Comment by Tony Iton, M.D., J.D., MPH, Director, Alameda Co. Public Health Dept.
Life Expectancy Gap Is Not The Result Of Bad, Stupid, Or Lazy People
The news coverage of these provocative research findings has thus far focused on the "health behaviors" (i.e. smoking, diet and physical inactivity) of the populations in these communities as an explanation of the increasing life expectancy gap in the U.S. This logic seems to suggest that these unhealthy behaviors occur in a vacuum and are somehow regionally distributed. There is abundant research, including the recently released Alameda County Health Equity Report, that suggest that federal, state and local policies that shape the social consequences of being poor in America are as important if not more important than individual health behaviors, and may in fact, indirectly influence the prevalence of these unhealthy behaviors.There are a constellation of social policies affecting the lives of people in low income communities that effectively conspire to deprive them of opportunities to achieve a healthy life. These include policies related to minimum and living wage, health insurance access, education funding, housing, land use, incarceration, transportation and others. Central among those policies, and certainly among the most pernicious, is the low quality of public education that results from underinvestment in public pre-school and K-12 education systems in many of these same counties that are demonstrating falling life expectancies. Education is supposed to be the ultimate equalizer that gives poor kids an opportunity to achieve the American Dream. It is ostensibly the ladder out of American poverty.
The effect of this systematic deprivation of important social resources and opportunity is a profound sense of despair and hopelessness that has become pervasive in these communities and contributes to a state of chronic stress among many individuals. Chronic stress has detrimental physiological consequences leading to higher rates of high blood pressure, obesity, diabetes, and a cascade of related chronic diseases such as heart disease, kidney failure and stroke. This is not primarily the result of bad, stupid or lazy people; it is the failure to recognize how social policy and its consequences are inextricably bound to health consequences. Disease and death are not randomly distributed in populations, to a large extent, the distribution is socially patterned and consequently, predictable.
This study is a harbinger of things to come. It is foreseeable that life expectancy will continue to decline in these communities until a concerted effort is made to systematically identify and strengthen the core social determinants of health that plague these communities. We need not feel that these are insoluble problems. Focused efforts and policies directed to improving the social consequences of poverty will serve to decouple the tight linkage that presently exists in America between being poor and having poor health. We are smarter than this; we can do better as a Nation if well-intentioned people come together and work on constructive solutions.
