Munich American Peace Committee (MAPC)
Radio Lora, 9. Oktober 2006
Alternative Radio
Stephen Bezruchka
Von der Wiege bis zum Grabe....
Der Einfluss der frühen Kindheit auf die Gesundheit des Erwachsenen
Vashon Island WA, 19. April 2005
Stephen Bezruchka lehrt an der
University of Washington und arbeitet als Notarzt in einer Klinik in
Seattle. Schwerpunkt seiner Forschungsarbeit und seiner zahlreichen
Veröffentlichungen sind die Auswirkungen sozialer
Unterschiede auf die Gesundheit der Bevölkerung.
Meine sehr geehrten Damen und Herren, sollten Sie hier hergekommen
sein, weil Sie etwas Nützliches für Ihre Gesundheit und die
ihrer Kinder erfahren möchten oder weil Sie glauben, dass Sie
diese durch Ihr Verhalten beeinflussen können, dann muß ich
Sie leider enttäuschen. Denn 50 Prozent unserer Gesundheit als
Erwachsene wurden bereits im Mutterleib oder während der ersten
Lebensjahre festgelegt oder sogar schon als unsere Großmutter mit
unserer Mutter schwanger war. Und das ist der Grund, weshalb wir eine
der kränksten reichen Nationen sind, kränker als so manches
arme Land und warum uns statt eines langen Lebens, statt Freiheit und
dem Streben nach Glück, ein kurzes Leben, die Illusion von
Freiheit und viele Krankheiten beschieden sind.
Niemand kann bestreiten, dass sich der Gesundheitszustand in dem
reichsten und mächtigsten Land der Welt im Laufe der letzten
Jahrzehnte gravierend verschlechtert hat. Wir träumen von
Fortschritt während die Kindersterblichkeit zunimmt. Die Ursache
dafür ist unser Versagen als Bürger. Wir haben unsere
Verantwortung für die Gemeinschaft an die Reichen und
Mächtigen abgegeben und damit die Kluft zwischen Arm und Reich,
die für unseren schlechten Gesundheitszustand verantwortlich ist,
vertieft. Denn je mehr einer hat, um so weniger kümmern ihn
„die das unten“ und je weniger man sich um „die da
unten“ kümmert, um so gefährdeter sind sie. Es wird
Jahrzehnte dauern, diese Mißstände zu beheben.
Der Einfluss des sozialen Status auf die Gesundheit eines Menschen ist
eine der wichtigsten medizinischen Erkenntnisse der jüngsten Zeit.
Danach korreliert das Maß wirtschaftlicher und sozialer
Sicherheit mit dem körperlichen und seelischen Wohlbefinden. Die
Menschen sind gesünder und leben länger, je weniger weit die
Schere zwischen Arm und Reich geöffnet ist.
Als ich in Standford vor 35 Jahren mein Medizinstudium begann, war ich
davon überzeugt, dass Gesundheit ausschließlich das Ergebnis
guter medizinischer Versorgung sei. Damals hatten nur 14 Länder
eine höhere Lebenserwartung als die USA.15 Jahren später
mußte ich feststellen, dass wir bereits auf Platz 22 abgerutscht
waren, und heute ist die Kindersterblichkeit die höchste unter den
reichen Ländern. Für mich ergibt sich daraus, dass die
Gesundheit einer Nation weniger mit der Qualität ihrer
medizinischen Versorgung zu tun hat, sondern von gegenseitiger
Anteilnahme und Fürsorge abhängt. Gesundsein kann kaum allein
das Ergebnis ärztlicher Ratschläge für richtiges Essen,
viel Bewegung, Nichtrauchen, Safer Sex und das Anlegen von
Sicherheitsgurten sein, wenn in Japan, dem gesündesten Land der
Welt, die Männer doppelt so viel rauchen wie in den USA. Es
muß also andere Gründe für den schlechten
Gesundheitszustand der amerikanischen Bevölkerung geben.
- 2 -
.
Bis vor kurzem wurde Gesundheit anhand der Lebenserwartung definiert,
doch inzwischen gibt es zahlreiche wissenschaftliche Belege für
den Einfluss sozialer Lebensverhältnisse auf die Gesundheit, z.B.
die Höhe des Familieneinkommens, die allgemeine
Einkommensverteilung, die Einbindung in ein soziales Netzwerk, die
politische Teilhabe, gleiche Rechte für Männer und Frauen,
Rassismus, Umwelteinflüsse, Kinderbetreuung, die Anzahl der
Gefängnisinsassen und natürlich auch der Zugang zu
medizinischer Versorgung. In einer Gesellschaft, der das Wohl des
Anderen am Herzen liegt, kann es keine großen
Einkommensunterschiede geben, keine unterschiedlichen politischen
Einflußmöglichkeiten, keine überfüllten
Gefängnisse, keine benachteiligten Frauen und keine Kinderarmut.
Natürlich wird man von Regierungsseite leugnen, dass diese
Faktoren die Ursache für unseren schlechten Gesundheitszustand
sind. Ich aber bleibe dabei: je mehr sich eine Gesellschaft um den
Einzelnen kümmert, um so gesünder ist sie und um so
höher ist die allgemeine Lebenserwartung.
Während Plato vor 3000 Jahren glaubte, dass in einer
funktionierenden Demokratie der Reichste nur viermal reicher sein
dürfe als der Ärmste, verdiente laut New York Times ein
amerikanischer Firmenchef 2004 das 531 Fache eines Arbeiters, 1980 war
es noch das 42 Fache gewesen. Im gesunden Japan verdient der Chef
lediglich 10 mal soviel wie seine Arbeiter. Und um während der
Wirtschaftskrise, Ende der 90er Jahre, Entlassungen zu verhindern,
nahmen japanische Manager sogar Gehaltskürzungen in Kauf.
Können Sie sich etwas Ähnliches in diesem Land vorstellen?
Dabei weiss man inzwischen sogar innerhalb der Bush-Regierung, dass
„gleichere Gesellschaften gesündere Gesellschaften
sind“. Vielleicht sollten unsere Gehaltszettel in Zukunft
folgende Warnung tragen: „Ihr im Vergleich zu dem Ihres Chefs
niedriges Gehalt ist schädlich für unser aller
Gesundheit“. Denn nicht nur die Armen leiden unter den
großen Einkommensunterschieden, auch „die da oben“
sind um so gesünder je kleiner die Kluft zwischen Arm und Reich
ist. Lieblosigkeit und mangelnde Solidarität machen uns alle krank.
