Survival of the Richest WRITTEN BY John Easton ART BY Allen Carroll PRINT-FRIENDLY VERSION

Looking at how social factors affect human health offers proof of conventional wisdom—and some more surprising insights into disease and prevention.

“Them that’s got shall get,” goes the old Billie Holiday song, challenging the accepted notion of the United States as an exceptionally mobile society. “Them that’s not,” the lyrics continue, “shall lose. So the Bible”—plus, it appears, mountains of demographic data—“said, and it still is news.” Also still news is a growing recognition of the connections between “getting” and “losing” and health and disease and the relentless discovery of ways in which deprivation, of any sort, can impair well-being.

Extreme poverty has long been associated with reduced lifespan, but now studies are revealing that not just the very poor—the malnourished or the homeless—but people in each socioeconomic category have worse health than those a notch above them. Similar links between resources and risk have been found in every modern industrial society, human societies throughout history, and even among nonhuman primates and other social animals.

Many of these ideas can be traced to a few pioneers, among them Alvin R. Tarlov, MD’56. Three decades ago Tarlov—chair of Chicago’s department of medicine from 1968 to 1985 and now executive director of the Texas Program for Society and Health, a consortium based at Rice University—began to study how health is affected by social factors.

Such study of social determinants has been slow to take off, however, because the topic is inherently so wide ranging. Doctors don’t often chat with economists, who seldom work with sociologists, who rarely seek out lawyers. So Tarlov protégé Mark Siegler, MD’67, a physician with a penchant for ethics, and his Chicago colleague Richard Epstein, a lawyer with a taste for economics, pulled together a conference this past November at the Law School—“Social Determinants of Health and Disease: Recognizing the Contributions of Dr. Alvin R. Tarlov.”

Practitioners of the social-determinants approach vary widely but agree that those concerned with public health should no longer focus simply on biology, on germs and genes, but should shift more attention to such variables as financial resources and social status, cognitive skills and educational background, racial attitudes and ethnic practices, personal behavior and lifestyle, even a person’s neighborhood and friends.

A key factor in the growth of modern industrialized societies is also a fundamental component of good health: “physiological capital,” or the accumulation of health resources. In 1750, noted Robert W. Fogel, a Chicago Nobel laureate who applies the tools of economics to historical problems, one-fifth of the English population was kept out of the labor force because of poor health, largely chronic malnutrition. These down-and-outs were smaller, frailer, sicker, and died younger than working people. Since about 1800, however, increased access to food has meant a dramatic improvement in public health—from 1750 to 1975 the average Englishman’s body size increased by nearly 50 percent—and a more capable workforce.

Particularly important were the improved well-being and nutrition of pregnant women. Well-fed moms gave birth to bigger, healthier children. This initial investment, Fogel explained, “reduced the rate of depreciation,” meaning that newborns who acquired more health resources early in life could fight off the diseases of old age longer. The result was a kind of “biological but not genetic evolution,” survival not quite of the fattest but of those with a sufficient nest egg of calories.

One good measure of this progress is the decline in infant mortality. In 1800 some 17 percent of English children died in infancy and a whopping 79 percent of the children born to poor mothers weighed less than five pounds. Today England’s infant mortality has fallen to less than 1 percent, and fewer than 8 percent of newborns weigh under five pounds.

While some may explain these health-status improvements by citing better medical care, Fogel attributed them to better nutrition and an improved environment. Physician intervention could “slow the rate of depreciation of physiological capital,” he admitted, but the real gains in public health came from better diets, access to clean water, and better sanitation, which have delayed the onset of the chronic diseases of aging by five to ten years. As for exact figures on the salutary role of the environment versus health care, Fogel was “in the middle of applying for a grant” to determine precisely that.

Yet it isn’t only the impoverished whose health is affected by socioeconomic status. While Fogel has focused on the English poor, Sir Michael Marmot, director of the Whitehall I and II studies of civil servants, researches the British middle class. These long-term studies—the first, which began in 1967 and followed participants for 25 years, and Whitehall II, which began in 1985 and is still under way—have shown, said Marmot, head of epidemiology and public health at University College, London, that the social gradient in health extends from the bottom to the top of society. Among civil servants, “none of whom is poor,” the first study found that the least well off had mortality rates nearly eight times as high as the wealthiest. More important, there was a significant gap between each step in the hierarchy. In other words, “The problem is not confined to the high risk at the bottom.”

Nor is the problem purely economic. In the United States, Marmot added, 77 percent of whites live to at least age 65, but only 61 percent of blacks live that long. Even more revealing, 65 percent of poor whites live to 65 but only 30 percent of poor blacks do.

What causes such discrepancies? Is it access to health care? No, Marmot said. Is it genetics—do better genes lead to better health and higher socioeconomic status? No. Is it primarily income, which is closely tied to education? Again, no, Marmot answered. On an international scale U.S. blacks are far from poor, yet their life expectancy is comparable to the residents of Kazakhstan, where income is measured in goats. More significant than actual income is relative deprivation—where one lies in the local hierarchy, a notion that applies not simply to finances but also to power and independence at work, levels of social participation, education, and early life experiences, all of which can influence behaviors, such as smoking and drinking, that have a health impact. “Control over life,” he said, “and opportunities to participate fully in society are powerful determinants of health.”

