A review by John M Repp of the new book Inequality Kills Us All: COVID-19’s Lessons for the World by Stephen Bezruchka (Routledge: New York, 2023)
The study and understanding of global health requires that countries’ health measures be compared. Dr. Bezruchka makes the striking statement “A person who knows only one country knows no country” (p.49). I remember collecting signatures for a petition against the U.S. invasion of Iraq before the invasion of Iraq on March 20, 2003. Out of curiosity I asked the people who were signing if they had lived outside the country or spoke another language. Many had, mostly former exchange students or Peace Corp volunteers. They knew it was wrong to invade Iraq. Bezruchka took the opportunity to work and live in Nepal for the 10 years after he got his medical degree to practice and develop a clinic into a teaching facility.
Some of the primary health measures which can be compared are 1) longevity (how long we live), 2) infant mortality (per cent of babies born alive), and 3) maternal mortality (the percent of mothers who die birthing babies). Currently, the United States is behind the first 44 nations in longevity. If there were a Health Olympics, we would not make it out of the trials.
In addition to comparing countries, we can compare the same country over time, and show improvement or not. For example: in the early 1950’s, the United States was very near the top of the standard population health measures. 70 years later, we are very far behind in most measures. Our overall health has improved since the 1950’s but in comparison to all other wealthy countriesand a few others we lag.
In addition to us slipping down as far as longevity goes, Bezruchka explains that we have not done well in comparison to other wealthy countries in another population health measure child mortality. (p.11) (the number of children dying every day during their first five years.) “ about 50 children die here every day who wouldn’t die if we had Slovenia’s rate” of child mortality. That number of our children dying is much higher than mass shooting deaths, but “where is the alarm?” asks Bezruchka.
Tragically, very few Americans know about these facts because it is not discussed in our media. Even thirty years ago, it was barely discussed in global health study circles. The same is true of our COVID-19 numbers. We lead in absolute numbers of cases and deaths.
The big question is WHY? Why do we, the richest country in the world, have such bad health relative to other wealthy countries?
It is not because we don’t spend a lot of money on health care. We spend almost as much as the rest of the world combined! We concentrate our spending on the old and the sick. By way of contrast, “the Scandinavian countries spend up to sixty (60) times as much per capita on childcare than the United States does.” (p.99) This sixty times per capita includes a fully paid year leave of absence for the mother, which we say we cannot afford.
It is not health care that makes for a healthy population. The health care system is used most when our health is failing. The factors which are important for health are not just good living conditions like housing, a meaningful job, safety, but more importantly it is the respect of others and being held in good standing. We are a social species. Bezruchka writes: “..humans are an altruistic species when it comes to group behavior”
We are told we live in a meritocracy, that everyone reaches the level of competence and is rewarded accordingly. In the private sector, the pay difference can be 300 times or more, the wealth difference even more. This inequality cannot be justified and creates stress in the society. The poor blame themselves for not being rich, and the rich look down on everyone. And now with the pandemic, we have too much bad stress in our bodies which leads to chronic health burdens. Such a stressful society hurts even the longevity of the rich, thus the title: Inequality Kills Us All.
On page 113, Bezruchka has printed a graphic from the Department of Health of Hawaii. (see below) It shows the image of a high mountain with a stream, becoming a waterfall, turning into a river that empties into the ocean. Upstream are the root causes which is “political context and governance.” and the “social/economic conditions”. On each side of the waterfall are listed the social determinants of health, conditions like racism, pollution, poverty, income, and wealth. Next to the coastline are “access to health care” and “the risk factors like smoking and obesity”. In the ocean are the downstream effects like cancer, arthritis, heart disease and diabetes. We are told that lack of access to health care and risk factors like smoking and obesity rather than the upstream root causes are the cause of our low health numbers. Bezruchka writes: “Health results from collective decisions made through the political process.” (p.113) The importance of political decisions, like allowing such massive inequality, more tax cuts for the rich and not paying for a year’s parental leave of absence, is bad for our country’s health but these root causes are not examined.
Hawaii has the best health of our 50 states, but the Japanese are the healthiest people on earth. The story of Japan on page 165 to 166 is very instructive. At the end of the war, the life expectancy would have been 24 years. The United States then occupied Japan for 5 years. General Douglas MacArthur was the head of the occupation. He and his team wrote the new Japanese Constitution.
Article 9 abolished the military. Other articles instituted a democratic process, with women’s suffrage, free universal education, the worker’s right to organize and bargain collectively, and the right to a minimum standard “of wholesome and cultured living.” The 13 large family corporations called zaibatsu that dominated the economy were broken up. A maximum wage was set up, and the leaders of the zaibatsu got an even lower maximum wage. MacArthur purchased the rice producing land from the 37,000 landlords and sold it back to the tenants for the price he paid. 94% of the lands changed hands. Historians have seen it as “the most successful land reform ever” (p.166) More than 70 years later, Japan is the healthiest country in the world.
The case of Russia shows us the opposite of Japan. After the collapse of the Soviet Union in 1991, the state assets were commandeered by the oligarchs and Russia experienced a rapid health decline. Pre-breakup level health has been restored, but it took 30 years for that to happen. (p.66)
Something like the Japanese recipe could work in the United States. Bezruchka writes that the decline in our nation’s health is only going to get worse. This book should be used by many study groups, reading a chapter at a time, and figuring out how to build a movement to deal with inequality.