- 3 -
Wie gesund man als Erwachsener ist, hängt davon ab, was wir im
Mutterleib und bis zu einem Alter von 4 bis 5 Jahren erlebt haben.
Jeder, der gegen medizinische Tierversuche demonstriert, sollte sich
auch über unsere globalen Armutsexperimente am Menschen aufregen.
Doch nicht alle Tierversuche sind so eindeutig übertragbar wie der
folgende: Wenn Rattenmütter, ihre Rattenbabies ablecken und
pflegen, dann werden diese wiederum ihre Nachkommen abschlecken und
pflegen, selbst wenn sie diese Fürsorge nicht von der leiblichen
Mutter, sondern von einer Ersatzmutter erfahren haben. Umgekehrt werden
nicht geleckte und nicht gepflegte Rattenkinder später auch ihre
Kleinen nicht lecken und pflegen. Hege und Pflege sind also nicht in
unseren Genen festgelegt, sondern durch die äußeren
Bedingungen einer ganz frühen Lebensphase. Dafür gibt es zwei
wissenschaftliche Belege:
1. stressbedingte Hormonausschüttungen und
2. von Stress beeinflusste Vorgänge im Gehirn.
Bei Gefahr lösen Adrenalin und Cortisol lebensrettende
Fluchtreflexe aus. Wird die Hormonausschüttung jedoch von
Verkehrsstaus, Ärger mit dem Chef und unbezahlten Rechnungen
ausgelöst, dann schafft dies bereits bei einem Ungeborenen im
Bauch einer gestressten Schwangeren die Veranlagung zu Diabetes, hohem
Blutdruck und Herzinfarkt. Das im Gehirn gebildete Hormon Oxytocin
reguliert nicht nur die Geburtswehen und den Milchfluss, sondern ist
darüber hinaus auch verantwortlich für weibliches
Fürsorgeverhalten, soziale Bindungen und
Kommunikationsfähigkeit. Hohe Oxytocinwerte verstärken
den Impuls zum Hegen und Pflegen, während hohe Cortisolwerte ein
Hinweise auf mangelnde Zuwendung sind. Je mehr Stress eine sozial
benachteiligte Schwangere ausgesetzt ist, um so weniger Chancen hat ihr
Baby, gesund auf die Welt zu kommen und gesund alt zu werden. Besonders
wichtig für die frühkindliche Entwicklung ist die Bindung an
eine Bezugsperson, fehlt sie, wird viel Cortisol ausgeschüttet,
was später zu Depressionen führen kann. Im Laufe des ersten
Lebensjahres entwickeln sich Gehör und Sprache. Je reicher die
„Sprachenwelt“ eines Kindes, um so größer seine
Ausdrucksfähigkeit als Erwachsener. Vom 2. Lebensjahr bis zum
Teenageralter bildet sich das Sozialverhalten aus, d.h., die
Fähigkeit zu spielen, sich einzufühlen, soziale Signale zu
verstehen und Kontakt aufzunehmen. Auch hier bestätigen die
Studien den großen Einfluss sozioökonomischer
Lebensbedingungen auf spätere sowohl kognitive wie emotionale
Leistungen.
In den USA steigt und steigt die Säuglingssterblichkeit, es gibt
immer mehr schwangere Teenager und arme, kranke, oft Alkohol und Drogen
abhängige Alleinerziehende, aber der Staat unternimmt nichts und
die Bürger haben ihre Seele längst an die Reichen und
Mächtigen verpfändet. Ganz anders in Schweden, dem
zweitgesündesten Land der Welt, das seine niedrige
Säuglingssterblichkeit und hohe Lebenserwartung hohen
Einkommenssteuern, bezahlten Elternzeiten und gut ausgebildeten
Kinderbetreuerinnen verdankt. Wir müssen endlich der
maßlosen Gier ein Ende bereiten und aufhören, die Reichen
immer reicher zu machen. Nur so kann unser Land und gleichzeitig auch
unser Planet wieder gesund werden. Denn Chancengleichheit und
Ökologie sind die zwei Seiten einer Medaille. Deshalb müssen
wir alle unsere ganze Kraft dafür einsetzen, unsere
Souveränität als Bürger dieses Staates wieder
zurückzugewinnen. Demokratie bedeutet mehr als nur alle 4 Jahre
zur Wahl zu gehen. Demokratie ist nicht das, was wir besitzen, sondern
das, was wir tun. Sollte uns unsere Gesundheit und die unserer Kinder
und Enkel diese Mühe nicht wert sein?
STEPHEN BEZRUCHKA
From Womb to Tomb: The Influence of Early Childhood on Adult Health
Vashon Island, WA 19 April 2005
Stephen Bezruchka is a senior lecturer at the University of Washington
and works as an emergency room physician in Seattle. His particular
areas of research are population health and societal hierarchy and its
application to health. He is author of numerous articles and essays.
His most recent contribution is to Sickness and Wealth, a collection of
essays on the effects of global corporatization on health.
Let me begin with a few assumptions. One is that you are here because
you are interested in your health and that of your children. The second
is that most of you assume that producing health in yourself or your
children is something that one does today and reaps benefits tomorrow
or the next day, or even in the coming year. I appreciate your interest
and want to challenge the second assumption, namely that we can
strongly influence our health by what we do today because that is not
consistent with what we know to be true.
At least half of what influences our health as adults is determined by
what happened to us when we were in the womb and for the first few
years of life thereafter. Our health is influenced by what happened to
our mother when she was in her mother's womb. Maternal grandmothers are
important for our health. Fathers and grandfathers have some impact,
but not as much.
It is only from considering such factors that we can come to understand
why our health, collectively as a nation, is worse than that of people
in about 25 other countries, pretty well all the other rich countries,
and a few poor ones as well. We are about as healthy as Cuba, the
country we have been strangling for over 45 years. Although we have a
country that espouses life, liberty and the pursuit of happiness, in
reality, we end up with a short life, the illusion of liberty and the
pursuit of illness.
What's wrong?
