Defining Public Health

"We are all responsible for all."

-Fyodor Dostoyevsky

Overview

What is the true measure of success for a society? What is it that makes us happy, healthy, stable and in balance with the world around us? Is not our success really our ability to understand and adapt to the realities of our world for the best outcome possible for any given circumstance? What if we were to find that the very nature of our social system was actually reducing our quality of life in the long term? As will be argued in this essay, modern social structures, values and practices have deviated away from, or are largely ignorant of, what true societal health means. What our social institutions today give priority to or discount by design, coupled with the goals and motivations associated with personal “success”, which are all too often clearly “decoupled” from what true life support and advancement means, is a subject given little thoughtful consideration in the world today. In fact, most “prosperity” and “integrity” measures for the human condition are now haphazardly equated to mere economic baselines such as GDP, PPI or employment figures. Sadly, these measures tell us virtually nothing about true human wellbeing and prosperity.

The term public health is a medical classification, essentially defined as: “the approach to medicine that is concerned with the health of the community as a whole.” While often narrowly used in relationship to transmittable disease and broad social conditions, the context here will extend into all aspects of our lives, including not only physiological health but mental health as well. If the value of a social system is measured by the health of its citizenry over time, assessing and comparing conditions and consequences through simple trend analysis and factor accounting should give insight into what can be changed or improved on the social level.

The central context here is how the social condition itself - the socioeconomic system - is affecting human health on the whole. In the words of physician Rudolph Virchow: “Medicine is a social science and politics nothing but medicine on a large scale.” Virchow recognized that any public health issue is invariably related to society as a whole. Its structure, characteristics and value reinforcements have a profound influence on the health and behavior of a society and arguments regarding the merit of new social ideas inevitably come down to a rational assessment of quality through comparison.

Since each respective component of public health has its own characteristics and causality, we can also work to consider alternative approaches to a given problem resolution or improvement that might not be currently in practice, but clearly should be. An analysis of current public health components to understand what is happening over time and in different circumstances, coupled with a per case evaluation of each issue with an inferential consideration of what could “fix” or “improve” these results on the largest possible scale, is the basis of the train of thought expressed here.

It is the conviction of TZM that the existing social model is a cause of “social pathology”, with a perpetuation of imbalance that is unnecessarily generating both physiological and psychological disorders across the population, not to mention systemically limiting human potential and problem resolution in many ways. Of course, this context also naturally extends into environmental health, meaning the state of the planet, as such ecological problems/pressures/alleviations always have an effect on our public health in the long-term. However, that will not be a focus in this essay.

This analysis will separate the subject of public health into two general categories - physiological and psychological - with each category broken into categorizes that represent dominant problems seen in a relevant percentage of the overall population. However, let it be well understood that physiological and psychological outcomes rarely, if ever, have singular causes. There is a bio-psycho-social relationship to virtually all human phenomena, illuminating, once again, the multi-level symbiosis characteristic of the human being. In other words, while the problem being focused on might be considered “physiological” on the surface, the underlying cause of that outcome might very well be “psychological” or “sociological”, for example.

The Economic Factor

As noted, the main thesis of this essay is to show the deep effect our global socioeconomic system has on public health, with a specific focus on the power of poverty, stress and inequality. If one was to take a quick glance at the major causes of death globally, as put forward by the World Health Organization, clear differences based on the economic state of a region, such as the fact that cancers are more common in high income societies while diarrhoeal diseases are more common in low income societies, gives insight as to how the broad context of socioeconomic position can affect public health.

Mahatma Gandhi once said “Poverty is the worst form of violence.” His context relates to the unnecessary deaths caused by poverty in the sense of the broad limitations such severe financial restrictions have on health. This idea was later encompassed in the term structural violence, defined by Dr. James Gilligan as “...the increased rates of death and disability suffered by those who occupy the bottom rungs of society.” He differentiates structural violence

from behavioral violence, where the former “operates continuously rather than sporadically”.

Please note that the term “violence” in this context is not limited to the usual classification of physical harm, such as person-to-person combat or abuse. The context extends to include the often unseen social oppression that, through the chain of causality characteristics inherent to our social system, leads to the unnecessary harm of people, both physical, psychological or both. Examples of this can range from obvious to complex in the chain of cause and effect.

