Health and Wealth: The Downside of Plenty

One would hope that beneath all the noise emanating from Washington DC, serious policy discussions were actually taking place. Prominent among these should healthcare. The relative value of the Affordable Care Act or any potential alternatives aside, an oft-overlooked aspect of national health is the impact of lifestyle factors that greatly impact health outcomes in the long run.

Even the most lightly informed individual can be trusted to know that America has one of the highest obesity rates in the world and is the worst in this regard among developed Western nations. Sure, Michelle Obama advocated for healthy diets in schools, but the impact of such advocacy hardly entered into policy discussions on healthcare. While healthcare spending in the US is the highest in the world, a cursory look at measures of outcomes leaves observers underwhelmed. A pair of lengthy posts at Random Critical Analysis get at why this connection between high healthcare expenditures and middling outcomes in the US misses the mark in some critical ways. First, "exceptionally high health care expenditures are well explained by [America's] unusually high material standard of living."1 Secondly, "gaps in health outcomes are quite well explained by behaviors (or at least indicators there of) related to diet and lifestyle." These reasoning behind these points are put forward in great detail and backed up with data in the posts. Without delving into the rabbit hole of individual points brought up therein, a key takeaway is that wealth and a high standard of living can lead to some negative trends in national health.

Looking beyond the US and other wealthy nations, a case study demonstrating this negative relationship between wealth and health comes from a favorite country of mine, Cuba. With the fall of communism in Russia, Cuba faced severe shocks through the 1990s as the largesse of its greatest benefactor disappeared. The shortages of food and fuel during the "Special Period" wreaked havoc on the Cuban economy and disrupted the patterns of daily life. Buses no longer operated and Cuban farms could not support the population. The consequences of this for the average citizen were smaller portions, more walking, and a greater proportion of food supplied by local farmers.2 Nationally, this meant that public health improved with regards to several measures.

A study published in the BMJ found that the average Cuban lost 12 pounds of weight in the early years of the Special Period, diabetes prevalance fell 53% between a peak in 1986 and 1997, coronary heart disease mortality rates fell 34.4% between 1996 and 2002, among many other markers of health. Not all the health impacts were beneficial during this crisis. The death rate for the elderly increased 20% between 1982 and 1993. The Special Period was an incredibly trying time for the Cuban people as all aspects of life were disrupted.

That weight loss occurs as a result smaller portions and more walking is not surprising. That diabetes and heart disease rates fall following weight loss is also unsurprising. What is surprising is that these would occur sharply on a national level. When the trend globally has been just the opposite.

The Special Period did come to an end in the second half of the 1990s. As economic normalcy returned, so did the aforementioned health measures begin to rise once again. Physical activity levels have tapered off as vehicles have returned to the roads, food intake returned to pre-crisis levels by 2002, and obesity rates have shot up. Diabetes measures have returned to or surpassed levels prior to the crisis, though heart disease mortality has stayed low.

This all is not to celebrate the glories of failed economic systems. Instead, it ought to display the complexity of healthcare and the difficulty of tackling public health issues. A country getting wealthier is objectively a good thing, but that wealth can come at a cost. Peculiar beneficial effects can be found in otherwise disastrous circumstances. Most Cubans would probably accept the tradeoff of higher obesity and diabetes rates for buses that run and reliable access to food. As debates in Washington go on about the merits and faults of single payer, insurance mandates, pre-existing condition coverage, and the litany, perhaps more heed should be given to examining how to decouple growing wealth from growing waistbands.

1 One of the arguments presented is that the relationship to be examined should not be healthcare expenditures and per capita GDP, but rather healthcare expenditures and Actual Individual Consumption (AIC). AIC takes into account goods and services purchased by households in addition to services provided by non-profit institutions and governments. In this sense, it is a better reflection of standards of living and in this regard the US leads other countries. Further, the relatonship between healthcare spending and AIC is best modeled non-linearly. In this the US is no longer that outlier it appears to be when a simple linear analysis of GDP vs spending is conducted. As a country's standard of living increases over time, its healthcare spending and outcomes often look more like the US.

2 The Special Period also demonstrated the ingenuity of responses to a crisis. Bizarre looking camello trailer buses were a much-maligned Havana staple for more than a decade. Organopónicos, public urban organic farms, are still commonplace today.