I won't say anything that is speculative in the sense that leading
scientists and our Federal Government don't say in official or
respected publications. Last Friday in the New York Times
Op-Ed page, well known economist and commentator Paul Krugman pointed
out how much our health status is poor compared to other countries.
Most of these concepts are not seriously discussed in schools, or in
the various media when health is talked about. I will tell you what I
think needs to be done for our country to regain its health standing in
comparison to other rich countries, what medicine we need to take.
I want to make two points. One is that our health, yours and mine, if
we are from the USA, the world's richest and most powerful country, has
deteriorated profoundly over the last decades, if we compare ourselves
with other rich countries, namely our health relative to them has
declined. For the first time since 1958, our infant mortality rate has
also risen. More infants are dying while we perpetuate the illusion of
progress.
The second point is that the cause of this health decline, the
diagnosis, stems from changes in our own habits, but these are not the
individual health-related habits that we all come to learn about, but
from changes in our habits as citizens, as the sovereign people of this
country. We are abdicating our responsibility as citizens to govern
ourselves and are selling this right to the rich and powerful. This
results in a bigger gap between rich and the poor which I now identify
as the root cause of our poor health. In doing this we've abrogated our
sovereign rights to decide our own future. That is now in the hands of
the rich and powerful, and our corporate elite, who look after their
own welfare very profitably, but not ours. This diagnosis is actually
hopeful because once we come to understand the cause, and the reasons
behind it, then the steps necessary to return to the road for health
become apparent. There is no quick fix. The time required for getting
ourselves healthy again will take decades at least. The reason is that
it is in the first few years of life where the medicine to make us
healthy again has to work in order that we as adults regain our health.
Three people stood alongside a river on a brisk afternoon.
All of a sudden they heard a cry for help from a person, caught in the
river's fast-moving current, trying desperately to stay above water.
One of the people along the riverbank started yelling at the drowning
victim, "What's wrong with you, don't you know how to swim?" The second
individual offered the desperate person discount coupons for swimming
lessons.
Fortunately, the third was a public health worker who jumped in the water and pulled the drowning person out.
Over time more and more people came floating down the river in need of
help. Researchers showed up and counted how many people made it part of
the way or all of the way out of the river and how many fell back in.
They also collected other kinds of information about the risk-taking
profiles of the people, their family backgrounds and educational levels.
A few progressive individuals decided to head upstream to see what was causing so many people to fall into the river.
More and more older folk, came floating down the river crying out for
help, and it was not possible to pull them all out despite everyone's
best efforts. Quite a few were lost. It became very expensive to keep
pulling victims out of the river.
Some of those who were pulled out ended up back in the river.
People soon realized that pulling casualties out of the river would
never be sufficient to reduce this problem. Too many kept falling in!
Upstream, they found younger citizens who were enticed into the river.
The group found signs that read, "Go for it," "Just do it" and "Come to
river country." Signs said the river "won't slow you down" and "It
doesn't get any better than this." All around were cleverly constructed
images that associated friends, success, sex, self-esteem, and the good
life with the edge of the river and the rushing water. As these people
looked around more they discovered that children were particularly
transfixed by all these colorful signs showing sexy men and women,
sports stars, sophisticated people and charismatic role models. They
found a few warning signs but generally the barriers to risky behaviors
and the messages about caution were over-whelmed by the almost magical
inducements promoting swimming in the dangerous waters.
2 The upstream group thought to make the environment safer to keep
people out of the river. But it was tough and they met with a lot of
resistance. The river marketers said that the irresponsible behavior of
a few bad apples, who did not know their own limitations when it comes
to swimming, should not be allowed to ruin the fun for everyone else.
The real problem, they argued, was that people were just not
responsible enough.
If each individual would just be more careful, treat the river with
more respect, and learn how to avoid the strong current or how not to
fall in, there would be no problem. The marketers argued that it was
the responsibility of the family and the individual, not government or
industry, to make sure the river was used wisely. Shouldn't families
begin instilling better morals and teach their children how to navigate
the currents in the river? They should develop better family values and
institute swimming curricula for the local schools.
A few of the group painted over the billboards that were enticing
people into the river. Others advocated for legislation requiring
warning signs and counter-ads to be erected alongside the glamorous
pictures. Still others brought attention to those who were erecting the
signs in the first place, claiming they must share responsibility for
the adverse consequences of their actions. The promoters turned to the
government, claiming that the protestors were infringing on their
freedom of speech. The public health workers countered that it is
government's role to protect those vulnerable to the messages,
particularly children.
A few others realized that there was still more territory upstream to
be explored. Certainly exploitive marketing practices, misleading
advertising, and general lack of responsibility of various corporate
interests were important, but younger people were coming down the river
in greater numbers from further upstream.
This small group headed further up to the source and found conditions
allowing large numbers of children to easily slide off the steep slope.
They plunged onto floatation devices and slid in great masses into the
river to drift downstream. The reason they slid was because of the
steepness of the slope. It was the steep slippery slope of
neo-liberalism or trickle-down economics that politicians had told them
was good for all. The slope was not the same steepness everywhere.
Where it was steeper, adults were desperately clinging to their foot
holds and trying to push off those who were below them, since they felt
that those people were destabilizing the slope. This was going on all
the way up to the top so even some of those who seemed secure higher up
toppled down into the river. Where the slope was less steep, people
felt more secure and would extend support to those above and below them
as they negotiated the hazardous terrain. But for the children, where
the adults were on the steeper slope, they easily careened into the
river to glide downstream because the adults were too concerned with
hanging on. However, where the slope was less steep, the adults played
with the children and few of them ended up in the water.
The pubic health workers at the source discovered that the problem they
wanted to address was a simple one. Namely the precipitous slope. So
they crafted a plan to take some of the material up high and put it
down lower and create a stable platform for everyone. They built a
retaining wall so that no one had to fall into the river, no matter how
much they played on the less steep slope they had rebuilt. Then slowly
vegetation began growing and the area became covered with plants that
improved the environment for everyone. Many creatures began to live
there and harmony became the norm. The adults were able to play with
their children safely, and no one ended up in the river. Ultimately,
having a less steep slope was the solution to the public health
problems.
