Bez’s Blog #13: Population Health and Political Updates

The new year brings new information and a new perspective on planetary health. We ended last year looking at adverse childhood experiences. This blog will begin with the latest vital signs for human health on the planet and then delve into political directions to heal the situation. In October’s blog the latest health Olympics ranking for 2021 were revealed showing the U.S. had dropped to 44th among UN nations in life expectancy. I grew up in Canada as did David Zakus, how is that nation doing? It ranks 13th with a life expectancy of 82.7 years while the U.S. is 77.2. That gap of 5.5 years is huge. If the United States eradicated its two leading causes of death, heart disease & cancer, it would tie or be close to Canada in life span. Japan, the longest lived nation, is at 84.8 years. Canada is two years behind. To be fair, the United Nations does its own calculations for its annual Human Development Report using the best data available at the time of publication. The World Health Organization has its own figures and process as does the Central Intelligence Agency, a branch of the U.S. government. Then each country reports its own health outcomes. The actual values differ slightly. For example, the United States National Center for Health Statistics (NCHS) released its 2021 mortality report in December with American life expectancy of 76.4 years, 0.8 years lower than the UN figure. Increased causes of death from COVID-19 and unintentional injuries were presented. Deaths from opioid use, though not mentioned there, were the leading injury category responsible for a third of those deaths.There were American media reports of the huge life expectancy drop for the U.S. pointing out that the value was the same as in 1996, some 25 years back. They included the Washington Post, but not the New York Times, and a selection of other major outlets. Mention was also made of spending $4.2 trillion dollars on healthcare which is about half of global expenditures. Clearly medical care does not explain the American health decline.The NCHS report avoided any comparisons beyond what the outcomes were for the previous year. One of the steadfast measures of progress in the world has been the steady rise of life expectancy, with only two striking exceptions since the end of World War II.The two anomalies were the decline in high AIDS prevalent nations in Sub-Saharan Africa beginning in the 1990s and in a few countries of the former Soviet Union after its break-up in 1991. My fear is that health declines in the United States will be like what happened in Russia. Upstream reasons for Russia were the rapid increases in income and wealth inequality which is now happening in America.I have used the UN figures to be consistent over the years and tell people that this represents the United States in the best possible light. That is, the United Nations excludes non-member nations such as Taiwan and others with small populations such as Monaco and The Vatican.Understanding the determinants of health presented in Blog #4 highlighted political context and governance as the most upstream factor. Let’s explore further the political determinants of health.What is politics? Many definitions. One I like is “who speaks, who is spoken to, and for what purpose.” Another is “who has the right to tell whom what to do.” Politics is about power, who has it and how it is used. There is a tendency in the United States to avoid discussions about politics by ordinary folk. By contrast whenever I meet someone from Kerala state in India, all they ever want to talk about is politics.That one’s health depends on political choices grounded in the country in which you reside is mostly outside of people’s radar despite incontrovertible evidence. Rudolf Virchow, the founder of modern cellular pathology, reporting on the 1848 typhus epidemic in Upper Silesia said: “Medicine is a social science, and politics nothing but medicine on a grand scale.” His term medicine means public health today. The statement is often referred to as public health’s biggest idea.My way of deciding the truth about something is complex and multifactorial. Does it make sense given what I know? What do others think? Searching peer reviewed scientific studies is an important part of that process. Meet with those who believe the concept. Get to know them and form your own impressions. Present the idea to various people in different venues and gauge responses. Meet with those who disagree.The paper highlight above, a systematic review of reviews concludes: “Countries with social democratic regimes, higher public spending, and lower income inequalities have populations with better health.”One important study looked at U.S. states and life expectancy from 1958 to 2017. States with liberal political policies had significant health improvements while conservative states did not. The difference was most marked after the 1970s. Among the domains looked at were issues of abortion, education, criminal justice, gun control, labor rights, healthcare, taxation and voting. Subsequent research looking at working age mortality found similar results.The graph at the top demonstrates life expectancy trends for all U.S. states with Connecticut an example of a state with liberal political policies and Oklahoma one with conservative.Another graph (below) uses examples of the six longest lived states’ trends compared to the six with the lowest life expectancy in 2017. Clearly liberal state policies were associated with substantial gains in longevity especially after 1988 compared to those with conservative policies.The take-home message is that political choices and policies a democratic society makes determines its health. Global trends in political policies seem to be taking us towards less desirable health outcomes. Future blogs will explore this paradoxical course.

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