Late last year, economists Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Science documenting the rising morbidity and mortality in mid-life white men and women in America, especially for those with a high school degree or less. They attributed this increase, a reversal of historic trends, to an epidemic of alcoholism, other drug use disorders, and suicide. Their findings are a wake up call for the US. Not only is something seriously wrong — it's getting worse.
As a community psychiatrist (that is, one who works in the community providing publicly funded care) in Pittsburgh, I was not at all shocked to read the paper and the several others that followed and found essentially the same thing. Working both in inner city black Pittsburgh and the more racially mixed Mon Valley, the primary site of Pittsburgh's once vaunted steel mills, I have seen twenty years of increasing psychiatric burden and disability with what seemed to be a marked increase in mortality — all linked to increasingly fragmented, chaotic families, extraordinary work instability, trauma, violence, and alcohol and substance use. While human services and health care were clearly in the picture in the lives of many (health care increasingly so with the Affordable Care Act), other critical institutions — steady work, solid education, high qualify day care, stable housing, organized communities – seemed to be less present, casualties of deindustrialization and neighborhood decline. With the economic collapse of 2008 and the rise of the opiate epidemic, conditions have felt like they are in free fall, with tattered individuals and the remnants of families struggling to hang on.
My day-to-day job is to do what I can to help people find ways to overcome their distress and rediscover their capacities and capabilities to find a way forward. Of course, I don't do this alone. It requires a team effort to help suffering people recover and manage their illnesses and organize the resources they need to put a life together. We have some resources to do this, such as the ACA's expansion of Medicaid in Pennsylvania. But still the observation of Julian Tudor Hart, a renowned British physician working among the miners in Wales, rings true: the people with the greatest need generally have the least access to resources. Hart called this the "Inverse Care Law."
For a long time and to this day, this has been the American approach to health care, though the ACA does a bit to address it. Given this, some Americans may assume that the recent increase in mortality among white folks reflects a lack of access to needed care.
The work of two other Brits, Thomas McKeown and Michael Marmot reveals the inadequacy of this belief. McKeown made the trenchant observation that it wasn't health care that made people healthy, but rather the conditions in which they lived. Marmot pressed this observation and, in a series of famous studies of civil servants in the British Government, found that health status was tied in a step-wise fashion with class. Poor working-class people had worse health then their middle-class colleagues who in turn were less healthy than the highly paid executives. These findings created a fire storm around the world, but some thirty years later, the idea has finally begun to find its way to the US in the form a focus on the "social determinants of health." Where people live, their income, the resources available to them, the web of social relationships they experience, all come under this rubric. Health isn't just about people's lifestyle — whether they smoke or drink — or about their access to health care. It is fundamentally about the kinds of lives people live and how they are socially structured. Health is profoundly ecological– it reflects the social habitat and physical environment people live in.
This new focus permits us to say that what's happening to the health and well-being of poor white folks is clear evidence that the life worlds and social circumstances of their lives are falling apart. Their social habitat is strained, and the strain is showing up in a looming body count.
We could do more to make it easier for people to access the resources they need beyond health care and by tapping into their capabilities and capacities to find ways to flourish. Steps in this direction include concepts like the "medical home", an expanded version of accessible team- based primary health care that focuses on people's well-being over the life course, providing preventive and clinical services, promoting health and connecting people to the resources needed for healthy living. In psychiatry, the recognition that people with psychiatric challenges have untapped capacities to recover — to find meaningful ways to live — is reshaping clinical approaches so they connect with and build on those capabilities. These innovations are all good, but they are woefully insufficient given the scale and scope of what the nation faces.
To achieve what we need to achieve, our society needs to move the conversation about health and well-being upstream, away from a focus on health care alone, and link health and health care with general social policy. The moves towards "the social determinants and processes of health," "health in all policy," "population health," and "health impact assessments," backed by a politics of social inclusion, are the ways forward to achieve health and social equity.
The country we create determines the patterns of life and death of the people who live here. It's not a job just for doctors and other health care providers. We are all stewards of the health of the people of this country. Increasing numbers of people won't thrive and will die young until we fully embrace this responsibility.
Kenneth S. Thompson MD is a public service community psychiatrist in Pittsburgh whose career has been focused on improving psychiatric care and achieving health equity.
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