ere’s a sad fact about the United States, the country with the highest per-capita spending on health care in the world: Wealthy people are significantly healthier than poor people. That gap exists in part because the rich can afford better health care than the poor. But there’s much more to it than that.
As leaders in medical education, health care delivery, and social equity in medicine, we were deeply distressed by the fortunately derailed Republican health care proposal that would have left 14 million currently insured Americans without health coverage by next year. Five million of those individuals would have lost coverage through Medicaid, which provides access to health care for people living in poverty.
Yet we weren’t surprised by this rebuke of the poor. Regardless of political ideology, Americans often strive for unbound individualism, believe that hard work yields success, and trust in the principles of a free market. These values are so ingrained that we accept them as common sense and foregone conclusions, forgetting that they are actually the result of human attempts to shape the world as we wish it to be.
Unwavering commitment to such values, however, leads to a disregard for and even contempt for a growing portion of our nation’s populace: the poor. Many tend to blame personal irresponsibility, laziness, or immorality for poor people’s lot in life and their excessive cost to our health care system. That perpetuates the toxic and inaccurate belief that individuals are fully and exclusively responsible for their circumstances. Such sentiments create an environment that permits those in power to broadly dismiss the health of the poor.
Far too many people overlook or ignore social determinants of health. These are the conditions into which people are born and that influence how they grow, work, live, and age. This wider set of forces and systems shape the conditions of daily life and have a profound influence on health through the life course. Racism, sexism, xenophobia, and other forms of prejudice influence health as dramatically as biological factors do.
Discriminatory systems born from hundreds of years of prejudice create chronic stress and a lack of access to healthy, affordable food and housing, safe outdoor spaces, and fair-wage jobs. These inequities and others have led to millions of people focused on surviving rather than on thriving.
As a result, residents of metropolitan US areas have vastly different life expectancies across short distances that encompass steep grades of social and economic inequality. Black women and infants in the US have far higher adverse outcomes during pregnancy than white women and infants. Individuals with serious and persistent mental illness, who lack adequate social support and access to care, die on average 25 years earlier than the general public. A new series in The Lancet highlights how income inequality is driving the ever-widening gap in health between the poor and the not-poor in America.
Liberation theology, a progressive Catholic movement that emerged in Latin America in the 1960s, argued that the poor get sick and die not because of individual choices but because social forces such as racism, classism, and sexism gave great privilege and power to some in society and deeply wounded others. Such social forces disproportionately cause sickness and death among the poor as the result of what is called structural violence — the idea that the structures of a society can inflict damage on the health of poor communities. This is no less true today.
To repair such wrongs, advocates of liberation theology argued that we needed to make a preferential option for the poor, meaning we must work to ensure that the poor receive the best care and support available, beyond simply our surplus.
We believe that a preferential option for the poor is desperately needed today. It can be achieved in part by changing how health care providers learn to understand their patients.
We are members of the Social Medicine Consortium, a collective of individuals, universities, and organizations fighting for global health equity. Today, on World Health Day, the consortium released a consensus statement titled “Advancing Health Equity This Generation: The Case for Social Medicine.” Before going further, we would like to recognize and deeply thank the hundreds of health professionals from all over the world who have spent the last year and a half shaping the consensus statement.
The statement calls for the disruption and transformation of the way we train health professionals in the US and around the world to more honestly incorporate learning about the social and structural determinants of health so these professionals are prepared and able to make a preferential option for the poor.
More than 250 leaders in the global health equity movement have signed the consensus statement. (You can sign it here.) Many of these leaders, the majority of whom are trainees in the health professions, will gather on April 29 at Malcolm X College in Chicago to deepen their commitment to advancing health equity through community building and improving social medicine skills. Every medical school in Chicago is participating, recognizing that this initiative matters enough to transcend local market competition in health care.
As educators of future health professionals, we have found that a framework emphasizing a preferential option for the poor offers a just and more accurate alternative to how the US currently understands and responds to health inequities. We reject the idea that it is natural for the poor and people of color to die earlier than others, and instead recognize that health inequities are the result of conspiring forces of our society’s creation. We reject the idea that some lives are more valuable than others, and instead affirm the equal dignity of all. And we reject the idea that we are in a zero-sum, competitive game of finite resources, and instead affirm that we are all better off when we value, respect, and uplift all members of society.
We have no illusion that an organization like ours or a consensus statement can rapidly reverse several hundred years of the evolution of health and educational systems rooted in racism, sexism, classism, eugenics, exclusion, careerism, colonial medicine, and a refusal to truly address the root causes of illness. But we can try.
Michael Westerhaus, MD, is co-director of SocMed and assistant professor of medicine at the University of Minnesota. Amy Finnegan, PhD, is the co-director of SocMed and chair of Justice and Peace Studies at the University of St. Thomas in St. Paul, Minn. Jennifer Goldsmith is the managing director of EqualHealth and administrative director of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. Evan Lyon, MD is medical director of the Heartland Alliance. Casey Fox is executive officer of EqualHealth. Michelle Morse, MD, is the founding co-director of EqualHealth and assistant program director of the internal medicine residency program at Brigham and Women’s Hospital. The authors are cofounders of the Social Medicine Consortium.