Hourglass Nation

Hourglass Nation

Has America become a country without a viable middle, where people either rise to the top or sink to the bottom? And if we have, asks George Kaplan, who's spent the past 30 years studying the impact of social inequalities on human health, are we willing to stay that way?

George KaplanWhen he moved with his parents to Skokie, Illinois, in 1951, nine-year-old George Kaplan learned something about how America works. In Skokie, he and his family lived in a small brick home. But in nearby Evanston, where Kaplan went to school, lots of people lived in big mansions, and there were two YMCAs—one where blacks went, and one where whites went.

The everyday reality of discrimination jolted him out of any complacency he might have had. By the time he started high school, Kaplan had become involved in social-justice issues and was swept up in the heady currents of the era. The anti-war and civil rights movements and the vast cultural changes of the 1960s “became part of me, internally,” he says, “and I sort of seamlessly moved into thinking about issues of social stratification and health.” In college and grad school, Kaplan trained as an experimental psychologist, a discipline he subsequently taught at Stanford. Eventually he found his way into health psychology, which in turn led him into epidemiology and public health—a vocation that let him combine his scientific pursuits with his social values. He completed a post-doc in epidemiology at the University of California, Berkeley, in 1981 and embarked on a career as a social epidemiologist.

In the early days of his work, social scientists seldom thought about health issues, and public health scientists seldom considered the psychosocial and other nonmedical determinants of health. Kaplan says he had “the luxury of being able to point in two different directions while pushing people to broaden their horizons.”

He joined the University of Michigan School of Public Health faculty in 1997 and became the Thomas Francis Collegiate Professor of Public Health in 2003. During his tenure at Michigan, he founded and directed the UM Center for Social Epidemiology and Population Health and the Robert Wood Johnson Foundation Health and Society Scholars Program and was also a research professor at the UM Institute for Social Research. He was elected to the Institute of Medicine and became the first public health scientist to be invited to address the Nobel Forum at the Karolinska Institute in Sweden.

In hundreds of published papers on the role of behavioral, social, psychological, and socioeconomic factors in health and health inequalities, Kaplan has demonstrated time and again that our health is inextricably tied to the social and economic realities of our lives—and that things like where you live and work matter.

Earlier this year, Kaplan received emeritus status from UM and moved to the San Francisco Bay area, where he continues to research what he describes as “the links between ‘social divides’ and ‘health divides.’” Before leaving, on a cool spring day in Ann Arbor, in an office brimming with cardboard boxes, books, papers, and his own luminous photographs of wildlife and landscapes, Kaplan took a break from packing to reflect on the state of health and health care in America, and what these say about who we are.

Findings: When you started your career 30 years ago, few people seemed to grasp the connection between society and health. Would you say there’s widespread agreement today that human health is directly affected by the circumstances in which people live?

Kaplan: No, I think there’s still a broad segment of the population that believes that health is driven by the choices people make, which reflect their individual values and preferences, and by the doctors they see, and that neither reflects societal influences.

How do you change their minds?

Part of the challenge is to show that people’s choices reflect the constraints on their lives. If, for example, somebody is less than one paycheck away from being on the street, if they live in a neighborhood which is full of risks and bereft of resources, it’s not surprising that they would tend to eat foods that provide them with cheap calories. So junk food is not an unreasonable choice. A lifetime of these constraints leads people to feel hopeless. We’ve done a series of studies over the years that show that feelings of hopelessness are powerfully related to health outcomes. The progression of atherosclerotic disease in the carotid artery is faster among people who are hopeless.

And with the economic crisis, people’s sense of hopelessness is deepening …

We don’t have studies yet of the effect of foreclosures and job terminations, of people having their assets wiped out so that they can’t invest in their children and don’t have funds to pay for their retirement. But everything we do know suggests there will be substantial health costs associated with this—particularly when you consider that at the same time these economic problems are occurring, there’s a further unraveling of the social safety net. I’ve heard of places where emergency medical technician teams have been cut back because there’s not enough money, where extended school programs have been cut back. Emergency food programs are being dramatically challenged. The safety net is failing right now, and I believe that will ultimately have impacts on the body—the body politic affects the body corporeal. We make band-aid fixes to unemployment insurance, extend it a little bit here and there, but we don’t have enough programs to help this huge population of discouraged workers who have lost their jobs. We don’t have any programs writ large to give them hope.

So unless we change our priorities, we face a health crisis on top of an economic one?

I think that what some people refer to as the “hour-glass society”—where the middle has shrunk away, and people either rise to the top or sink to the bottom economically—is an extraordinarily important issue. It tests our mettle. How much inequality at the social and health level can we tolerate and still be an intact, productive society in which people are able to live their lives in a healthy and fulfilling way? The evidence suggests that all it takes is a Katrina and a housing bubble and a few other things to lay clear the deep vulnerability that exists in this population.

Have we reached the end of the American dream?

We’ve gotten ourselves into a deep hole in many regards, but I actually believe it’s remediable. It will require everything from grass-roots action to top-down action—from community members organizing to improve neighborhood conditions, for example, to federal action to change tax and transfer policies so that the opportunity landscape of the working poor is improved. Without all of that coming together, I think we’re going to have a long haul, but when it does come together, it can do wonderful things.

Do Americans have the will to do what it takes?

I think most Americans—most people—want to live their lives in rewarding ways. They want to see their children do better than they did. And I think most people want to get along with people like themselves and with people who aren’t like themselves. They don’t want to live in a gated society. They don’t want to have to put up razor wire and bulletproof glass. They want something different, and good health is part of that.

