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The following article is excerpted from A Healthy Society: How a Focus on Health Can Revive Canadian Democracy, by Dr. Ryan Meili. It has been edited for length. Leaders and Legacies is running a multi-part series based on this book.
Addressing the social determinants of health doesn’t just help those most in need; it helps everyone, regardless of social position. This is why the concept is so important: everyone benefits. This approach can be used to reach across divisions of class, race, geography, or political affiliation.
The poverty and ill health of some affect us all. Poverty is a drag on the economy. When people live in poverty they are unable to participate fully in public life and the marketplace, and are unable to contribute to the common account through taxes. They are also more likely to require health services, fall into the prison system, or require social assistance. People who do not have decent housing or access to education are less able to participate in the economy as customers, workers, or innovators. As their health suffers, the costs are borne by taxpayers. Our jails are not filled with hardened criminals (at least not when they go in); the vast majority of crimes against property and people stem from poverty. Our safety, prosperity, and satisfaction with society are decreased by gross inequality.
In The Spirit Level: Why More Equal Societies Almost Always Do Better, epidemiologists Richard Wilkinson and Kate Pickett present compelling evidence that the degree to which resources are unequally distributed has a significant impact on the health of everyone. Countries that are more equal, such as Japan or the Scandinavian nations, have much better health outcomes overall than less equal countries such as the United States or Britain. While the ill effects of inequality are greater for those at the bottom of the social ladder, the impact is not limited to the poorest few. Health outcomes follow a gradient of wealth: people with low income have worse health than the middle class, whose health is not as good as that of higher-earning professionals, and so on up the social and economic ladder.
But even the wealthiest people in an unequal society are less healthy than they would be in a more equal society. Whether it is the stress of constant competition and jockeying for position, the threat of personal ruin, or the burden of a large, marginalized population on public services and the social fabric, there is something about the experience of living in a society with a vast gap between rich and poor that damages everyone’s health, resulting in more mental and physical illness, shorter life spans, greater levels of obesity, and higher infant mortality for everyone. Less equal societies suffer more of the social problems that lead to negative health effects, experiencing higher levels of violence, imprisonment, illiteracy, and teen pregnancy.
Life in a more egalitarian country, on the other hand, benefits the health of everyone, from the least advantaged to the most successful. The editors of the British Medical Journal grasped the significance of these findings: “The big idea is that what matters in determining mortality and health in a society is less the overall wealth of that society and more how evenly that wealth is distributed. The more equally wealth is distributed the better the health of that society.”
Any serious attempt to address health disparities must therefore involve a plan to address not just poverty, but wealth disparity as well. This is not an easy idea to sell, especially not in countries that have a strong systemic commitment to inequality. One need only recall the “Joe the Plumber” incident during the 2008 US presidential election, in which the mere suggestion of spreading the wealth of society more equally caused a huge uproar. This shows the degree of influence held by those interested in maintaining the current level of inequality. But if the cause of ill health is, as the Closing the Gap report asserts, the inequitable distribution of power, money, and resources, then any serious attempt to address health inequities must involve a plan to distribute resources more fairly.
When hearing stories of people living in poverty, the response is often that they are poor because of their own bad choices. People who succeed in life are those with the drive, determination, and skills to get ahead; they are people who make wise decisions.
To choose well, one needs to have had the chance — through good role models, through childhood development, through access to the basic necessities of life — to have developed some real wisdom. While there’s no way to make a system that can force people to make wise choices, we can work toward one where more people have the opportunity to do so. By making the social determinants of health a primary driver of public policy, we can develop a society where more people have the chance to succeed and to live better lives as a result.
Providing everyone the opportunity to improve their lives, to escape poverty and experience the fullness of health, is not just the right thing to do, but also the smart thing to do. It is a delightful coincidence that our future wellbeing depends not on our selfishness but our generosity, our sense of justice. The growing gap between rich and poor impoverishes us all, diminishing the quality of life for rich and poor alike.
The dream of a truly healthy society offers us a shared goal with the power to reach across the differences that separate us. It allows us to connect with our neighbours in recognition of our common vulnerability and our common desire to live full and healthy lives. By systematically addressing the determinants of health, and continually measuring our success, we can do both what is right and what is smart. We can chart a path of meaningful progress. We can improve the health of people and of the political system at the same time.
– Dr. Ryan Meili is a family doctor at the West Side Community Clinic in Saskatoon and head of the Division of Social Accountability at the College of Medicine at the University of Saskatchewan.
Next: Leaping Across the Divide