Transcript: What Determines Health - Part 1 | Oct 15, 2003

(music plays)

Against a blurry background of blue and pink pills, a video reel displays pictures of medical gear such as a needle, a scan of a human body and heart rate monitors.

The title of the show slides in: “Mini-Med School.”

Then, John Frank stands on a stage in a university auditorium giving a lecture. He’s in his mid-fifties, with a goatee and receding blond hair. He’s wearing glasses, a white shirt and a dark patterned tie.

Behind him, a computer screen is projected on a tall white wall.

John says IT'S MY PLEASANT
TASK TO TALK A LITTLE BIT ABOUT
HOW PEOPLE GET SICK IN THE
FIRST PLACE.

A caption appears on screen. It reads “John Frank. University of Toronto.”

He continues AND I'M NOT GONNA RESTRICT
MYSELF TO HEART DISEASE OR
CANCER, OR ANY ONE DISEASE,
BECAUSE I'VE STUDIED DOZENS OF
DIFFERENT DISEASES IN MY CAREER
AS AN EPIDEMIOLOGIST.

The caption changes to “What Determines Health.”

He continues AND FOR WHICH FAMILY PRACTICE
WAS A VERY GOOD TRAINING, THE
FIRST 25 YEARS OR SO.
AND AH, I, I, I NEED TO DO
THAT, TO HELP YOU UNDERSTAND
THE BIG PICTURE.
THAT IN THE BIG PICTURE THERE
ARE SOME PATTERNS THAT REPEAT
THEMSELVES, THROUGH HISTORY AND
IN DIFFERENT SOCIETIES, ABOUT
THE, THE CAUSES OF ILL HEALTH
IN GENERAL.
THE AH, THE KIND OF THINKING
THAT I'M GONNA TALK ABOUT
TONIGHT IS REALLY LARGELY DUE
TO A GROUP OF COLLEAGUES THAT I
REFER TO, IN THE CANADIAN
INSTITUTE OF ADVANCED RESEARCH,
FOUNDED BY FRASER MUSTARD, WHO
WAS A MENTOR TO ME AND STILL
IS.
AND FRASER HAD MANY IDEAS IN
THE MID 80S ABOUT HOW TO MOVE
RESEARCH FORWARD IN CANADA.
NOT JUST HEALTH RESEARCH, BUT
ALL KINDS OF RESEARCH.
AND ONE OF THEM WAS TO FORM
GROUPS OF PEOPLE FROM DIFFERENT
DISCIPLINES, DIFFERENT ACADEMIC
BACKGROUNDS.
HE'D GET THEM TO THINK TOGETHER
ABOUT A PROBLEM, AND I WAS
LUCKY ENOUGH TO BE BROUGHT INTO
SUCH A GROUP IN 87, CALLED THE
POPULATION HEALTH PROGRAM.
AND WE TALKED ABOUT IDEAS WITH
ECONOMISTS AND ANTHROPOLOGISTS
AND MEDICAL EPIDEMIOLOGISTS
LIKE MYSELF, AND THAT, THAT WAS
A WONDERFUL EXPERIENCE.
AND THE IDEAS I'M GONNA PRESENT
TO YOU WERE REALLY PUT TOGETHER
BY THAT GROUP OF PEOPLE.
AND LATER IN THE SLIDE SHOW,
YOU'LL SEE THE BOOK THAT WE
WROTE TOGETHER.
I GET NO ROYALTIES.
THEY'RE ALL GIVEN TO GOOD CAUSE
FROM THAT BOOK AND IT'S STILL
AVAILABLE ON ORDER.
THE FIRST THEME IN THESE IDEAS
IS THAT MEDICAL CARE IS
WONDERFUL AND IT'S GETTING
BETTER ALL THE TIME.
BUT THERE ARE INHERENT
LIMITATIONS TO WHAT IT CAN
ACHIEVE.
AND THAT TO SEE SOME OF THOSE
LIMITATIONS WE NEED ONLY LOOK
BACK IN HISTORY, AND NOT VERY
FAR BACK TO SEE THAT IT MAY NOT
BE SUCH A POWERFUL DETERMINANT
OF THE STATUS OF HEALTH OF A
WHOLE POPULATION, A WHOLE
SOCIETY.
IF WE WERE TO TAKE ALL OF HUMAN
HISTORY OVER THE LAST 200,000
YEARS AND COMPACT IT INTO ONE
CALENDAR YEAR, WE WOULD BE ABLE
TO SAY THE HUMAN POPULATION ON
THE PLANET REALLY STAYED VERY,
VERY LOW AND STABLE UNTIL VERY
LATE IN THE YEAR.

