The Occupy movement began almost three months ago in New York City and now seems to be everywhere. The rallying outcry from Occupy has been “We are the 99%” but many are still confused by the movement and aren’t sure what it’s about. At its heart, the Occupy movement is a collective outcry against the increasing power of corporations in our society. Recent Supreme Court decisions like Citizens United v. Federal Election Commission which blocked a ban on corporate political spending have only increased the power of corporations in our political process while diminishing our own voices… to the point where politicians seem to think that corporations are people, too.
With every political debate and decision whether it has to do with bailouts, food, commerce, business regulations, or the environment, the not so invisible hand of corporations guides politicians and policy with an iron fist. It’s become increasingly obvious that we no longer live in a democracy when corporations (owned by the few) wield power and influence over our elected officials and govern every aspect of our society, our lives, and diminish our voices as citizens. But what does this or the Occupy movement have to do with healthcare?
Unfortunately, healthcare is not immune to the influence of corporations. The Affordable Care Act is a herculean achievement but is it really the solution we would have constructed if there were no corporate influence on the legislative process? Is this what we would have hoped for?
As physicians we strive for evidence based medicine and yet function in a society where evidence based politics is untenable because of the power of corporations and the reification of market forces. According to a report by the United Health Foundation entitled America’s Health Rankings, the annual improvement in America’s health has declined by 69% compared t o 20 years ago. As Americans we spend more than any other country on healthcare (~15% of GDP) and yet we still rank at the bottom of industrialized countries in terms of infant mortality and life expectancy. In fact, life expectancy in more than 1,400 US counties has fallen even further behind other developing nations than they were seven years ago. While technology and the quality and sophistication of health care are improving, disparities in health care are increasing particularly for ethnic minorities and low-income populations (Agency for Healthcare Research and Quality, 2010 National Healthcare Quality Report; Agency for Healthcare Research and Quality National Healthcare Disparities Report).
The reasons behind this are myriad but the social and economic disparities in our society coupled with the lack of a nationalized healthcare system result in hundreds of thousands of deaths each year. While we spend billions of dollars on healthcare, biomedical research, counseling and education, rarely do these interventions address the underlying structural and social determinants of health.
Thomas Frieden, the Director of the Centers for Disease Control and Prevention summarizes the factors that affect health using a pyramid model with clinical interventions and counseling and education at the very top. At the top of the pyramid are counseling and education and clinical interventions which are the primary focus of most “health interventions.” Meanwhile, at the base of the pyramid, with potential for the largest impact are socioeconomic factors or the social and structural determinants of health which receive little attention. A multitude of factors contribute to these social and structural determinants including income inequality, poverty, housing, racism, and inadequate investment in education. Investment in these factors is often limited and particularly vulnerable to budget cuts during a recession… Yet ironically, these are the very investments that have the highest social and economic returns in society.
Economists have been writing about the alarming increase in income inequality for many years now. The Occupy movement is simply trying to bring attention to this reality. The following graph starkly illustrates the chasm and the increasing concentration of wealth among the “1%” in the United States in the past 30 years.
While the wealth of the 1% has increased astronomically, poverty has also steadily increased and according to the US Census Bureau was at rate of 15.1% of households in 2010 (that’s 46 million people). Between 2004 and 2007, more than 31% of US households had at least one spell of poverty lasting two or more months. As the White Hall study showed almost 25 years ago, health does not trickle down.
As physicians, we bear witness to the ripple effect that poverty, income inequality, and lack of education have on the health and lives of our patients. According to a recent study published in the American Journal of Public Health, in the year 2000 alone, almost a quarter of a million people died in the US because of low levels of education, more than 130,000 died due to poverty, 176,000 due to racial segregation, 119,000 to income inequality and 162,000 to low social support. How many of us as physicians have struggled to care for patients whose medical problems were enmeshed in social problems that our biomedical training didn’t equip us to address? Isn’t it time we also join the outcry against the inequality that makes our patients ill?
Unfortunately, the root causes of illness among our patients will not be fixed simply by increasing access to health care. Nevertheless, these deaths are preventable. We need to hold our elected leaders accountable to us and to our patients. It’s our responsibility to advocate for increased access to healthcare for our patients when they need it but to also help build a society where our patients can lead healthy lives so that they don’t need it. It’s time that we as physicians become more vocal about our individual or collective support for the Occupy movement and what it stands for. At the end of the day, we are the doctors not just for a 1% or the 99% but for everyone. Our oath makes us responsible for the health and wellbeing of all people not corporations.