Letter to the Editor, The American Prospect

Ezra Klein’s article “Wealth-Care Reform” (June 09) puts forward some positions that need to be questioned. Citing Michael McGinnis’s article in Health Affairs, Klein concludes that genetic predisposition accounts for 30% of a person’s health; social circumstances, 15%; environmental exposures, 5%; behavioral patterns, 40%; and shortfalls in medical care, 10%. In summary, if the genes you inherit from your parents are good, and if you eat properly, drink in moderation, do physical exercise, and do all the other things that health behavorists tell you to do, you are already in control of 70% of your health and longevity. The type of work you do, the type of place where you live, and the income you earn – among other economic and social circumstances – and the medical care you receive (or don’t receive) account for the remaining 30%.
The problem with this information, which forms the basis for the rest of Klein’s article, is that it is profoundly wrong. Klein far underestimates the impact on health and longevity of the non-behavioral and non-genetic factors. The best proof of just how erroneous this information is that a person in the top 5% of income of the U.S. population lives, on average, 15 years (yes, 15 years) longer than a person in the bottom 5% of income. And there is a gradient of mortality (and longevity) by class in the U.S. – not just a difference between the top and the bottom, but a steady gradation of difference for everyone in between. The higher your level of control over your own life, work, and place of residence, depending on class, status, and social network, the longer you are likely to live. As a matter of fact, if everyone in society had the same risk of dying at a particular age as do those at the very top, we would prevent more deaths than with any other type of intervention.
There is a close relationship between social inequalities and mortality differentials. The more unequal a society is, the higher is its mortality rate in any age group, and the worse its health indicators. The poor health indicators of the U.S. when compared with other developed societies are precisely because the U.S. is the most unequal of the developed societies. And these inequalities affect all classes, including those at the top. The top third, by income, of the U.S. population has worse health indicators than the bottom third in the U.K. (which is less unequal than the U.S.). And this gradient of health and mortality remains even when behavioral variables are standardized – that is, when comparisons are made among people of different classes and status, but with the same behaviors. These findings (from the WHO Commission on Social Determinants of Health report) have been widely cited in the world media but not much discussed in the U.S. media, and not mentioned once by the country’s top four newspapers.
Another problem with Klein’s article is its highly reductionist view of what health actually is. Health is not just the absence of disease; rather, it is the quality of life an individual enjoys. Most diseases in the developed world are now chronic, which means that the primary function of a health system is care rather than cure. And it makes a lot of difference for people with chronic conditions whether they are taken care of properly or not. The quality of health care has a huge bearing on the quality of life of people with chronic conditions (a majority of patients overall). To reduce this to a mere 10% is reductionist to an extreme.