He runs a PowerPoint presentation. A slide shows a line graph. It reads “200,000 years represented as one calendar year.”

He continues MEANING QUITE RECENTLY IN
HISTORIC TIME.
AND IT'S ONLY QUITE TOWARDS THE
END OF DECEMBER, OR THE LAST
SEVERAL HUNDRED YEARS, THAT WE
BEGIN TO SEE AN INCREASE HERE.
LARGELY IT'S THE RESULT OF,
INITIALLY OF BEING ABLE TO DO
AGRICULTURE, TO FARM.
BUT THERE WAS SOMETHING ELSE
THAT HAPPENED, AND IT DIDN'T
REALLY HAPPEN UNTIL THE LAST
CENTURY OR TWO.
AND IT CAUSED THIS INCREDIBLE
EXPLOSION OF PEOPLE, AND OF
COURSE THERE'S ONLY TWO WAYS
YOU CAN GET MORE PEOPLE, OR
INDEED ANY SPECIES ONTO A
PLANET.
THEY EITHER HAVE TO DIE LESS
OFTEN OR THEY HAVE TO MAKE MORE
BABIES.
AND BELIEVE IT OR NOT, PEOPLE
DID NOT DISCOVER HOW TO MAKE
BABIES IN THE 1800S.
THEY KNEW ABOUT THAT.
SO, THE ANSWER OF COURSE IS
THAT THEY BEGAN TO DIE LESS
OFTEN.
MUCH, MUCH, LESS OFTEN.
AND THE PUZZLE THAT WE STILL
HAVE TODAY IS WHY?
CAUSE DEATH, EARLY DEATH'S A
MARKER OF COURSE OF BAD HEALTH
STATUS.
THE BEST MARKER THERE IS.
IT MEANS THAT THE HEALTH STATUS
VASTLY IMPROVED ALL OVER THE
WORLD, AT LEAST THE DEVELOPED
WORLD STARTING ABOUT 100 AND,
200 YEARS AGO.
WE KNOW SOMETHING ABOUT THIS
FROM THE WORK OF THOMAS
MCKEOWN.
A CANADIAN WHO WORKED IN THE
U.K.
HE PASSED AWAY ABOUT A DECADE
AGO.
AND HE WAS THE FIRST PERSON TO
GO BACK AND LOOK AT THE
INFORMATION FROM THE U.K.
REGISTRAR GENERAL'S RECORDS OF
DEATHS AND CAUSE OF DEATH,
STARTING IN 1838.
AND WHAT HE NOTICED WAS THAT
WHEN HE WENT BACK AND PULLED
OUT THE DEATHS PROBABLY DUE TO
TUBERCULOSIS.
IN THOSE DAYS IT WAS CALLED
FISSUS OR CONSUMPTION.
AH, BUT IT WAS A PRETTY CLEAR
CUT CAUSE OF DEATH BECAUSE OF
ITS SYMPTOMS AT LEAST IN
ADULTS.
AND HE WAS ABLE TO SHOW THAT
THE RATE OF DEATH FROM
TUBERCULOSIS WAS GOING DOWN
LONG BEFORE WE FIRST FOUND OUT
THE KIND OF BUG THAT CAUSES IT,
OTTERKOCH.

He uses a laser pointer to point to another line graph.