A simple “macro” example would be the prevalence of diarrhoeal diseases in poverty-stricken societies. These diseases kill about 1.5 million children each year. It is completely preventable and treatable and while the infection itself is spread through contaminated food and drinking-water, or from person-to-person as a result of poor hygiene, its very preventability and rarity in first world nations by comparison shows that the real cause is now not the disease itself, but the poverty condition that enables it to flourish. However, the causality doesn’t stop there. We then need to ask the question: “what is causing the poverty?”

A more abstract “micro” example would be human development problems when adverse pressures in family or community structures occur. Imagine a single mother who, due to the financial need to raise her child, must work for income a great deal in order to make ends meet, limiting her availability for the child personally. The pressures not only reduce needed support and guidance for the child's development, she also develops tendencies for depression and anxiety due to the ongoing stress of debt, bills and the like, and frustration-driven abuse begins to materialize in the family. This then causes severe emotional loss in the child and the development of neurotic and unhealthy mental states emerge, such as a propensity for drug addiction. Years later, still suffering from the pain felt in those early periods, the now adult child dies in a heroin overdose. Question: what caused the overdose? The heroin? The mother's influence? Or the economic circumstance the mother found herself which disallowed balance and thoughtful care of her child?

Clearly, there is no utopia for the human condition and to think we can adjust the socioeconomic system to thwart all such “structurally” related issues, macro and micro, 100% of the time, is absurd. However, what is possible is a dramatic improvement of such public health problems by shifting the nature of the socioeconomic condition in the most strategic manner we can. As we proceed with the per case analysis of major mental and physical disorders in the world, it will be found that the true imperative for public health improvement rests almost entirely on this socioeconomic premise of causality.

According to Gernot Kohler and Norman Alcock in their 1976 work An Empirical Table of Structural Violence, a dramatic 18 million deaths were found to occur each year due to structural violence and that study was over 30 years ago. Since that time the global gap between rich and poor has more than doubled, suggesting now that the death toll is even much higher today. In effect, structural violence is the most deadly killer on the planet. The following chart shows rates of death of a specific demographic, revealing the more broad correlation of low-income and increased mortality.

(Above) G. D. Smith, J. D. Neaton, D. Wentworth, R. Stamler and J. Stamler, ‘Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: I. White men’, American Journal of Public Health (1996) 86 (4): 486-96.

Physiological Health

The core physiological problems of the human population today include major mortality producing epidemics such as cancer, heart disease, stroke, etc. Relatively minor problems that not only reduce quality of life, but also often precede those major illnesses include high blood pressure, obesity and other issues that, while less critical by comparison, are still usually a part of the process that can lead to major illnesses and death over time.

Again, it is important to remember that the causality of these “physical” diseases is not strictly “physical” in the narrow sense of the word as modern study has found deep psychosocial stress relationships to seemingly detached physiological issues. According to the World Health Organization, the most common shared major causes of death in low, middle and high-income countries are heart disease, lower respiratory infections, stroke and cancer. While each of these illnesses (and many more) can be found related to the causal points that follow, for simplicities sake heart disease will be a focus here.

Case Study: Heart Disease

While the treatment of heart disease has led to a recent mild global decline in heart attacks and deaths overall, the diagnosis of heart disease has not subsided and by some regional studies is on the rise, or on pace to increasing substantially. Coronary heart disease is still considered by the WHO as the “leading cause of death” globally and it has been found that while there are genetic factors in play, 90% of those dying “have risk factors influenced by lifestyle” and overall the disease is widely considered preventable if lifestyle adjustments are made.

In short, well established relationships to high fat diets, smoking, alcohol, obesity, high cholesterol, diabetes and other risk factors allow us to extend the causality of heart disease and when we follow the influences, the most profound broad influence found has to do not only with absolute income, but relative socioeconomic status.

The WHO makes it generally clear that on the global scale, lower socioeconomic status breeds more heart disease and naturally more of the risk factors that lead to it. This, on one side, depicts a direct economic relationship to the occurrence of disease. There is no evidence to show that genetic differences between regional groups could be responsible for these variations and it is obvious to see how a lack of purchasing power leads people into lifestyles that include many such risk factors.