The most significant finding in health research is that the social and
economic environment in which people live is the primary determinant of
their health. The level of economic and social support people have is
correlated with their physical and mental well-being. People are less
sick, live longer, are happier and feel better when there are smaller
gaps between the rich and poor in society. It is this upstream source
of problems that ultimately must be addressed to produce health. We
must link what is observed downstream with these upstream conditions.
To do so we need to understand the upstream-downstream connection and
to cultivate and use your voice to make these conditions visible and
meaningful.
Upstream, we the people in the USA need to change the slope of the bank
at the source to prevent people from falling in the river. Children are
especially vulnerable. We must bring down the record gap between the
rich and poor which prevents true democracy from working, causes ill
health and leads to early death. This is an unlikely prescription for a
medical doctor to offer, one who continues to practice medicine in the
emergency department. It is what we must do, at least if we follow
evidence-based guidelines.
Let me explain how I came to think about what makes a population
healthy because it is not what I was exposed to in medical school or
anywhere else for that matter. I began medical school at Stanford 35
years ago because after doing graduate work in mathematics at Harvard I
wanted to do something useful and there was no question in my mind then
that providing health care was the most important part of producing
health. When I began, there were some 14 countries that were healthier
than the United States when we compared the average number of years
lived by the people in a country.
This is called life expectancy, is routinely reported and is a good measure of health.
After working as an emergency doctor for 15 years, I discovered that
our health, yours and mine, considered as a country, had declined by
1992, compared to the health of citizens in about 21 other countries.
Yes, we were living longer than our parents, but compared to people in
the other rich countries, not that much longer. I had not expected the
decline to continue when I was in medical school, as I came to the US
from Canada seeking the best and thinking the US was number one. Now it
was clear the best was getting worse. I hadn't a clue why. The only
thing I was sure of was that medical care had little to do with health
of populations. Sure, I could tell myself I saved a life in the ER
occasionally, but most of the time I found it hard to think that
medical care had that much impact, despite the hype accorded it.
If you don't know something, you might reasonably consider going back
to school. I went to public health school, Johns Hopkins, the biggest
in the world to find out what made a population healthy. What I learned
there affirmed my belief that medical care had little to do with
health, but as to what mattered to explain our health decline, well,
they didn't ask that question.
Thomas Pynchon wrote in Gravity's Rainbow, "If they can get 3 you
asking the wrong question, the answers don't matter." I try to not let
schooling interfere with my education.
My discovery over the last thirteen years has been incredibly exciting,
profound, and challenging. Exciting because there are real answers to
this most basic of questions. Profound because they go back to basic
truths about our species and how we live.
And challenging because although what needs to be done to produce
health is so simple it is difficult to get people acting on it.
Here is what I learned. Our health in this country has declined compared to other countries, and in absolute terms.
There is no debate about this. The Institute of Medicine, a federally
funded agency that looks at health issues, in its 2003 publication,
“The Future of the Public's Health in the 21st century," on page
20 writes, "For years, the life expectancies of both men and women in
the United States have lagged behind those of their counterparts in
most other industrialized nations." At some point, we didn't lag
behind. You will find that in the late 1940s and early 50s we were one
of the healthiest countries in the world. In absolute terms last year
our National Bureau of Health Statistics reported that for the first
time since 1958, our infant mortality rate, the proportion of babies
born that die in the first year of life has gone up. Our infant
mortality rate is already the highest of all rich countries, so their
report sounds a death knoll.
The second concept, the diagnosis, is what determines health in a
population is the nature of caring and sharing relationships in that
population. I mean how well we look out for one another. Health is not
produced by how well we look after ourselves. It is not what we do to
make ourselves as individuals healthy, namely the usual do's and don'ts
that I preach to my patients all the time: eat right, exercise, don't
smoke, wear a condom, buckle your seat belt. There is nothing wrong
with following that individual advice, it isn't wrong. But that advice
is not that important when it comes to our health. Why do I say that?
Take the healthiest country in the world by any measure, Japan. Twice
as many men smoke in Japan as in the USA.
Japan smokes the most of all rich countries, yet it is the healthiest.
I'm not saying that is the reason Japan is the healthiest country
namely the men all smoke. If I made that statement, you would be wise
to discount everything else I say.
But what that observation tells me is that although smoking is bad for
you, compared to other things, it isn't that bad. There are worse
things we do for our health than smoke cigarettes.
What are those? Not caring for and sharing with each other.
I'm a scientist, I started out as a mathematician, where everything
proceeds in a logical fashion from a few axioms or basic concepts. So
you should demand proof from me for what I say. I do this in my courses
in the school of public health and community medicine at the University
of Washington. Students in their course evaluations are always amazed
at how logically the arguments proceed. Even then they find these
concepts hard to believe because they have not been brought up to think
that way.
If we define our health as a country by the average number of years
lived, the life expectancy, and if caring and sharing produces health,
how can we measure caring and sharing and relate it to health? The
science on this subject is amazingly diverse and consistent in its
findings. There are measurements of social capital, of extent of
friendships, of income distribution, of political participation, of
gender equality, of racism, of environmental quality, of child welfare,
of numbers of prisoners (we house one quarter of the world's jailbirds)
of access to medical care and many others. If we care for and share
with each other, then there won't be such a big gap in incomes, or
differences in political power, or numbers of prisoners, or women being
treated unfairly, or children living in poverty, (a UNICEF report
released last month shows our commanding lead in having the most poor
children of all rich countries.) In all of these, there are strong
associations of these measures with health outcomes. Note that I said
associations, and critics will say association doesn't imply causation.
They are right. How can we infer causation from association? Our
federal agencies have spelled out the criteria to use, beginning in the
1964 Surgeon General's Report linking smoking and health. I won't
trouble you with that academic exercise, but the association linking
caring and sharing behaviors of a society to its health is causative.
Societies that care for and share with each other are healthier than
societies that don't.
You may say that what I'm talking about are death rates.
You don't care how long you live, you just want to be happy, even if
you don’t live to a ripe old age. What I say also applies to
quality of life measures such as happiness, and it will not surprise
you to learn that our happiness as a nation has been declining.
A measure of caring and sharing is income distribution, namely how do
we decide what to pay various people in society for the work they do.