He continues LONG BEFORE WE HAD THE FIRST
DRUG, STREPTOMYCIN TO TREAT IT,
IN THE 40S, AND LONG BEFORE WE
HAD ANY VACCINE AGAINST IT,
B.C.G.
SO, HE CORRECTLY CONCLUDED THAT
THIS ENORMOUS DECLINE IN ONE OF
THE WORLD'S GREAT KILLERS
COULDN'T BE DUE TO MEDICAL
CARE.
HE SAW THE SAME PATTERN IN
DISEASES OF CHILDREN.
BUT HE WASN'T AS CAREFUL AS HE
SHOULD HAVE BEEN ABOUT NOTICING
THE TIMING OF THE DROP.
FOR INFANTS, THIS HAPPENS TO BE
WHOOPING COUGH, A BIG KILLER OF
INFANTS AND CHILDREN IN THOSE
TIMES.
IT'S STILL TODAY IN THE
DEVELOPING WORLD.
HE DIDN'T NOTICE THAT THE
DECLINE DIDN'T BEGIN UNTIL THE
LATE 1800S, AND THEN HAPPENED
REALLY OVER JUST A HANDFUL OF
DECADES DOWN TO MODERN LEVELS.
AGAIN, BEFORE WE KNEW THE
ORGANISM, BEFORE WE HAD
IMMUNIZATION AND LONG BEFORE
ANTIBIOTICS TOUCHED THE
DISEASE.
SO, MCKEOWN GUESSED RIGHT THAT
MEDICAL CARE COULDN'T HAVE
CAUSED THOSE INCREDIBLE
DECLINES IN DEATH.
AND HE THOUGHT THE ANSWER MUST
HAVE BEEN GENERALLY IMPROVED
NUTRITION.
HE KNEW IT COULDN'T BE WATER
AND SANITATION, BECAUSE THESE
TWO DISEASES ARE SPREAD BY
DROPLETS, LIKE SARS.
RIGHT?
YOU CAN HAVE THE CLEANEST WATER
IN THE WORLD.
IT'S NOT GONNA PROTECT YOU FROM
SARS.
YOU JUST HAVE TO BREATH
SOMEBODY ELSE'S EXHALATION.
SO, THE TRUTH OF THE MATTER IS
THAT HE CORRECTLY DEDUCED THAT
IT HAD TO BE SOMETHING ABOUT
THE WAY PEOPLE WERE LIVING.
BUT HE MISSED SOME IMPORTANT
CLUES.
HE MISSED THE FACT THAT BRITISH
PARISH BIRTH RECORDS SHOW THAT
IN THE LAST FEW DECADES OF THE
LAST CENTURY, ORDINARY PEOPLE
WITH NOTHING BUT VERY PRIMITIVE
METHODS OF BIRTH CONTROL, WHICH
I NEED NOT DESCRIBE TO YOU.
SOME OF YOU ARE OLD ENOUGH TO
KNOW WHAT I MEAN.
MANAGED TO SPACE THEIR CHILDREN
MUCH FARTHER APART.
THEY BEGAN TO HAVE CHILDREN,
NOT IN A FAMILY LIKE THIS,
ALFRED THE FIRST, BORN WAY BACK
AROUND 1850.
THE BABY, ALFRED, WITH ONE
SIBLING EVERY YEAR OR TWO.
THOSE THAT SURVIVED.
A QUARTER OF THEM ALL DIED BY
AGE FIVE.
BUT RATHER, FAMILIES BY THE
EARLY 1900S BEGAN TO LOOK LIKE
FAMILIES TODAY.
MAYBE THREE, MAYBE FOUR
CHILDREN ON AVERAGE.
AND ALFRED OF COURSE, THEREFORE
TWO TO THREE YEARS YOUNGER THAN
THE NEXT SIBLING.

A slide displays a family with one daughter and one son. It reads “1930. Alfred Life Expectancy: 65.”

