Blog Action Day - 10/15/08 - Poverty and Health -- Lack of Money May Not Be the Real Problem

Once again it is October 15, and Blog Action Day has rolled around for the second time. This year the issue for discussion is poverty. This blog, focusing on medical and scientific issues from a usually political point of view, doesn't exactly lend itself to this issue, but let's see what I can do.

Debility due to malnutrition.

That is the definition of poverty.

What's that you say? You think poverty has a different definition? Well, that's because you don't use my dictionary.

The medical definition of poverty is exactly that: debility due to malnutrition. Says so right in the medical dictionary. I can't blame you for thinking I've gone off my rocker (but do recall I am certifiable and could go postal on you at a moment's notice). The word poverty had a different meaning to me as well until about two minutes ago when I looked it up in the medical dictionary. The definition that first came to my mind was probably the same you thought of: the state or condition of having little or no money, goods, or means of support; condition of being poor; indigence. Believe it or not, the medical world is actually concerned about this more common definition, as poverty affects the health of our patients in many ways.

Researchers are also focusing on how poverty ('low socioeconomic status') influences health. From the Center for the Advancement of Health:

Socioeconomic status is one of the strongest predictors of health and longevity. It is not poverty or wealth alone that is the factor: researchers have found that at each step down the socioeconomic ladder, health is poorer on average and people die younger.

The most obvious way that this could happen is through less access to medical care. But this is apparently not the only reason:

The influence of socioeconomic status on personal health cannot be explained solely by access to good health care. Also playing significant roles are health behaviors (diet, exercise, smoking, abuse of alcohol and drugs) and stress associated with disparities in income, wealth, education, and occupation.

Further analysis uncovers more surprising findings. Lack of money isn't the real problem either:

When people think about socioeconomic status and health, they assume it's abject poverty, that there's a threshold at the poverty level, a point above which your needs are met and everything should flatten out. But that's not how it is.... Even at the upper socioeconomic levels, where everyone has good housing and adequate nutrition and their physiological needs are met, there is still a difference in health and well-being between those at the top and those just near the top, and there's a gradient that follows on down to the bottom of the economic ladder.

And it isn't just where you are right now. There is a cumulative effect of being economically disadvantaged that follows you throughout your life:

We've learned that the health of older individuals today shows the strong footprints of their economic histories from decades earlier. My colleagues and I asked how many times over the last 29 years they had been living at income levels below 200 percent of the poverty line, which used to be the standard cutoff for "disadvantaged" levels. Then we looked at their current health and found that the cumulative burden of economic disadvantage was visible in all of the outcomes.

It even begins before you are born:

We see the intrauterine transmission of social class as a biological phenomenon: children born with lower birth weights, less than optimal placental weight and head circumference have worse futures. These often represent the effects of prenatal malnutrition and poor medical care, stress and a whole variety of other things experienced by people who are poor. We think that what these studies are showing is the tracking of disadvantage through the uterus into birth outcomes and subsequent disease.

What causes this? Stress, or rather, a particular kind of stress:

There's this gnawing issue of social ordering, about being higher or lower in the social hierarchy, that affects health. You find it no matter what indicator you use, whether you use income, occupation, or education. We're studying this in animals, because animals on the low end of their hierarchy also display worse health than higher-ranked animals.

How does this work? It isn't clear. It may be through more than one mechanism:

One concept is what we call reactive responding. The lower you are in the socioeconomic hierarchy, the more you have to respond to stimuli that are immediate and emotion-driven and that don't give you much chance to plan your response. Often, the stimuli involve some kind of threat. So your immediate response is quite negative.
You develop negative expectations that may become self-fulfilling prophecies, which themselves create more physiological arousal. The system can become hyperactive and not turn off. Or, it may give up and not turn on at all, so you have almost no reaction to even serious threats. That also turns down the immune response and puts you at risk. We need to understand a lot more about the mechanisms involved.

But what does this do to the individual? Is this it -- or only one aspect of it?:

According to the article, the question Farah et al. set out to investigate is the extent of low socioeconomic status on neural structure.
She and her colleagues have investigated the issue by trying to tease out which aspects of poverty alter specific cognitive skills, such as memory, language, and the ability to delay gratification. The researchers studied a group of African-American children of low socioeconomic status, who had been tracked from birth through high-school graduation by Hallam Hurt, a pediatrician at Penn.
Over the years, Dr. Hurt's team had assessed the home environments of the children, monitoring how nurturing parents were, and how intellectually stimulating the homes were—for example, whether the children had access to books and visited museums.
Farah et al. reportedly found that cognitive skills were linked with particular features of the environment, such as how "intellectually stimulating" the home environment was.
To test why, the researchers did MRI scans of the children. They found that students raised in nurturing homes generally had bigger hippocampi, the portion of the brain associated with forming and retrieving memories. The discovery dovetails with previous research in rodents, which showed that rats raised in a stressful environment develop smaller hippocampi.

And even more troubling is this finding:

In recent years there's new literature that shows that it's not just how much money the people in a particular area have that predicts how healthy that population will be. It's also how fairly the income and wealth are distributed. In geographic areas with more egalitarian distribution of income there's better health, and that effect is actually independent of the average level of income or the relative poverty rates in the area.

Of course, all of this does not provide any solutions or cures for this problem. In fact, if health disparities follow a gradient up the socioeconomic spectrum from bottom to top as suggested above, it may not matter if we get rid of abject poverty (for lack of a better term). The only thing that will change is the types of problems we'll see along the raised-up spectrum. But at least this information points in some intriguing directions about how to help reduce suffering. And points out that, at least in regards to health, in poverty, a lack of money may not be the real problem.