A 2009 study in the American Journal of Epidemiology called “Life-Course Socioeconomic Position and Incidence of Coronary Heart Disease” found that the longer a person remains in poverty, the more likely he or she is to develop heart disease. People who were economically disadvantaged throughout life were more likely to smoke, be obese, and have poor diets and the like. In an earlier study by epidemiologist Dr. Ralph R. Frerichs, focusing specifically on the socioeconomic divide in the city of Los Angeles, CA, found that the death rate from heart disease was 40 percent higher for poor men over all than for wealthier ones. Given our original thesis to consider a link from the social system itself to the prevalence of disease and their associated risk factors, we need to consider the direct relationship of stress & purchasing power. Beginning with the latter, which is more simple, clearly poor health habits occur in lower income environments due to the lack of funds for better nutrition, medical attention and education. For example, many of the high fat, high sodium risk factor foods leading to heart disease tend to be the most inexpensive food found in stores.

It is worth noting that our socioeconomic model produces goods based upon the purchasing power of targeted demographics. The decision to produce poor quality food goods is made for the interest of profit and since the vast majority of the planet is relatively poor, it is no surprise that in order to meet that market, quality must be reduced to allow for competitive buying.

In other words, there is a market for each social class and naturally the lower the class, the lower the quality. This reality is an example of a direct social system link to causality for heart disease. While education about the difference between quality food products could help the decision process of a poor person to eat better, the financial restrictions inherent to their condition could easily make that decision difficult if not impossible as, again, such goods are more expensive on average. In an age where food production and human nutrition is a well understood scientific phenomenon as far as what works and what doesn’t - what is healthy and what isn't on the whole - we have to wonder why the abundance of deliberately unhealthy foods and detrimental industrial methods exist at all. The reasoning is that human health is not the pursuit of industrial food production and never has been due to the isolated interest to generate income. More on this incentive disorder inherent to the market economy in later essays.

The Stress Factor

Let's now consider the role of stress. Stress has more of an effect on heart disease than previously thought and this isn't just referring to the statistical fact that lower income peoples tend to have a propensity to cope by smoking and/or drinking, manifesting high blood pressure and hence disregard their bodies and well-being due to the ongoing struggle for income and survival. While those factors are clearly evident and, again, found tied to the inevitable stratification found in the market economy, the most detrimental form of stress comes in the form of psychosocial stress, meaning stress related to one's psychological connection with the social environment.

Professor Michael Marmot of the Department of Epidemiology and Public Health at the University College of London directed two important studies relating social status to health. Using the British civil service system as the subject group, they found that the gradient of health quality in industrialized societies is not simply just a matter of poor health for the financially disadvantaged and good health for everyone else. They found that there was also a social distribution of disease as you went from the top of the socioeconomic ladder, to the bottom and the types of diseases people would get would change on average.

For example the lowest rungs of the hierarchy had a fourfold increase of heart disease based mortality, compared to the highest rungs. Even in a country with universal health care, the worse a person's financial status and position in the hierarchy, the worse their health is going to be on average. The reason is essentially psychological as it has been found that the more stratified a given society, the worse public health is in general, specifically for the lower classes.

This pattern has been corroborated by many other studies over the years, including a deep collection of research organized by Richard Wilkinson and Kate Pickett. In their work, The Spirit Level – Why Equality is Better for Everyone, they source hundreds of epidemiological studies on the issue, outlining how more unequal societies perpetuate a vast array of public health problems, both physiological and psychological. Heart disease aside, some cancers, chronic lung disease, gastrointestinal disease, back pain, obesity, high blood pressure, low life expectancy and many other problems are also now found to be linked to socioeconomic status in the broad view, not just singular risk factors. There is a social gradient in health quality across society and where we are placed in relation to other people has a powerful psychosocial effect. Those above us have better health on average while those below us have worse health on average.

In fact, a statistical comparison of public health between countries with high levels of income inequality (such as the United States) and those with lower levels of income inequality (such as Japan) reveals these truths quite obviously. However, such generally deemed “physical” illnesses are only part of the public health crisis generated by inequality that, again, is yet a consequence unto itself originating out of the direct, immutable stratification inherent to our global social system.