He continues TWO TO THREE YEARS YOUNGER THAN
THE ONE ABOVE IT.
AND WHAT WE NOW KNOW IS THAT,
THAT IS THE KEY TO MASSIVELY
REDUCING INFANT MORTALITY.
HOW?
BECAUSE JUST HAVING A SIBLING
TWO OR THREE YEARS EARLIER,
INSTEAD OF ONE YEAR EARLIER,
MASSIVELY IMPROVES YOUR CHANCES
THROUGH THREE, OR AT LEAST
THREE DIFFERENT MECHANISMS.
FIRST, THE MOM IS NOT TRYING TO
LOOK AFTER TWO LITTLE ONES AND
BREAST FEED TWO LITTLE ONES AT
ONE TIME.
AND EARLY WEANING IS AVOIDED.
SECONDLY, THE MOM IN THOSE
TIMES WOULD ACCUMLATE LIKE
WOMEN, POOR WOMEN ALL OVER THE
DEVELOPING WORLD DEFICIENCIES
IN IMPORTANT NUTRIENTS LIKE
VITAMIN A AND IRON, WHICH SHE
WOULD BE UNABLE TO TRANSMIT TO
BABIES CLOSE TOGETHER.
AND THE BABIES WOULD BE BORN
WITH SEVERE, BUT OFTEN NOT
APPARENT, IMMEDIATELY APPARENT
DEFICIENCIES IN WHAT WE CALL
MICRO NUTRIENTS.
THEY COULD LEAD TO HUGE
MORTALITY, HUGE DEATH RATES
WHEN THEY GOT MEASLES,
DIARRHEA, PNEUMONIA AND SO
FORTH.
AND LASTLY, IT TURNS OUT THAT
HAVING A SIBLING THAT MUCH
OLDER MAKES IT MUCH MORE LIKELY
THAT THEY'RE IMMUNE TO THOSE
ONE TIME CHILDREN'S DISEASES
LIKE MEASLES, AND THEREFORE
THEY DON'T BRING IT HOME TO THE
BABY.
SO, WE NOW KNOW THAT THIS
STRATEGY OF CHILD SPACING CAN
ALSO HELP OTHER COUNTRIES TO
REDUCE INFANT MORTALITY.
BUT WHAT'S MY MESSAGE?
MY MESSAGE IS THAT IT HAD
NOTHING TO DO WITH MEDICAL
CARE.
WHY WOULD PEOPLE SPACE THEIR
CHILDREN MORE?
WHAT SOCIAL AND CULTURAL AND
ECONOMIC FACTORS COULD MAKE
PEOPLE, WHO ONLY HAD COITUS
INTERRUPTUS, REMEMBER THAT?
BOY, THAT'S A LONG TIME AGO.
ABSTINENCE.
STILL NOT VERY POPULAR, AND
PRIMITIVE METHODS OF ABORTION.
HOW, HOW COULD THEY MANAGE IT?
HOW COULD THEY SPACE THEIR
CHILDREN?
WE THINK NOW IT MUST HAVE BEEN
FEAR.
THERE WERE SEVERE RECESSIONS.
THEY COULDN'T FEED ANOTHER
MOUTH, AND WE ALSO KNOW THAT
FOR THE FIRST TIME IT BECAME
ILLEGAL TO SEND YOUNG CHILDREN
OUT TO WORK.
AND THEREFORE EVERY MOUTH
WASN'T AN EXTRA PAYCHEQUE.
NOT A VERY PRETTY PICTURE OF
HUMAN NATURE.
BUT I HAVEN'T ANSWERED A
QUESTION.
I HAVEN'T TOLD YOU ABOUT THAT
FIRST DECLINE.
THE ONE ABOUT THE TUBERCULOSIS
THAT STARTED SO MUCH EARLIER.
REMEMBER?
THAT FIRST GRAPH STARTED WAY
BEFORE THE 1880S.
AND WHO DIED OF TUBERCULOSIS?
HAVE YOU BEEN TO OPERA
RECENTLY?
WHAT'S ALWAYS HAPPENING IN
OPERA WHEN YOU GET TO THE GREAT
ARIA?
THERE'S SOMEBODY ON STAGE AND
THEY'VE BEEN COUGHING BLOOD FOR
MOST OF THE PLAY, OR THEY
PRETEND TO.
RIGHT?
AND THEN THEY MIRACULOUSLY HAVE
ENOUGH WIND IN THEIR TEARILY,
DESTROYED LUNGS TO DO ONE MORE
ARIA.

The audience laughs.

