Recreating Society for Better Health

US society has been doing badly. That simple judgement comes from examining health statistics. Figure 6.7 from Sandro Galea’s book, The Contagion Next Time, shows the evidence, based on Raj Chetty’s work (Figure 1).¹ The graph shows three clear features of population health, here measured as life expectancy. First, health follows the social gradient—the lower the income, the shorter the life expectancy; it is not simply the poor versus the rest. Second, the gradient got steeper between 2000 and 2014; inequalities in health increased. Third, from around 2008, there was no improvement in life expectancy—even a decline—for the poorer two income quartiles. Not shown here is that from 2014, US life expectancy declined for the next three years.

The thesis of The Contagion Next Time is that this health picture reflects the operation of deep structural forces in society. We cannot understand what happened to health simply by examining access to health care or features of human behavior. We have to go deeper. Hence my comment that the society has been doing badly.

Galea’s focus is the United States, but in recent years health in the United Kingdom has, to some extent, followed the dismal path of the United States. From 2010 on, the increase in life expectancy in the United Kingdom, which had continued for a century, slowed dramatically and just about ground to a halt. The social gradient in life expectancy grew steeper; inequalities increased. And life expectancy declined for the most deprived decile outside London.² The evidence showed clear adverse trends in what we have called the social determinants of health.³ Plausibly, and consistent with Galea’s thesis, it was political choices and the organization of society that led to this worsening health picture.

All of this was before the pandemic. An effect of COVID-19 was to expose and amplify the underlying inequalities in society. Further, the United States and the United Kingdom were among the countries with the highest excess mortality during the pandemic. Not only did both our countries show marked inequalities in who succumbed to COVID-19, but overall mortality was high. Galea’s thesis is that the United States, and I would add the United Kingdom, was vulnerable to the pandemic precisely because of marked social, economic, and racial inequalities. It may also work at another level: the kind of societies that allow such inequalities to develop do not have the social organization to handle a pandemic well. Both in the United States and the United Kingdom, the dithering incompetence, and worse, of national governments in the face of the pandemic was of tragic proportion.

One of Galea’s important themes is that the US focus on the individual is antithetical to the kind of social action necessary to improve population health and reduce inequalities. There was a time in the United States when there were important discussions between those on the political right and those on the left about where responsibility for health should lie on the spectrum from the individual to the society. Galea, perhaps harking back to such halcyon days, writes:

Politics may well be the most important foundational influence on health. Politics fundamentally shapes the distribution of the resources necessary for health. These resources include money, legal protections, the expectation of a level playing field in society, and the focus of public opinion, with its power to either alter or entrench the status quo.

It is difficult to avoid the impression that the possibility for such reasoned and necessary debate has been destroyed by intense political polarization in the United States. The megaphone employed by the former occupant of the White House, and his followers, has drowned out reasoned discussion. That said, the health problems on which Galea focuses did not begin with the presidential election of 2016. A report from the Institute of Medicine in 2013, taking note of the US high expenditure on health care, gave little ground for US self-congratulation as it documented the poor health performance of the United States compared with other high-income countries.⁴

In the same vein, Case and Deaton riveted national attention on “Deaths of Despair”—the rise in mortality among middle-aged White men and women from poisonings, suicide, and alcohol-related disease.⁵ There is a social gradient in such deaths—the fewer the years of education, the higher the mortality. Case and Deaton focus on people without a four-year college degree and show all the ways that the kind of influences that Galea discusses mean worse lives at home, at work, and in the community for these people—a complex that Case and Deaton argue leads to “despair.” Despair may influence political choices, as well as life and death. There was a correlation, geographically, between deaths of despair and voting for Donald Trump in 2016.⁶ That kind of association continues into the COVID era with vaccine reluctance higher in Trump-voting counties.

A welcome feature of The Contagion Next Time is its emphasis on values: compassion, the pursuit of social and economic justice, and understanding that health is a public good. Would politicians exercising compassion readily make the decisions that consign children to being raised in poverty? On social and economic justice, Galea quotes Martin Luther King: “We have deluded ourselves into believing the myth that capitalism grew and prospered out of the Protestant ethic of hard work and sacrifice. The fact is that capitalism was built on the exploitation of the poor—both black and white, both here and abroad.” More prosaically, it is a focus on justice that led my colleagues and me at the UCL Institute of Health Equity to label our own prescription for a post-COVID future, Build Back Fairer.⁷

Hilary Cooper and Simon Szreter, in After the Virus, conduct an historically informed inquiry into what society should look like after the pandemic.⁸ They write that the Elizabethan poor laws in England in 1601 formed the first welfare state, based on collectivist-individualism: universal provision of a social safety net and, over time, collective provision of education and other essentials that provided the conditions for individuals to flourish. That could form a credo, consistent with Galea’s argument. To create a fairer distribution of health now, and prepare for future shocks, we need the social commitment to creating the conditions in which all individuals can flourish.