Psychological Health

Perhaps more profound in its public health implication is the result of social inequality on our mental or psychological health. This extends into behavioral reactions and tendencies such as acts of violence or abuse, along with emotional issues like depression, anxiety and personality disorders.

A general trend assessment of depression and anxiety in developed countries, countries that many intuitively would think would have more joy and ease due to the material wealth available, reveals a much different reality., A British study examining depression among people in their 20s found that it was twice as common in 1970 than it was in 1958. An American study of about 63,700 college students found that five times as many young adults are dealing with higher levels of anxiety than in the late 1930s. A 2011 study presented at the American Psychological Association showed that mental illness was more common among college students than it was a decade ago.

Psychologist Jean Twenge of San Diego University located 269 related studies measuring anxiety in the United States sourced between 1952 and 1993 and the aggregate assessment shows a dramatically clear trend in the rise of anxiety over this period, with, for example, the conclusion that by the late 1980s theaverage American child was more anxious than child psychiatric patients in the 1950s.

A 2011 NCHS report revealed that the rate of antidepressant use in America among teens and adults (people ages 12 and older) increased by almost 400% between 1988–1994 and 2005–2008. Antidepressants were the third most common prescription medication taken by Americans in 2005–2008.

While a genetic component for depression may have relevance, the trend rate clearly shows an environmental causality as the driving force. In the words of Richard Wilkinson: “[A]lthough people with mental illness sometimes have changes in the levels of certain chemicals in the brain, nobody has shown that these are causes of depression, rather than changes caused by depression...although some genetic vulnerability may underlie some mental illness, this can't by itself explain the huge rises in illness in recent decades - our genes can not change that fast.“

It appears our relative social status has a profound effect on our mental wellbeing and this tendency can also be found in what could be declared as the evolutionary psychology of similar primates as well. A 2002 study performed with macaque monkeys found that those who were subordinate/lower in a given social hierarchy had less dopamine activity than the dominant ones and this relationship would change as different sets were regrouped. In other words, it had nothing to do with their specific biology – only the social arrangement that reduced or elevated their dopamine levels. It also found that lower hierarchy monkeys would use more cocaine to compensate. This is revealing as low dopamine levels in primates (including humans) are found to have a direct correlation to depression.

The pattern has become very clear and while direct stressors such as job security, debt and other largely economic factors inherent to the social system may play a major role, the relevance of socioeconomic status itself is still dominant. The following chart is a comparison of overall mental health and drug use by country. It includes nine countries, sourcing data from WHO surveys, including anxiety disorders, mood disorders, impulsive disorders, addictions and others. One can clearly see that the United States, which also has the highest level of inequality, has an enormous level of mental health and drug disorders as well in comparison to the less stratified countries, with Italy being the lowest in mental health disorders of the group.

Even perceived social status, such as the caste relationships found in countries like India, can have a profound effect on confidence and behavior. A study performed in 2004 compared the problem-solving abilities of high caste Indian boys against those of low caste Indian boys. The results demonstrated that when caste was not publicly announced before the problem solving began, both sets of boys achieved similar results. The second round, before which the caste of each group was publicly announced, the lower caste group fared much worse, and the higher caste much better, producing very divergent data compared with the first round. People are greatly influenced by their perceived status in their society and often when we expect to be viewed as inferior, very often we perform as such.

In conclusion to this subsection regarding the psychosocial, inequality-based phenomenon that shows a clear relationship to psychological wellbeing, it is important to quickly make clear the vast range of issues found related. When it comes to education, social capital (trust), obesity, life expectancy, teen birth, imprisonment and punishment, social mobility, opportunity, and even innovation – countries with less income inequality do better than those with more income inequality. Put another way, they are more healthy societies.

Case Study: Behavioral Violence

Coupled with the above issues relating to inequality in society, there is one that deserves a deeper look: behavioral violence. Criminal psychologist Dr. James Gilligan, former head of the Center for the Study of Violence at Harvard Medical School, wrote a definitive treatment on the subject in his work Violence: Our Deadly Epidemic and its Causes. Dr. Gilligan makes it very clear that extreme forms of violence are not random or genetically induced, but rather complex reactions that originate from stressful experiences, both in the long and short term.

