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):
Click for full-sized image
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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I have a chronic illness (moderate asthma) and a learning disability (ADHD). I’m lucky to have health insurance from two different sources that covers my medication costs completely, otherwise I’d spend upwards of $1000/month on meds.
Even with one form of coverage, I was paying about $400/month in meds, which is about half my monthly pay as a grad student. Add in missed work time and poor performance back when my disease was poorly controlled, and there’s your poor health -> low wealth.
Before I got my second health insurance, I was usually stressed over medication costs, and I couldn’t afford to eat properly and I was working so many extra hours to make ends meet that I didn’t have much time for exercise. Add in the fact that poor diet, medication noncompliance due to expense (“food, heat, or meds? Pick any two” was a problem I encountered often – for several months I lived off Mr Noodles, rice and vitamin pills so I could buy most of my meds) and lack of exercise worsens pretty much any chronic disease out there, and there’s your low wealth -> poor health.
So this is a bit of a “yeah, obviously” thing to me, but it’s interesting to learn how it’s very much not a “yeah, obviously” thing to those in good health.
Actually, I think this post is aptly named, if not obviously so. The power of Dr. House is to look objectively at the situation and perform experiments to determine which outcomes are most beneficial; in the course of which Dr. House will be rude, cause folks pain, and in the end get results.
Here I see the same thing. There was a problem determining causation of a symptom (poor health) and an assumption in the establishment (poverty & poor health is caused by bad decisions independent of environmental concerns – a clear case of blame the victim). The study did the work of House, bringing to light that ghettoizing the poor is counter-productive. I’m sure there was some rudeness and pain somewhere along the way…
There have been several studies that show your income level will adjust to match those with whom you interact in friendship and community. Perhaps its because of the chance to network and hear about opportunities when they arise. Perhaps because we rise up to the expectations of our peers. Perhaps because more affluent communities provide superior services such as education and food selection.
Thanks for bringing this to light. The question then is: How can I effect where the poor are housed in my community? Any suggestions?
I don’t have any recurrent pain, difficulty sleeping, food allergies, mental distress, social anxiety
How’s your blood pressure? (The proper answer to me is “none of your business”, but you should know the actual answer and if you don’t should probably get it checked. Nasty critter, hypertension. Asymptomatic until it causes a stroke.)
A strong case can be made for either.
I’d say the strongest case is for both. But this study demonstrates that significant progress can be made with a fairly simple exogenous change. It’s interesting that even the comparator group got some benefit. Perhaps they felt less insecure because they had stable housing and therefore had lower cortisol levels?
My blood pressure is pretty stable within the healthy range. Plus, I’m 27, so hypertension isn’t really one of those things I worry about that much. I stay active and avoid salty foods, but I’m not really going to worry too much about my cardiovascular health until I’m in my late 40s.
Rate of housing and number of moves were equivalent between the two groups, so ‘being housed’ per se doesn’t explain the differential effect. But yes, security and stability have a bunch of lifestyle benefits, not the least of which is the ability to have food in a fridge rather than eating on the run all the time.
Remember that epidemiologist on House who poisoned one of their patients to fake a positive outcome to his experimental malaria cure?
Epidemiology: the most evil of medical specializations!
Remember that episode of House where shut up?
Strictly speaking, epidemiology isn’t a medical specialization. It’s not even a branch of medicine – it’s a branch of science.
What’s an epidemiologist doing with a malaria cure? That’s an infectious disease thing.
Excellent news!
Also, it’s not lupus.
Still learning,
Robert
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).
That does sound harder. Is there any literature on how to do this effectively? I have a couple of ideas, but no idea of how effective they would be:
1. Subsidize grocery stores which sell a full range of food including fresh fruits and vegetables to move into higher poverty neighborhoods.
2. Plant trees. I have a vague memory that trees actually do a lot to improve a neighborhood’s desirability, though I don’t remember by what metrics.
3. Make the area safer by whatever means work best (more police, police with higher integrity and more integration into the neighborhood, cleaning the streets more often, making sure there are enough street lights and they are reliably working, etc)
4. Microloans to people in low income areas. If they work in low income countries-and apparently they do-why not in low income neighborhoods?
5. More sidewalks, parks, community centers, bike lanes, etc. And enforce the bike lanes-don’t let them become parking places, especially not for cops.
6. Enforce the 40 hour work week and make minimum wage such that a person working 40 hours at minimum wage will be making a living wage overall. Overwork leads to sleep deprivation and lack of time/energy to cook properly.
Any idea if any of this would work and/or is economically and politically possible?
I can’t speak to some of your points, but I can add a little bit of information about how physical improvements are being handled in social housing communities in Toronto (I have no doubt that similar things are happening in other Canadian and US cities; I’m just most familiar with Toronto).
Here, the approach to “de-ghettoizing” social housing (and simultaneously improving/renovating the housing and neighbourhood) has been to promote redevelopment of sites like Regent Park or Alexandra Park, with new private residential construction providing the funding to rebuild the social housing. That can lead to significant improvement in the accessibility of basic services and amenities like the new grocery store and bank in phase one of the Regent Park redevelopment, as well as the introduction of more accessible and connected streets and sidewalks. (I know that social housing tenants were also supposed to be given job opportunities through those new businesses, though I don’t know how that’s going to be tracked or how long it will last.) It has definitely made the area easier to police, and will hopefully help connect it better with the rest of the city. This strategy is justified on the grounds that a) it’s the only way to get the funding to make needed changes to the social housing, and b) mixing incomes will lead to better outcomes for the social housing tenants.
There are some questions that remain about this strategy for environmental change, however, one of the biggest ones being that the lives of the existing tenants and their community are pretty seriously disrupted by relocation during the redevelopment process itself. Gentrification is also a concern, because even though the existing social housing is being rebuilt on the site (mostly), the much larger influx of higher income people is expected to draw in businesses and services targeting their needs as well as even more condo development offsite. It’s hard to know how the social housing tenants will be affected and how inclusive the resulting community will really be. There is an ample urban planning literature that suggests that “social mixing” in and of itself tends not to help people living in poverty get out of poverty.
In short: I think that the physical improvements to the environment are basically good, and will make it easier for social housing tenants to remain active, feel safe, and access healthier food, community services, and so on. And at least in an overall context of residential growth, it’s possible for government bodies to leverage private investment to make those improvements. However, the effects of changing the social environment by inter-mixing market housing targeted at people with higher incomes is more difficult to gauge.
A correction:
“biophysical measures of health like body mass index”
BMI is not a measure of health, it is merely a description of the body (and not even a good one). Likewise, obesity is not a disease, it’s a ratio of height and weight that was never meant to be applied to single individuals. Also, health and weight are not the same thing; weight does not determine health – healthy behaviors (plus genetics/environmental occurrences) do.
http://www.npr.org/templates/story/story.php?storyId=106268439
http://www.no-obesity-epidemic.org/
http://jama.ama-assn.org/content/282/16/1547.short
A good example: I have two friends who are women with bmis around 27 – “overweight”. One has a body fat percentage of 32%. The other has a body fat percentage of 18%. The first genuinely is overweight due to some health issues that prevent a great deal of exercise and affect her metabolism. The other is an athlete who makes me and my fifteen hours of exercise a week look like a couch potatoe by comparison.