You cannot live a productive and active life if you’re not healthy, and unhealthy societies are not productive societies. So I think there is that impulse in American society. The question is how to mobilize it. I personally think that there could be a movement based on the same kinds of claims we saw with the Voting Rights and Civil Rights Acts of 1964 and 1965—for policies directed at dignity and human worth and equality, which would also enable people to live healthy lives and contribute to society.

Something like a Health Rights Act?

I think the clamor about health insurance now is more than just people being concerned about the cost of health care. People have a sense that there’s something wrong. They may not know how to fix it, but they do have a sense that there ought to be some fundamental human rights that have to do with health, that have to do with safety, that have to do with children having futures, and that have to do with participation in society.

As an epidemiologist, what’s your role?

It’s both trying to show the extent to which differential patterns of health exist—that social inequality and health inequality march in lock-step—and the extent to which changes in education and tax policy and changes in neighborhoods can have an impact on these differences. And then trying to translate that information in a way so that policymakers have access to it.

What specific steps do we need to take in order to address the problem of health disparities in the U.S.?

The first thing is to have health-impact assessments that monitor the impact of policy on health and health inequalities, so that we begin to see that what we do as a society affects our bodies as well as the conditions of our streets and wallets.

Then we need to begin a series of life-course investments. We now understand that early childhood is extraordinarily important, but so is middle school, and so is adolescence, and so is the period when people enter and build their careers, and so is old age. We need to start having integrated programs which allow mobility, growth, and success along the life-course, because disadvantages at any point accumulate to create health problems later in life and losses to society from those health problems.

We now know that, like real estate, health is location, location, location. Where you live makes an enormous difference in terms of the air you breathe, the schools you go to, the work, transportation, housing, streets, violence levels, etcetera, that you live with on a day-to-day basis. So unless we create some innovative strategies to fundamentally change the nature of disadvantaged neighborhoods, we’re in trouble.

A Life's Work

Since 1980, George Kaplan has published more than 200 papers on the role of behavioral, social, psychological, and socioeconomic factors in health and health inequalities. Here he talks about 5 studies he feels have made an impact.

  • Poverty and Health (American Journal of Epidemiology, 1987) Location, location, location. This was the first epidemiologic study to show that living in a poverty area was associated with an increased risk of death—above and beyond individual characteristics such as income, race, work status, access to medical care, or whether people smoked or drank or were obese or depressed. We’d known beforehand that people who were poor tended to have worse health. This study showed that neighborhood also matters.
  • The Health of Poor Women Under Welfare Reform (American Journal of Public Health, July 2005) The welfare reform act of 1996 is seen as a success by some, largely because of lower costs to federal and state governments. We conducted the first study that carefully measured the health of women going through welfare reform, and what we found suggested that their health was being endangered. Many single women with children who were moved to TANF (Temporary Aid to Needy Families, the new welfare program, which has a lifetime eligibility of five years) were thrust into a job market with few skills, no child care, and poor trans- portation, and were required to work in jobs with variable working hours, poor benefits, and no future. For those women who had the most serious economic problems, we found measurable changes in the biological markers of stress. The rates of a marker suggestive of diabetes were also twice as high.
  • Inequality in Income and Mortality in the United States (British Medical Journal, 1996) Societies create inequality through wages, through the accumulation of wealth across generations, and through taxes and transfers. They also create health inequality. This paper demonstrated that residents of states in the U.S. with greater gaps between the rich and the poor had poorer health—and states with the biggest gaps between the rich and poor had higher mortality rates. Economic inequality was also related to educational outcomes, crime, and—my favorite—the number of books per capita in public libraries.
  • Cumulative Impact of Sustained Economic Hardship on Physical, Cognitive, Psychological, and Social Functioning (New England Journal of Medicine, 1997) Being poor is bad for your health, and being poor for a prolonged period of time is even worse. This study showed that people whose incomes were below 200 percent of the federal poverty level for a period of 29 years had worse physical and mental health and poorer physical functioning. Poverty is a life-course phenomenon, and the portion of your life-course that you spend in poverty lays a footprint on your health.
  • Lifting Gates—Lengthening Lives (In Social and Economic Policy as Health Policy, New York: Russell Sage, 2008) In this study we looked at the huge changes in the economic circumstances of black women in the decade following the Civil Rights and Voting Rights acts of 1964 and 1965. Because of the increased opportunity provided by these acts, black women in the South moved from working as maids to being clerical workers. We found that by 1979, employed black women and employed white women were basically at parity in terms of income—and those better jobs and increased economic well-being led to big health changes. We saw large declines in the disparities in cardiovascular disease between black and white women, and we saw the difference in life expectancy between blacks and whites go down—mostly in the South, where these changes were the biggest.

New Directions

During his tenure at Michigan, George Kaplan founded and directed the UM Center for Social Epidemiology and Population Health and the Robert Wood Johnson Health and Society Scholars Program. Both initiatives “reach far across campus,” Kaplan says, and both provide a forum through which faculty and students from disciplines as disparate as public policy, neuroscience, sociology, economics, cardiology, and urban planning, among others, can work together to deepen their— and our—understanding of how social divides become health divides.

Now that Kaplan has moved to emeritus status, colleague Ana Diez Roux, professor of epidemiology, has assumed the directorship of both entities. An expert in the relationship between neighborhoods and health, Diez Roux—who was recently elected to the Institute of Medicine—hopes to expand the global health component of the center and to further the work of the Health and Society Scholars Program in promoting interdisciplinary research by top young scholars.