There are many different statistics for income distribution used by
economists and sociologists and again I won't bore you with the arcane
details of those and instead take a simple concept, namely how much
more the boss makes compared to an average worker. I use mainstream
data sources such as the New York Times, Business Week or Newsweek
because I have had experience with getting articles published there and
with the fact-checking process. Before they allow you to get something
in print, they verify your numbers and sources.
In January 25, 2004, the New York Times
reported in the front business page that a boss in the US makes 531
times what an average worker makes. The boss makes in half a day what
you and I make in a whole year. If you have looked at almost any
newspaper in the last decade, you've seen many reports about how the
income gap has sky rocketed in this country over the last few decades. Business Week reported that the gap was only 42 to one in 1980. In the same issue of the New York Times,
they mentioned that in Japan, the world's healthiest country, the boss
only makes ten times what an average worker makes. As a measure of
caring and sharing, during Japan's economic crisis in the late 1990s,
bosses and managers took pay cuts, rather than laying off workers. You
can't imagine that happening here. It won't take place unless we the
people made it happen.
So more egalitarian societies are healthier societies. The feds state
this pretty bluntly. The Institute of Medicine's “Future of the
Public's Health in the 21st Century” I mentioned earlier, on page
59 they write: "more egalitarian societies (i.e.
those with a less steep differential between the richest and the
poorest) have better average health." That is clear to me, and this
document was written during the current administration.
Perhaps we should have a warning on our paycheck along the 4 lines of:
"your low pay compared to the boss is bad for everyone's health in the
US." Notice I said your low pay is bad for everyone's health.
Don't let me get away with such a pronouncement for this is a profound
statement in which lies our salvation. There are now several studies
demonstrating that the rich may be adversely impacted by inequality, in
other words the rich have worse health than if they were less rich in a
smaller gap society. While those who are poorer will always have poorer
health, it is apparent that the rich are more harmed by inequality from
living in high gap states in the US. The rich would have healthier
lives if they weren't so rich in a smaller gap society. Part of our job
is making the rich aware of this. Not an easy task but a doable one.
We no longer care for and share with each other and therein lies the
reason for our poor health as citizens of the USA. At what point in the
human lifespan, from womb to tomb, does caring and sharing matter most?
The next point is also substantiated in federal documents. The time
when caring and sharing matters most for our health as adults, the most
important determinant of our health as adults, is the condition of our
being from the time we are a gleam in our parent's eyes until the age
of 4 or 5.
In order to have the healthiest adult life, the conditions in early
life, especially while you are in your mother's womb, and for the first
few years outside, are the most critical ones for our health as adults.
This is fantastic information for it tells us where we must act to
produce health.
Epistemology, is a fancy word for how we come to know things. How do
doctors come to know what they know about health. In medical school, I
was taught physiology, how the body works. My daughter was taught the
same thing this year in grade 10. On what basis did we learn how the
body works?
From the references in my student physiology book, I find that the
studies were mostly done on dogs. At Stanford Medical School back in
the early 1970s where they perfected heart transplants, much
experimenting went on in dogs. The animal rights people get upset about
this, and to them I suggest that they join the human rights people in
drawing attention to the experimenting going on in humans in this
country and in the world at large where we are creating so much
experimental poverty to see how it affects our health. In 50 years time
people will look back on this era and be horrified at what we did, just
as today we are aghast at the Tuskegee experiments that took place only
40-50 years ago where we didn't treat African-Americans with syphilis
as we wanted to study progression of the disease.
What we know about how human bodies work comes from various animal
studies. These results are then evaluated to see if they explain the
common findings in humans. Some animal studies don't appear to
translate to human findings, but many do.
It allows me to decide how to investigate illness as a doctor and to
prescribe treatment. If you are hemorrhaging and we replace your
fluids, you survive, something we learned from bleeding dogs. The
results of such animal experiments are routinely accepted. There are
others that are overlooked for strange reasons. Many of the overlooked
studies dwell on various behaviors, rather than physiological
parameters such as blood pressure, or glucose levels.
One example I first learned from Michael Meaney at McGill University
concerns mother rats. Studies on rats show that mothers who lick and
groom their pups, their babies, will have those pups lick and groom
their babies when they become mothers. For mothers who don't lick and
groom their pups, when the pups grow up and have their own babies, they
don't lick and groom them. If the pups are isolated from licking and
grooming mothers and not licked and groomed, then when they become
mothers, they don’t lick and groom their pups. And vice-versa,
pups from non-licking and grooming mothers who are licked and groomed
by other rat mothers will lick and groom their babies when they become
mothers. Nurturing behaviors appear to be transmitted in non-genetic
means. Epigenetics describes how this happens but is yet to be taught
in school.
This example points out the importance of what happens soon after birth and how that affects subsequent generations.
The biology behind this has two facets. One relates the stress that you
and I experience, and its hormonal manifestations. The other to what
happens in the brain, which is also related to the stress of society.
We have a physiological system that responds to imminent danger by
fighting or fleeing, the so-called fight or flight response. It is
mediated by cortisol and adrenaline produced in the adrenal gland.
These substances ready your body to succeed in escaping the danger.
They save your life. But produce these chemicals most of the time while
stuck in traffic, or mad at your boss, or worrying about paying bills,
and they turn out to be responsible for half of the diseases of modern
society, from diabetes, to high blood pressure to heart attacks.
I'm impressed in studies on pregnant sheep and their offspring demonstrating the importance of stress in the womb.
I'm not sure why sheep are such a good animal to study, but you've
probably all heard of Dolly, the first cloned animal who was a sheep.
Studies show that the fetal lamb secretes cortisol in response to
stress, whether it is getting inadequate nutrition or not enough oxygen
or whether the placenta is behaving badly and allowing mother's
cortisol from her own stress to reach the fetal lamb. So the fetal lamb
has to deal with its own cortisol production from being stressed, as
well as it's mothers, and then its own cells are sickened by both. With
too much cortisol Hamlet might say we are more susceptible to "the
thousand heartaches and the natural shocks the flesh is heir to" and
the lamb more quickly "achieves the sleep of death." This same
endangerment occurs in humans. There is a vast scientific literature
supporting the concept that what matters for our health are conditions
early in life, especially those associated with stress.
What happens between generations? Irv Emanuel, a colleague of mine at
the University of Washington, studied out the importance of these early
factors. He has been interested in health outcomes that depend on our
mothers and grandmothers.
