On Sunday, All Saints Episcopal Church in our neighborhood is playing “In sickness and in wealth”  with a discussion to follow. This documentary uses people’s stories, people who work at the same company but have dramatically different lives, to illustrate the contribution to poverty and societal stress to the ill health of some Americans. The documentary makes the following point:

What needs to be done is to make sure that everyone is allowed access to the same opportunities even if they do not have the economic resources.  This would involve providing resources such as quality education, decent housing, access to affordable health care, and access to healthy food and safe places to exercise to everyone despite gaps in affluence.  Having access to such resources would simulate the control felt by the affluent when they come to make such choices regarding health.

The documentary was done in 2007. Things have not gotten much better. My friend Josh Freeman recently wrote about a presentation he saw by Stephen Woolf on the same topic done this year (found here). Josh reports that Stephen presented information familiar to those of us with an interest in public health but somehow lost in the debate over health insurance, such as that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located.

Doctor Woolf advocates the use of “Health in All” policies.  These policies take into account the reality that decision-making regarding transportation, land use, built environment, taxes, housing, agriculture, and environmental justice, for example, affect health.  For example, the fact that  2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle should inform policies regarding public transportation and land use, among others.

Turns out, we can purchase better health. If we want to make improvements in the health of our citizens, we probably should focus as much on education and improving the overall living environment (including improvements in working conditions) as we focus on health care insurance. There is now a calculator that allows counties to compare where they are to where they could be if only their citizens were better educated. For Mobile County, for example, just by improving our educational status to that of Shelby County (Alabama’s best) we could avert 459 deaths in the county.

To quote my friend, Josh, about the same observation in a Kansas comparison:

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.