I was recently reflecting on a fact that I usually ignore: I am in excellent health. That’s not to say I’m in excellent shape (I’m not), but I am able to live a more or less ‘normal’ life completely free of any infirmity. I don’t have any recurrent pain, difficulty sleeping, food allergies, mental distress, social anxiety… basically I’m kicking ass at life. When I consider what the reality is for many people, even if I restrict my thinking only to those in North America, I am still coming out ahead of a good chunk of the population who has to interact with the health care system in one way or another.
It is somewhat ironic that I make a living researching ways to improve the health care system, but that the only time I actually interface with it is when I go to the office. The irony expands a bit when I think of the myriad of ways in which people’s ill health makes working either an impossibility or a real difficulty. Even with a publicly-funded health care system, there is a severe economic consequence associated with illness. This association diminishes somewhat in white-collar jobs (unless you have some kind of injury that interferes with cognition, or a mental illness that makes knowledge work difficult), but your health is the foundation of your entire life if you work in a trade – a busted knee or a broken finger means the difference between working and starving.
Interestingly, the relationship between health and wealth works in the other direction as well. While the correlation between education/income and health are well-understood in the realm of health research, the evidence supporting causation is somewhat less robust. However, the picture is getting a little clearer:
Poor women, who moved to lower-poverty neighbourhoods, showed better Type 2 diabetes control and other health benefits, say U.S. researchers who called for changes in government initiatives to fight obesity. In an experiment described in Wednesday’s online issue of the New England Journal of Medicine, researchers followed 4,498 poor women and children who were enrolled in a program called Moving to Opportunity in 1994 to 1998. Among the group of women who were offered housing vouchers to move to lower-poverty neighborhoods, the rates of morbid obesity and diabetes were both about one-fifth lower than in the control group, lead author Yens Ludwig, a professor at the University of Chicago, and his co-authors found.
You can read the whole study for yourself here.
The researchers randomized 4500 women into three groups: a control group who received no intervention (Control), a group that was given standard housing vouchers (Comparator), and a third group who received vouchers that could only be redeemed in low-poverty areas (Experimental):
The women were observed over a period of 15 years for a variety of measures, including biophysical measures of health like body mass index and various blood markers for type II diabetes. What they found is that while poverty rates dropped in both the Experimental and Comparator groups, the drop was greater in the Experimental group (those who moved into low-poverty areas), who also experienced better health outcomes. Basically, moving out of poverty-stricken areas led to improvements in BMI and blood sugar.
Now, most people will look at a result like this and say “well yeah, obviously”, but it’s not quite so obvious. Much of the argument around health behaviour change is centered on endogenous vs. exogenous motivations. In the first camp are people who believe that health behaviour change must hinge on giving people greater skills to make better decisions – through education, training, encouragement and coaching. Those in the second camp think that health decisions are a product of the environment – that people know what is good and bad for them, but often lack access (for example, there is a corner store within walking distance, but not a place that sells fresh vegetables). A strong case can be made for either.
What this study suggests is that, even when controlling for those endogenous factors, the environment plays an important (and measurable) role in improving health. This has a few implications, both in terms of policy and our social conception of poverty and obesity. First, it means that we may see the same measurable improvements if we change the way we design neighbourhoods and provide housing. Recognizing that moving people with assisted incomes into low-poverty areas produces benefits that stretch beyond the mere benefits of having a home (which are not trivial) means that there is even more justification for eliminating NIMBY policies for social housing and instead mixing subsidized housing into low-poverty neighbourhoods. It may also mean that areas that are predominantly high-poverty may need to be redesigned to ensure that residents have sufficient access to nutrition and the ability to be physically active (which is a much tougher and more expensive job than de-ghettoizing poverty).
Second, these findings force us to confront some of the myths we have about impoverished people and health. While the research world has acknowledged the truth of this since at least the 1970s, the rest of us are a little slower to catch up and realize that health is a product of the physical and social environment. When we see higher rates of smoking and obesity among low-income people, our explanation can no longer be that poor people make bad decisions, which explains both their poverty and their health. We need to recognize that being poor makes us unhealthy, just as much as being unhealthy can make us poor. If we put as much effort into reducing poverty as we do into dealing with its health outcomes, we’d be much further ahead.
I can hear some of you calling ‘foul’ on the misleading title of this post. Fine, I relent. Here you go:
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