is that the only way to influence health and reduce disparities in health is to have some impact on medical care and the financing of medical care.
It is a sad truth that we are the only wealthy country in the world that doesn't consider health care a right for all members of society. I don't mean to indicate in any way that we shouldn't try to change that. But we're increasingly seeing that, in addition to delivery of medical care, issues of income distribution, labor policy, the structure and quality of community, housing all these domains that people don't tend to think of as involved in health policy are integral parts of the quality of health.
We have to get policy people to start evaluating the health impact of the economic and social policies that they propose. And we need to convince them that there's a tremendous need for training and for research in this area.
Next: Kristine A. Siefert