He showed the importance of the maternal grandmother in our health. To
paraphrase Wordsworth, "the daughter is the mother of the woman." To
understand what impacts the woman, we have to look before her mother to
her grandmother's situation.
By creating good conditions for your daughter, she will beget healthy grandchildren! It will take generations.
Another component to the stress response has not been prominently
featured in either high school or medical school curriculums, namely
the "tend and befriend" or "calm and connection" response mediated by
another hormone, oxytocin produced in the brain. The only thing I ever
learned about 5 oxytocin as a doctor was that it expelled stuff, either
uterine contents when I wanted to induce labor, or breast milk. It
turns out to have a vast repertoire of other actions. I wonder if the
reason it has been overlooked is that it tends to be more active in
women, and it 's men that do the studies. Men produce just as much of
it as women, but testosterone inhibits its effects while estrogen
promotes it. So faced with an emergency, what does a woman do? She
takes care of others, tends to her child, instead of abandoning it to
the attacker or threat. Oxytocin is a neurotransmitter in the brain and
is released during sex, massage, gossiping, trusting and many other
situations that are good for us. There is likely much more of this
chemical around in more caring and sharing societies and it might be a
factor in the licking and grooming of rat pups. While I can quote
studies that demonstrate higher cortisol levels in less caring and
sharing human societies, we don't yet have population studies with
oxytocin.
The lower down you are in society's pecking order, the lower your
income, status, wealth, job rank, education level, skin color, accent,
the more cortisol you produce. As the sheep experiments show being a
poor pregnant mom under stress, more of your cortisol gets into your
baby, and so the baby is born not on third base, it often doesn't even
get to first base. It stumbles as it leaves the plate after a bunt. The
science is clear: we are not all born equal. Those from more
disadvantaged early life situations are already slated to be less
healthy at birth and to become sick later. This is evident from their
having low birth weights and being born prematurely which are both
highly correlated with adult disease. All this happens before birth.
What about after?
The Institute of Medicine's treatise, "From Neurons to Neighborhoods:
The Science of Early Childhood Development" talks about brain
plasticity, namely the forming and reforming of neuronal connections in
early life based on social and environmental influences. Soon after
birth, the visual cortex, the part of the brain that processes visual
images is busy being sculpted. The most important reason is what
British psychiatrist John Bowlby termed secure attachment on a familiar
face that allows the infant to venture forth from a secure base to
explore the world, knowing the face will be there when she crawls back.
Eye contact is important here and we are the only primate species with
whites in our eyes so the infant can know whether the attachment figure
is looking at her. The report, “From Neurons to
Neighborhoods,” points out that children who are not securely
attached to a caregiver in early life have higher cortisol levels. As
adults, such individuals are more likely to have worse mental health
and depression. This is related to depression in the mother and
associated with cortisol.
Around the first year of life, the auditory cortex is busy, processing
sound and developing language skills. The range of vocabulary and
content is vital for later success at school and avoiding behavioral
problems later in life. If all you hear are cease and desist orders,
namely stop that, shut up, don't do that, you won't do as well as an
adult than if you were exposed to an engaging diverse vocabulary.
Creating a nourishing early language environment is very important for
adult health.
The frontal lobes of the brain are very plastic from around age two
until teenage hood. The frontal lobes are our social organ. Play,
sharing, looking out for one another and understanding social cues is
what this period of development is all about.
We have cohort studies, which follow children from birth into
adulthood. These demonstrate the profound importance of early childhood
conditions on brain development, success at school, and adult health.
To quote the Feds, in "From Neurons to Neighborhoods:" "Of all aspects
of children’s early environment, the family’s socioeconomic
status is most powerfully associated with children’s cognitive
skills when they enter school. The influence of socioeconomic status
during early childhood years appears to be stronger than SES in later
years." It is the steepness of the slope upstream at the source that
matters most. They write that "Children in single-parent families are
at greater risk for poor developmental outcomes." As well, they point
out that "Stress resulting from marked threats to physical or
psychological wellbeing can have dramatic effects on health and
development." And: "Psychosocial risks that affect maternal behavior
include poverty, family violence, and maternal depression. Supportive
and nurturing care giving can help protect offspring from these adverse
outcomes." Why is this important for us in the USA? I said that our
health was worse than that in the other rich countries, and that for
the first time since 1958, our infant mortality rate, a very sensitive
indicator of our health as a society is rising. This is very troubling.
A French demographer, Emmanuel Todd, noticed such a rise in the infant
mortality rate in Russia in the early 1970s and wrote a book in 1976,
La Chutte Finale in which he predicted the collapse of the Soviet Union
for just those reasons. Our CIA, the Central Intelligence Agency,
monitors infant mortality rates in parts of the world to see where the
next trouble spot will be. Our new intelligence director John
Negroponte is certainly kept informed of our infant mortality rise and
our decline as a society.
If early childhood is this important, then what do we do to foster good
child rearing in the USA? When does society exercise responsibility for
childhood? The only time the state legally intervenes is to make sure
you have your vaccinations at age 5 to go to school. Before that it is
a free-for-all. By age 5, the die is cast and getting your shots is not
going to make up for a disadvantaged time in your mother's womb or the
struggles of the first five years of life. All of us have some of this
early baggage to live with and I'm not saying you should not do what
you can now to better your health. I want you to listen to the advice I
give if you see me in the ER, because I think it still matters. But I
want you to recognize the importance of what happened before we were in
a position to make individual choices. We have to structure early life
in society for better health outcomes.
We have the highest teen birth rates of all rich countries, twice the
rate of the next closest country and that gap is increasing despite a
slight decline in our teen birth rates. The gap between the rich and
poor is related to teens giving birth, where there is a bigger gap,
more will have children. We also have studies demonstrating that when
teens are reared by a single parent, usually a poor mom, they will
initiate sexual activity earlier and get pregnant sooner than if they
are in a two parent family. The reason is clear, life is precarious,
you won't live that long, so begin your family earlier even though it
will be 6 a tough life. This is usually not a conscious decision, but
one made subliminally to adapt to the environment.