For example, child abuse, both physical and emotional, along with increasingly difficult levels of personal stress, have a direct correlation to both premeditated and impulsive acts of violence and while men have a statistically higher propensity towards violence due to largely endocrinological characteristics that, while not causing violent reactions, can exaggerate them upon the stress influence, the common theme is the influence of the environment and culture.

This is not to discount the relationship of hormones or even possibly genetic propensities, but to show that at the origin of this behavior is clearly not our biology, but the condition upon which a human exists and the experiences endured. Other common assumptions of causality, such as “instinct” are also far too abstract and vague to hold any operational validity.

Dr. Gilligan states: “I am suggesting that the only way to explain the causes of violence, so that we can learn how to prevent it, is to approach violence as a problem in public health and preventive medicine, and to think of violence as a symptom of life-threatening pathology, which, like all form of illness, has an etiology or cause, a pathogen.”

In Dr. Gilligan's diagnosis he makes it very clear that the greatest cause of violent behavior is social inequality, highlighting the influence ofshame and humiliation as an emotional characteristic of those who engage in violence. Thomas Scheff, a emeritus professor of sociology in California stated that “shame was the social emotion”. Shame and humiliation can be equated with the feelings of stupidity, inadequacy, embarrassment, foolishness, feeling exposed, insecurity and the like – all largely social or comparative in their origin.

Needless to say, in a global society with not only growing income disparity but inevitably “self-worth” disparity - since status is touted as directly related to our “success” in our jobs, bank account levels and the like - it is no mystery that feelings of inferiority, shame and humiliation are staples of the culture today. The consequence of those feelings have very serious implications for public health, as noted before, including the epidemic of the behavioral violence we now see today in its various complex forms. Terrorism, local school and church shootings, along with other extreme acts that simply did not exist before in the abstractions they find context today, reveals a unique evolution of violence itself. Dr. Gilligan concludes: “If we wish to prevent violence, then, our agenda is political and economic reform.”

The following chart shows rates of homicide across wealthy nations with varying states of social inequality. The United States, which is likely the largest “anti-socialist” advocate with little structural safeguards in place (such as a lack of universal health care), while also pushing the psychological ethic that “independence” and “competition” are the most important ethos - shows a massive level of violence. While debates over gun control and the like still persist in the American political landscape with respect to the epidemic, clearly that has nothing really to do with causality.

In Conclusion

This essay has attempted to give a concise overview of core causal relationships to human health on both the psychological level and the physiological level. The theme is how the socioeconomic condition in general improves or worsens public health overall, alluding to ideal conditions which would improve happiness, reduce general disease and alleviate epidemic behavioral problems, such as violence.

While direct economic relationships are very clear in how they reduce human health and wellbeing in the form of absolute deprivation, such as an inability to obtain quality food, labor-related time restraints that reduce emotional and developmental support for children, loss of education quality due to regional funding problems, along with case by case turmoil such as the fact that most marriages end due to monetary problems, the relative deprivation issue has been more of a focus here due to the fact that it is less understood and more relevant than most understand.

Put into the structural, socioeconomic context, these realities firmly challenges the ethos that competition, class and other “capitalist” notions of incentive and progress are drivers of social progress and health. The more we learn about this phenomenon, the stronger the argument becomes that the nature of our socioeconomic system is somewhat backwards in its focus and intent. Human progress, health and success are clearly not defined by the constant influx of market goods, gadgets and material creations for purchase. Public health and wellbeing are based on how we relate to each other and the environment as a whole and market induced stratification is extremely caustic to society.

The result is a hidden form of violence against the population and hence the public health issues we see are really civil & human rights issues, since they simply do not need to exist. When we see clear genocide in the world we object strongly on purely moral grounds. But what if there existed a constant genocide that is unseen but very real, perpetuated not by a specific person or group but by disorder born out of stress/effects generated by the traditional method of human interaction and economic ordering that has been created and codified?

As will be argued in the following essays, mere adjustments to the current socioeconomic system are not enough in the long-term to substantially resolve these problems. The very foundational principles of our current model are bound by hierarchical economic and competitive orientations and to truly work to remove those attributes and consequences is to completely transform the entire social system.

Source

• This essay belong to Zeitgeist Movement Defined: Realizing a New Train of Thought