Yet despair, emphasized Marmot, “is not warranted. Health for everyone can improve.” Lifespan and well-being for all social classes rose dramatically during the 20th century, and the “gap between rich and poor, between top and bottom, can change. The slope of the social gradient in mortality is not fixed.”

Where you find yourself in the social hierarchy may not be as important as who’s there with you. Arguing for the need to integrate sexuality into considerations of social factors affecting health and medicine was Chicago sociologist Edward O. Laumann, the world’s authority on sexual practices. His large-scale surveys of sexual behavior in the United States, and more recently around the world, have found high rates of sexual dysfunction in all 32 countries studied, with about 40 percent of women and 30 percent of men acknowledging sexual problems. “Is that a medical problem?” he asked. “Or is it inherent in the nature of sexual expression? Are there too many other things vying for our attention?”

In contrast sexually transmitted diseases are a crucial part of human health status and can only be understood in a sociocultural context. At first glance, Laumann said, it appears that STDs, like many health problems, are concentrated among the disadvantaged, with the highest documented rates found among inner-city African Americans. But that could be a function of reporting: the poor go to public clinics that notify the authorities, while the wealthy choose private physicians who are more discreet.

Indeed, Laumann’s recent research in China found just the opposite. The sexual revolution that swept the United States in the 1960s has had different effects behind the Great Wall. More than 80 percent of Chinese women, and 60 percent of men, have had only one sexual partner. Although few poor women catch sexually transmitted diseases, 38 percent of the wealthiest Chinese women have had chlamydia. What makes this infection so elitist? It turns out that the use of prostitutes is more socially acceptable in China, but costly. So wealthy men visit commercial sex workers, then bring the disease home to their wives.

Cutting across economic lines are social isolation and loneliness, factors that Chicago psychologist John T. Cacioppo called key determinants of health. In all age groups, he has found, loneliness predicts mortality, with increased rates of cardiovascular disease, stroke, and cancer occurring in those who are socially isolated. Efforts to intervene, such as providing short-term social supports for people recovering from a heart attack, have been “mostly unsuccessful,” largely because “we don’t understand the process” that creates such isolation: “There’s no particular pathophysiology.”

Nor are there obvious differences between the lonely and the non-lonely. They look the same. Their personalities are similar. They face the same difficulties in life. But lonely people, Cacioppo’s research has found, don’t cope as well with stressful events; they tend to withdraw rather than confront problems, perhaps because they have fewer opportunities to share their successes and frustrations or conspire with colleagues. Hit harder by stress, as they age the lonely develop more peripheral resistance—a sort of vascular teeth clenching—which reduces cardiac output, increasing the demands on the heart. They also have higher levels of the hormones associated with chronic stress. And they complain about sleeping poorly, a problem confirmed by studies reporting more microawakenings among lonely sleepers. An estimated 31 million people, most 65 or older, will be living alone by the year 2020. Cacioppo urged, “We need to find ways to support these people”.

Sociologist Robert J. Sampson, who recently left the University to take a post at Harvard, pushed the scope out beyond the individual to look at the health-related effects of neighborhoods. Since the 1920s poor, inner-city neighborhoods have been known as “hot spots” for unhealthy statistics: higher rates of violent crimes, child abuse, infant mortality, suicide, and accidental injuries. Clustering people by class, race, and health, Sampson noted, “is a robust and apparently increasing occurrence.”

But Sampson and colleagues have begun to uncover factors that can improve the health of even poor city neighborhoods. The Project on Human Development in Chicago Neighborhoods is a massive effort to assess community ecologies, a process the researchers have dubbed “ecometrics.” The project team began by dividing the city into 343 neighborhood clusters, each relatively homogenous in racial or ethnic mix, socioeconomic status, population density, and family structure. Then the researchers interviewed 8,782 residents and 2,900 business, law-enforcement, educational, religious, political, and community-organization leaders. They also videotaped 28,000 “micro-community environments” (such as street blocks) looking for health risks such as garbage in the streets, public intoxication, or unsafe housing.

They found several traits linked to better community health. Most important is what sociologists call “collective efficacy”—residents’ willingness to work together to solve a neighborhood problem. How eager, the researchers asked, are community members to step in if children are skipping school and hanging out on a streetcorner, or spray-painting graffiti on buildings? It turns out that higher levels of collective efficacy are associated with lower rates of current and future violence: “Social ties create the capacity for informal social control.” Just being next to a neighborhood with high collective efficacy, Sampson said, “is one of the best predictors of lower homicide” rates.

That statistic bolsters his overarching contention that “community-level prevention that attempts to change social environments” may prove an effective complement to traditional thinking about disease and its “individual and disease-specific approach.”

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