Studies demonstrate that being raised in a single parent family is not
only harmful for the parent's health but also bad for the child's
health. Children raised by a single parent not only have more sickness,
illicit drug and alcohol problems, and suicide attempts, but a greater
chance of dying than children raised in a two parent family. Any parent
can attest how difficult it is to raise a child these days. It is
harder to do it alone.
I could go on and on presenting depressing statistics about how
unhealthy we are compared to people in the other rich countries, and
some poor ones as well. But it is time to think of solutions. The cause
of our poor health is that we have given up our sovereignty to decide
what is best for you and I in this country. We have been led to believe
that as individuals we can achieve any level of health or prosperity we
want, we just have to pull up our bootstraps. The problem is that many
of us no longer have bootstraps. We gave those away to the rich and
powerful some time ago. We have to take back our collective bootstraps.
Where are we going to find them? Let's look in some other countries
that are healthier than we are to see how their bootstraps work to pull
people up.
Let's take Sweden, the second healthiest country in the world. Sweden
is a very diverse country, with over 10% of the people living there
being born outside of Sweden, comparable to the US rate. Swedes pay
high income taxes and have a wealth tax to supply funds for social
purposes. It is a decision they made, namely recognizing that everyone
does better when everyone does better. They understand the importance
of early childhood. In Sweden you have to take a year's maternity or
paternity leave at full pay. You can't get out of it. After the first
year, you can take an additional year of leave at 80% pay. After that
if you return to work, then your child can be placed in a government
run free daycare. The requirement to work in a Swedish daycare is that
you have to have a master's degree in play. The daycare experience is
about, learning to play with others. Such conditions give your child
the chance to develop secure attachment, be exposed to a rich
vocabulary and socialize with peers. It doesn't guarantee this will
happen. But it makes it more likely and the fact that child and adult
mortality in Sweden is so low compared to the US attests that it works.
Notice that I have said nothing so far about the role of health or
medical care in producing health, despite the fact that I work as a
doctor in emergency rooms. There are no data that support health care
as it is done in the US, at least, as having a positive impact on our
health. The reasons why are a whole other talk, but I mention it here
just so you don’t think I forgot an important piece. Health and
health care sound synonymous but they are not. Medical care is invested
in disease, and our abilities to discover disease are so sophisticated
now that I can say with certainty that if you think you are healthy,
you haven't had enough tests yet. We can find disease in anybody, but
I'm talking about health. Respected sources, such as the Oxford
Textbook of Public Health and others back me up on this seemingly
unintuitive concept. I'm not suggesting you don't receive medical care
when you need it, but don't look to health care to make a population
healthy.
Let me move on and ask how are we going to produce a caring and sharing
society in the USA and get back on the road to health? We can begin by
overturning pretty well all the recent legislation that gives
everything to the rich while we are to be satisfied by what trickles
down from them. Greed isn't good for our health. We have to make the
choice between greed and good if we want health. If we don't, then we
can continue to have ever less so the rich always have more. Maybe you
don't want the rich to have worse health because of this. Remember, I
said not only is your health impacted by inequality, but that of the
rich is as well.
Tax cuts for the rich and for rich corporations are not good for our
health. Back in 1940, US corporations paid 40% of our federal tax bill.
By 1960, it was 26%, by 1990, 13% and in 2000 only 7%. From 1996 to
2000 during a period of strong economic growth in the US, 60% of US
corporations paid no tax according to the general accounting office. In
2003, Time- Warner, for example, made 4 billion, 224 million dollars in
profits and paid no income tax. We can change that for we the people,
as I said, make the laws in this country. The intent to permanently
repeal the estate tax is another example of legislation that we should
not allow for it will be bad for our health if enacted. President FDR
said that both inherited power and inherited wealth were inconsistent
with the guiding principles of this nation. Our highest personal income
tax rates used to be 91% when we were one of the healthiest countries
in the world. Now they are 35% and our relative health decline mirrors
the drop in tax rates for the rich. We live amongst a few Hood Robins
that take from the poor and give to the rich.
We can have a maximum wage, just as we prescribed for Japan when we
wrote their constitution in 1946. At that time the maximum wage was set
at 65000 yen in Japan. Today the boss in Japan makes ten times what an
average worker makes while ours makes 531 times. Last year in the US,
the average wage for CEO's, the Chief Ego Officers, was 110 million
dollars, and in some recent years it has been up to seven times that.
Pay for the boss in the last decade has tripled, while corporate
profits have only doubled, and worker pay only went up 49% with
inflation eating up pretty well all of that gain. The average worker is
dying for a living. President Roosevelt a Democrat, put forth
legislation in 1942 to create a maximum wage for the US of $25,000 a
year at that time. We could go back to that kind of regulation, since
we almost had a maximum wage then.
President Nixon, a Republican, proposed a negative income tax in his
Family Assistance Plan of 1969. He said there would be a guaranteed
income for every family with children.
Newspaper support was 95% in favor. It passed the House of
Representatives and languished in the Senate as Nixon became embroiled
in Watergate. We could revisit that legislation.
Enacting it would help cope with the large numbers of homeless children that were not present back in Nixon’s time.
The medicine we need to produce health is one we used to take or
considered taking in the past, so we could compound it again in our
political pharmacy. Trickle-down politics is no better than
trickle-down economics. We must see that we the people are the source
of power, we are our population health doctors and we need to take that
power back. We can only do it by becoming aware of what makes a
population healthy and taking steps to produce health in ourselves. We
don't need more research on this. Asking for more research can be a way
of 7 subverting political action. If the goal is becoming healthy, we
know all we need to know.
The material I have presented can be considered a new paradigm for
looking at health. Our history is replete with scientific revolutions
and something that commonly occurs with revolutions is what can be
termed a "professionalization" of the old paradigm. As a medical
doctor, I find doctors are the most resistant group in this country
when it comes to trying to produce health. We love the old treating
disease model for that creates immense profits. We are very resistant
to the ideas I have described. MDieties do not want to think of
changing our disease perspective because we are comfortable with it
even though we die much younger than we should, at least compared to
people in about 25 healthier countries. Our health in this country is
so far behind others, that even if we eradicated our leading cause of
death, heart disease, we still wouldn't be the healthiest country in
the world. There is no MDeity out there that could contemplate winning
the war on heart disease as a possibility. But that shows how much our
health has declined.
