Correspondence

Explaining the Connection between Privilege and Health

N Engl J Med 1994; 330:139-140January 13, 1994

Article

To the Editor:

The articles by Keil et al.1 and Pappas et al.,2 the editorial by Angell,3 and the Sounding Board by Hurowitz4 (July 8 issue) deal with the relation between life expectancy and socioeconomic factors. One explanation may be an inverse correlation between longevity and muscular work. The hypothesis is supported by the general biologic principle that life span is related to the basal metabolic rate: shrews live only a few years, but parrots and crocodiles many decades. Women live longer than men. People with higher incomes or better educations live longer than those with a lower socioeconomic status. Finally, life expectancy has increased for all during the past century. Women perform less muscular work than men, as do people with higher socioeconomic status as compared with those with lower status, and workers at the present as compared with those in earlier eras. . . .

Hans E. Muller, M.D.
Staatliches Medizinal untersuchungsamt, D-38124 Braunschweig, Germany

4 References

1. 1

   Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC, Tyroler HA. Mortality rates and risk factors for coronary disease in black as compared with white men and women. N Engl J Med 1993;329:73-78
   Full Text | Web of Science | Medline

2. 2

   Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329:103-109
   Full Text | Web of Science | Medline

3. 3

   Angell M. Privilege and health -- what is the connection? N Engl J Med 1993;329:126-127
   Full Text | Web of Science | Medline

4. 4

   Hurowitz JC. Toward a social policy for health. N Engl J Med 1993;329:130-133
   Full Text | Web of Science | Medline

To the Editor:

. . . Patients must be able to read at least at a high-school level to understand most commonly used patient-education materials, health articles in the lay press, consent forms, and even prescription labels1-3. Reading deficiencies may be a particular impediment to preventive care because effective preventive care requires that patients become knowledgeable, active participants.

Researchers interested in socioeconomic factors should measure reading ability directly instead of relying on educational status as a surrogate. Several accurate, rapid screening tests of reading ability are available, at least one of which is in the public domain free of charge4. Interventions specifically designed for patients with low literacy skills may prove to be important in improving the health care of many, particularly those of low socioeconomic status.

Robert H. Jackson, M.D.
Terry C. Davis, Ph.D.
Louisiana State University Medical Center, Shreveport, LA 71130-3932

4 References

1. 1

   Jackson RH, Davis TC, Bairnsfather L, George RB, Crouch MA, Gault H. Patient reading ability: an overlooked problem in health care. South Med J 1991;84:1172-1175
   CrossRef | Web of Science | Medline

2. 2

   Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. Philadelphia: J.B. Lippincott, 1985.
   

3. 3

   Davis TC, Crouch MA, Long SW, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med 1991;23:433-435
   Medline

4. 4

   Davis TC, Long SW, Jackson RH, et al. Rapid estimation of adult literacy in medicine: a shortened screening instrument. Fam Med 1993;25:391-395
   Medline

To the Editor:

. . . Does it not stand to reason that people in the lower socioeconomic stratum of society eat fast food and high-calorie junk foods from “jiffy joints”? Nutrient-dense, organic food is expensive. High-calorie junk food is cheap by comparison. Consuming an excess of calories, without allowing for oxidative metabolic function, results in dangerous marginal malnutrition, analogous to choking an internal-combustion engine.

Derrick Lonsdale, M.B., B.S.
24700 Center Ridge Rd., Westlake, OH 44145

To the Editor:

. . . Physicians, owner managers, and other independent professionals may well share a feeling of control in their lives as well as a relatively high income. This feeling probably has a fairly high correlation with income, but it is not the same.

Income is an easy variable to measure, but it is very questionable whether it is the proper variable to use. I submit that some subtle variable dealing with our internal feeling of security is more likely to be the operative factor in differences in health between socioeconomic groups.

Frank C. Huber, M.D.
120 Canterbury Dr., Parkersburg, WV 26104

To the Editor:

We are puzzled that the editorial recommendation of Dr. Angell -- that we should “be more ready to regard medical illness as the result -- direct or indirect -- of social factors” -- is in disagreement with the proposal of Dr. Hurowitz to establish a “National Institute of Social Health.” Disparities in health according to socioeconomic status have been recognized for many years but have had little effect on medical research, clinical practice, or public policy. . . .

Suppose improved health in the population would be more likely to result from increased public expenditures on formal education than from increased expenditures on medical care. Would an organization of physicians support the implementation of this approach? A new structure appears necessary to extend public policy beyond “medicalization” paradigms, to improve health care, and probably also to understand better why spiraling expenditures on medical care in the United States over the past decade have resulted in only marginal improvements in health.

Theodore Pincus, M.D.
Leigh F. Callahan, Ph.D.
Vanderbilt University School of Medicine, Nashville, TN 37232

To the Editor:

Dr. Angell opens her clear analysis of the relation between socioeconomic status and health with the statement that “anyone who follows the medical literature knows that socioeconomic status is a powerful determinant of health.” She goes on to state that socioeconomic status “is perhaps the most mysterious of the determinants of health.” The striking statistical correlations do not, of course, indicate causation, although we who were introduced to medicine on the wards of city hospitals during the Great Depression saw how poverty determined who had scurvy, pellagra, and postabortion sepsis and aggravated all illnesses.

The correlation of socioeconomic status with health may, however, indicate two countercurrents: inferior socioeconomic status as a determinant of poor health and good health as a determinant of elevated socioeconomic status. Persons with a “healthy” hereditary endowment tend (through vigor, talent, and aggressiveness) to improve their socioeconomic status and find themselves in a salutary environment; those with a less healthy endowment may sink into a pernicious environment that exposes them to diseases and encourages the expression of inborn defects. The mystery of the correlation of health with socioeconomic status may lie partly in the mystery of the reciprocal influences of heredity and environment.

Norman B. Roberg, M.D.
via di Montoro 15, 00186 Rome, Italy

Author/Editor Response

Dr. Angell replies:

As the letters from Dr. Muller, Drs. Jackson and Davis, Mr. Lonsdale, and Dr. Huber exemplify, everyone seems to have a favorite theory to explain the correlation between socioeconomic status and health. But the very number and variety of these theories -- some of which are quite fanciful -- underscore the fact that we know little about this important connection.

Drs. Pincus and Callahan would like to see more attention given to the connection, and I agree. I am simply not certain that we need a separate institute to carry out the research. And, of course, there are many reasons apart from the correlation with health why we as a society might want to improve the conditions of the disadvantaged. Trying to do so does not need to wait for the results of research to explain the correlation between socioeconomic status and health.

Dr. Roberg raises the Darwinian possibility that the socioeconomically disadvantaged are somehow constitutionally unable to do better. I know of no evidence to support this belief, and a good deal of experience to counter it. In any case, it is implausible that the factors that lead to low socioeconomic status are the same that produce heart disease 30 years later.

Marcia Angell, M.D.

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