What would we have to do if we really wanted to achieve real health? What would it mean to come to terms with the inter-related effects of health at all system levels, from the cellular to the whole person, to the family, to the community, to the planet?
Some of the links between personal health and health at a larger system level are obvious. War, poverty, and ecological decline are among the greatest health risk factors.
Some are far less widely recognized. The effect of empowerment on health is a particularly striking aspect of the interplay between health at different system levels. Here are some indicators that empowerment may be among the most important determinants of health.
In a soon-to-be published book, Why Are Some People Healthy and Others Not? The Determinants of Health of Populations, Robert Evans cites a study by M.G. Marmot of more than 10,000 British civil servants over a two-decade period. The study found that an individual’s standing in the income and rank hierarchy was highly correlated with his or her life expectancy. For example, among males aged 40 to 64, the death rate was about three and a half times higher for those in clerical positions as for those in administrative grades. None of those studied were living in poverty, and all had access to Britain’s socialized health care system. The study found this status-related risk factor to be more significant in determining death than smoking, high blood pressure, or cholesterol.
Over a period of more than 70 years, other studies have confirmed this association. "The diseases change, the gradient persists again suggesting an underlying factor, correlated with hierarchy and expressing itself through particular diseases," Evans writes.
A study of free-ranging olive baboons in Kenya suggests a possible biological mechanism for this effect. The study, conducted by Robert Saplolsky, found that in dominant male baboons, the physiological responses to stress – the fight or flight syndrome – taper off more rapidly after a stressful event has passed, while in subordinate animals, the stress response continues.
Wondering if this could also be true of "free-ranging British civil servants," Marmot found that, on average, all ranks had elevated blood pressure while at work. But the blood pressure of the average senior administrator drops further at the end of the work day then does that of lower ranking workers.
Other studies show people in demanding, low-ranking jobs that offer little autonomy or room to exercise skills and abilities tend to have a higher rate of heart disease and death.
These and other studies suggest that exposure to stress is not necessarily either good or bad for the health. What seems to make the difference is having options as to how to respond to stress and having some sense that the stress is predictable and controllable, according to Evans.
Inequality is another factor that has a profound effect on mortality rates, according to Richard Wilkinson, a senior research fellow at the University of Sussex. It has long been known that life expectancy of those living in impoverished countries increases as the GNP per capita increases. But at a threshold of $4,000 – $5,000/per capita, further increases in GNP per capita have little effect on life expectancy.
In the developed world, "rather than the richest, it is the countries where income differentials between rich and poor are smallest which have the highest average life expectancy," Wilkinson writes.
In 1970, Britain and Japan had similar average life expectancy and income distribution. Over the last two decades, Japan’s income differential has narrowed to the point where it’s the smallest of any country recorded. Over the same period, Japan’s life expectancy has increased at an unprecedented rate and is now the highest on record, according to Wilkinson.
In contrast, British income differentials increased; the lowest social classes in Sweden now experience lower mortality rates than the highest social class in Britain.
These studies are amplified by Dr. Rudy Rijke’s studies of exceptional cancer patients (see Choosing Health in this issue). Many of those who lived well beyond their expected life had developed a strong sense of will – not simply a "will to live," but a will to live life fully – a sense of personal empowerment.
The importance of empowerment also comes through in examples of successful community-scale health promotion. In Hawaii, native people have improved their health in part by returning to traditional practices of raising, gathering, and preparing foods (see Reclaiming Tradition in this issue).
Project Piaxtla in Mexico began with treatment of disease and then moved to prevention. As the people began to see that they could have an impact on the conditions of their lives, they took on the structural causes of the hunger that was killing their children (see The Politics of Health in this issue). The Healthy Communities movement in the US, which is linked to the World Health Organization’s Healthy Cities program, works to empower people to take on crime, pollution, youth alienation, and lifestyle issues as a means to improving their health (see Healthy Communities, Healthy People in this issue).
There is certainly more to be learned about how empowerment affects health, but empowering people is clearly a no-regrets policy.
In choosing a doctor, debating health care reform, doing community work, or considering personal relationships, it seems that better health will result if everyone is empowered.
Evans, R.G.; Barer, M.L.; Marmor, T.R. (eds) Why are Some People Healthy and Others Not? The Determinants of Health of Populations, to be published by Aldine de Gruyter, NY.
Wilkinson, R.G., "National Mortality Rates: The Impact of Inequality?" American Journal of Public Health, 1992, Vol. 82, No. 8, pp. 1082-1084.