The USA used to be one of the healthiest countries in the world, back
when we cared and shared. We can go back to those values of caring and
sharing. We need to discard greed in favor of good.
I've talked about our health as people, whether in the womb, as
children, adults, or getting nearer to the tomb. Benefits extend far
beyond our species, to the physical environment.
Studies show that where the gap between rich and poor is smaller, the
rape of the physical environment is less. Equity and good ecology are
almost synonymous. You may think I'm espousing a one-size fits all
perspective. If the goal is a sustainable planet, caring and sharing
works. If the goal is wealth creation and all of us dying young, then
we just need to continue making the rich richer.
Some folks will say these ideas are all nonsense. How do we come to
know things in our travels from womb to tomb? In the past, we used to
ask our parents, talk with teachers, ask our friends what they think.
These days we Google and in 0.21 seconds, we are presented with
1,593,254 hits for just about anything. I find this incredibly
under-whelming as a way to learn. We get too much information and our
brain shuts down, as we don't want cognitive dissonance, and go back to
business as usual.
I am proposing to you here tonight that if the health of your children
is important to you and if the health of your unborn grandchildren is
important to you, then you must become familiar with the ideas
presented. Don't take my word for it, find out for yourself if they are
true. The illiterate of the 21st century will not be those who can't
read or write, but those who can not learn, unlearn and relearn. Verify
the statements from the Institute of Medicine's various reports which
available for free on the web. Then delve into other scientific
literature. Go to our Population Health Forum's website, which is a
diverse source of materials. It may take you a while to become
convinced, just as it did me. You can then teach what you have chosen
to learn. Get other people thinking about this question.
Band together to organize, and change the rules in this country that
determine who gets what share of the pie. Inequality hurts everyone,
including the rich, and it is time to redress that. But the rich and
powerful won't give up easily and will try to subvert you.
An example of how the rich and powerful subvert you is provided by
Martin Luther King Jr. He tried to carry out the Poor People's Campaign
in 1968 to get a half million citizens camping on the mall in
Washington, DC to press their legislators for an economic bill of
rights As citizens, we need to look at existing policies in this
country and new ones proposed to see what they do to the gap between
the rich and poor. If they increase it, then we can expect worse health
outcomes. If they decrease it, then we can count on a longer time
between womb and tomb. We can only influence existing and forthcoming
policies by working together to understand their health effects and to
help others recognize this. Such organizing begins in our communities.
The way to fight organized money is with organized people.
Recently a group of us met with our local congressman to get his take
on the forthcoming CAFTA or Central American Free Trade Act, which like
NAFTA demonstrated, promises to be bad for our health because it allows
the rich to take even further advantage of the poor. The politician
felt that unless we can turn out huge numbers of people such as Martin
Luther King Jr. used to do to support the defeat of this legislation
which hurts everyone, the likelihood of it passing are high. This is
the challenge ahead.
To summarize, I have pointed out that we as citizens in the US are less
healthy than people in all the other rich countries, and a few poor
ones as well. Fifty years ago we were one of the healthiest countries
in the world, but as we have lost interest in governing ourselves, and
allowed those with wealth and power to further concentrate their wealth
and power, our health compared to other nations has declined. All of
us, rich, poor and vanishing middle class alike pay the ultimate price
for living in the richest and most powerful country in world history,
we live less happy lives and die much younger than we need to.
If we accept that it is better for the rich to have everything and for
them as well as us to be so unhealthy, then all is well and we can
continue hanging on to the steep slope at the source. We could decide
that we actually desire a long life, shared liberty and happiness
rather than just its pursuit. Then we have work to do to gain back our
sovereign rights to determine our well being.
We cherish our democracy, or at least we talk about it, but mostly
follow Benjamin's Law: when all is said and done, more is said than
done. We are not aware of how much work it takes to have a democracy.
It means much more than voting once every four years. Even then, we
have the lowest voting rates of all countries. Plato said 3000 years
ago that for a democracy to function, the richest person should be no
more than four times as wealthy as the poorest. Today that is close to
a trillion to one, or a million to one.
So we don’t have a functioning democracy in this country, at
least one where we the people do much work in deciding who benefits
from the policies that are enacted in United States.
Democracy is not what we have, democracy is what we do.
Democracy is hard work, it takes lots of time, and can be painful to do
well. We feel we are too busy to work in the democratic process. It
takes too much time to understand the issues and to work together. If
we take the time for democracy, we will more than make up for it in
added years of productive enjoyable life.
What a fantastic investment in ourselves, our children and our grandchildren.
8 If well-being is important to you you will have to work to improve
our health for the rest of your lives. There is no quick fix, no way to
check a box on a form and send it in and all will be well. Each of us
must inventory our skills, interests and energy and act in concert with
those. If you do what you enjoy doing and what you can continue doing
for a long time that addresses the big picture of health, then it will
make a difference for this country. Personally I try to develop
curricula for middle and high schools so that our young people will
learn the need to make group decisions for our health. They need to see
that being healthy is not an individual matter, but something that a
society decides. For the young here tonight, ask your teachers about
these ideas.
I also write for audiences from the homeless to academics and teach at
the college level. It is difficult to make a living in this country
espousing economic justice so keep your day job.
After tonight, I want each of you to extend a hand to 3 others on the
steep slippery neo-liberal slope of trickle-down economics and tell
them what you learned tonight, and how it affects our health. You may
never know what results come from your actions, but if you do nothing,
there will be no results. One person, working alone, will not help that
much. We need solidarity sharing our efforts with one another. "If you
give me a fish, you have fed me for a day. If you teach me to fish,
then you have fed me until the river is contaminated or the shoreline
seized for development. But if you teach me to organize, then whatever
the challenge, I can join together with my peers, and we can fashion
our own solution." If we organize then the upstream source of the
problem will vanish and people won't be sliding into the river! And we
will all enjoy a much healthier and longer time between womb and tomb.
Thank you.
For more info –
Population Health Forum website
http://depts.washington.edu/eqhlth/
sabez@u.washington.edu
For information about obtaining cassette copies or transcripts of this or other programs, please contact:
David Barsamian
Alternative Radio
P.O. Box 551
Boulder, CO 80306-0551
(800) 444-1977
info@alternativeradio.org
www.alternativeradio.org
©2005