Poverty's impact on health

Editor's note: Healthcare providers and policy experts increasingly understand that a lot of the work of improving Americans' health has to take place outside the hospital and the physician's office, and must address the social determinants of health. Modern Healthcare reporter Andis Robeznieks recently sat down with one of the world's leading experts on the subject, Dr. Michael Marmot, director of the Institute for Health Equity at University College in London and past president of the British Medical Association, to discuss this work. Dr. Ardis Dee Hoven, president of the American Medical Association and an infectious disease specialist from Lexington, Ky., also participated in the conversation. What follows is an edited transcript:

Modern Healthcare: What did you find in the Whitehall Studies of British civil servants, and how are your findings relevant to the U.S.?

Michael Marmot: The Whitehall Studies were epidemiological studies of cardiovascular respiratory disease in employed people. The key finding was the social gradient in health. People second from the top had higher mortality, shorter lives and worse health than people above them. People third from the top had worse health than people second from the top. All the way, from top to bottom, the lower you were, the higher the mortality, the higher the morbidity and the shorter the length of life. This means that if we want to reduce inequalities in health, we have to act not only on the poor health of the poor, but on the whole of society to reduce inequalities in health.

That has led me to chair three reviews that I think are highly relevant to the U.S. I produced a report, “Fair Society, Healthy Lives,” that said what you could do practically in different domains: early child development, education, employment and living conditions, guaranteeing everybody the minimum income necessary for a healthy life, healthy and sustainable place in which to live and work and a social determinants approach to prevention. There are six areas of recommendations that would improve health and reduce avoidable inequalities in health.

MH: Can you describe how the AMA is using Dr. Marmot's research to act on improving outcomes for people with Type 2 diabetes and cardiovascular disease?

Dr. Ardis Dee Hoven: We're addressing cardiovascular disease and, in particular, hypertension around that, as well as Type 2 diabetes and looking at ways the medical community and the American Medical Association will be able to make effective changes throughout the country. What we are doing now is the beginning of relationships with physicians and other providers in the communities and the community itself, the YMCA, for example, in pre-diabetes issues and working with the Armstrong Institute at Johns Hopkins to handle hypertension in this country. The links with community services and partners are going to be very important.

MH: You've talked about how social determinants are a cause of health inequities, but we have to identify and analyze the causes of the cause. Can you tell us what you've found?

Marmot: Let's take obesity. Obesity is highly relevant to hypertension, to diabetes and to cardiovascular disease. What we find, particularly for women, is a social gradient. The lower you are in the hierarchy, whether classified by education or income or the affluence or deprivation of your neighborhood, the higher the prevalence of obesity. So we know it's totally useless to say to a patient, “You really should lose weight.” The more deprived the neighborhood, the greater the density of fast-food outlets. Fast-food outlets are a very good way to put on weight very quickly and very cheaply. So it's not enough to say to somebody lower in the hierarchy, “You should have nice fresh fruit and vegetables.” We know that's not going to be helpful to a single mom with two kids and worried about how to make ends meet. We've got to deal with the causes of the causes. That starts at the beginning of life with early child development, with education, right through the life course.

MH: Anything that the U.S. health systems or U.S. physicians can do to work on this problem?

Marmot: Absolutely. We produced a report in the U.K. that I've pushed actively to colleagues in Canada and the U.S. We talk about education and training of health professionals. We talk about looking at your patient's life circumstances, not simply seeing somebody who's got hypertension or is obese or smoking or diabetes and saying, “Here, take these pills and go away again.” It's actually looking at the patient in his or her environment. We talk about working in partnership with others on early childhood development with other organizations. We talk about the importance of advocacy. These are all things that physicians and other healthcare professionals can do. It's stepping outside their narrow environs of, “It's me and my patient,” to “There are things that are affecting my patient's life that are affecting her health and it's my responsibility to look at that broader picture.”

MH: Are there other nations where these healthcare inequities either don't exist or are greatly reduced?

Marmot: I'm not talking about healthcare inequities. I'm talking about health status inequities. That's a crucial distinction. This is not only about lack of access to healthcare. Inequities and lack of access to healthcare are indefensible. They should never exist in any civilized country and some countries have taken great steps to reduce inequities in access to healthcare. All countries have inequities in health, but to greater or lesser extent. The evidence shows there's a great deal you can do to make a difference.

MH: What are some of the things that the AMA and organized medicine are doing to make a difference in these areas?

Hoven: We're now collaborating with YMCAs and reflecting on the work that the CDC has done in the diabetes prevention program. We know there are about 100 million people who either are diabetic or are pre-diabetic. We're beginning to look at partnerships in communities where physicians begin to refer patients to YMCAs, and these programs talk about exercise, lifestyle changes including diet, and work toward weight reduction. We're going to be sure that the work the YMCA is doing is fed back into the physician's office or the clinic where the patient is getting care, so there is a continuum of care. It's not just, “Go to the Y and exercise.” It is going to be a formalized program where I as a physician can monitor my patient's progress and know exactly what is happening and what further recommendations to make. As these pilots work out, we'll begin further work in other communities.

MH: Are there any examples of such efforts going on in other countries that perhaps U.S. doctors can borrow from, or if there's anything that we're doing in the United States that other countries should perhaps be modeling?

Marmot: One developed in the U.S. is family nurse partnerships, looking at early child development. That's an excellent way to help families promote good early child development. That's not what a doctor does in his or her office. It's working in partnership with nurses who are specially trained to work with the most vulnerable families and can make a real difference.

In Britain, we developed Sure Start, which was inspired by Head Start in the U.S. We created Sure Start centers all around the country, not just for the most deprived children but for whole communities, and that's been a huge investment. We're now pushing it in lots of other countries.

MH: What are some of the barriers to advancing these efforts and what can physicians and organized medicine do to help bring them down?

Hoven: We have to talk about physician-led care teams and coordination of care, and using allied health professionals to their highest level of training and education in this country—the nurses, the physician assistants, the physical therapists, etc. We know there are about 70 million people with hypertension; 30 million have access to healthcare but still have poorly controlled hypertension. What are we doing wrong? That's what our work at the Armstrong Institute is going to teach us. What can we do in the clinical setting or with our collaborators in the community to connect the dots and get hypertension controlled and reduce it as a risk for cardiovascular disease?

MH: Are there any other examples of breakthroughs or successes that give you optimism that this work will succeed?

Marmot: I have a close colleague who is one of the conveners of the Self-Employed Women's Association in the state of Gujarat in India. You should see the poorest, most marginal women in India having their lives transformed by child-care centers, by the Self-Employed Women's Association taking to the Supreme Court of India the right of these women to sell vegetables on the street in the market, by providing healthcare, by providing insurance, by providing pensions, by negotiating loans to upgrade the slums in which they dwell. If you can take the poorest women in the world and improve their lives with no resources at all other than the goodwill and hard work and commitment of people to get organized, then you can do it anywhere.

Follow Andis Robeznieks on Twitter: @MHARobeznieks