John continues WHAT DISEASE DO
THOSE PEOPLE HAVE?
THEY HAVE T.B.
YOU KNOW, “LA TRAVIATA, LA
BOHEME,” IT GOES ON AND ONE.
SO, IT WAS A DISEASE OF YOUNG,
OTHERWISE HEALTHY ADULTS.
STARTING IN THEIR TEENS RIGHT
UP THROUGH.
AND THAT'S WHY WE THINK THE
EARLY TUBERCULOSIS MORTALITY
DECLINE, MUST HAVE BEEN DRIVEN
BY TOTALLY DIFFERENT FACTORS
THAN THE CHANGE OF BIRTH
SPACING.
NOW THE, THE ANSWER TO WHY AND
HOW DEATHS COULD HAVE STARTED
TO PLUMMET IN, AROUND 1700, HAS
BEEN A MYSTERY UNTIL THE LAST
DECADE.
AND THE WORK OF A VERY
RENEGADE, ECONOMIC HISTORIAN,
NAMED ROBERT FOGEL AT THE
UNIVERSITY OF CHICAGO, HAS
BEGUN TO SUGGEST THAT THE
ANSWER LAY IN IMPROVED
NUTRITION, WHICH THOMAS MCKEOWN
HAD GUESSED WITHOUT HAVING ANY
PROOF.
WHAT FOGEL DID TO PROVE THIS
WAS TO COLLECT THE OLD
RECRUITMENT RECORDS FROM THE
PRESS GANGS, WHEN THEY'D LINE
UP MEN AND BOYS THAT THEY
NEEDED TO GET INTO THE ARMY AND
MEASURE THEIR HEIGHT AND
WEIGHT.
HE FOUND THEM IN THE ARCHIVES
OF THE BRITISH, NORWEGIAN,
FRENCH, HUNGARIAN, AND OTHER
ARMIES.
HE PULLED OUT THE RECORDS AND
HE SHOWED THAT THE MEAN HEIGHT,
THE AVERAGE HEIGHT OF THESE
YOUNG MEN WAS STUNTED.
THEY WERE STUNTED.
AND THAT AS THE LAST TWO
CENTURIES HAVE GONE BY, EACH
GENERATION GOT TALLER AND
TALLER.
REMEMBER DAVID COPPERFIELD?
REMEMBER THOSE LITTLE, STUNTED
GUYS IN THE STREETS OF LONDON?
THEY WERE STUNTED.
AND THEY'RE STUNTED BY THE ONLY
MECHANISMS THAT REALLY CAN DO
IT AT THE POPULATION LEVEL.
POOR FOOD THROUGHOUT CHILDHOOD,
AND RECURRENT, INFECTION.
WHAT WE KNOW NOW FROM FOGEL'S
WORK IS THAT SOMETHING CAUSED
WESTERN NATION STATES AROUND
1700 TO START CARING ABOUT THE
NUTRITION OF THEIR POPULATION.
NOW, YOU KNOW A LITTLE ABOUT
THE KING OF FRANCE AND THE KING
OF ENGLAND AND THE OTHER KINGS
AT THAT TIME.
DO YOU THINK THEY WERE
MOTIVATED BY ALTRUISM AND GOOD
HEARTED HUMAN NATURE?
I DON'T THINK SO.
WHAT'S THE ONE THING THE KING
HATED TO HEAR WHEN THE HEAD OF
THE PRESS GANGS CAME BACK AND
SPOKE TO HIM ABOUT HOW
SUCCESSFUL THEY WERE IN
RECRUITING SOLDIERS?
HE HATED TO HEAR THAT THE
STREETS WERE FULL OF STUNTED,
UNHEALTHY, YOUNG MEN, BECAUSE
THERE WAS A WAR EVERY FEW
YEARS.
SO, THE KINGS BEGAN TO MOVE
FOOD AROUND TO THOSE PORTIONS
OF THE COUNTRY THAT WERE
INEVITABLY IN FAMINE, AND FOR
THE FIRST TIME THERE WAS AN
ACTIVE STATE POLICY TO REDUCE
MALNUTRITION BY VERY SIMPLE
FOOD TRANSPORT MECHANISMS.
SO AGAIN, MEDICAL CARE HAD
NOTHING TO DO WITH IT, AND IT'S
ALTHOUGH IT'S A SAD STATEMENT
ON HUMAN NATURE IT TELLS US HOW
THE BIG BRUSH STROKES OF
HISTORY ARE CREATED.
NOW, FOGEL'S MOST OUTRAGEOUS
CONCLUSION I SAVED FOR THIS
SLIDE, HE DID SOME
COMPUTATIONS.
ECONOMISTS, YOU KNOW, AND SAID
THAT THE SIZE OF PEOPLE HAD
INCREASED SO MUCH, BECAUSE OF
FEEDING THEM BETTER THROUGHOUT
CHILDHOOD, AND KEEPING THEM NOT
SO WASTED AND THIN IN ADULT
LIFE, THEIR MUSCLE IS BIGGER,
BECAUSE MOST WORK WAS PHYSICAL.
HE CONCLUDED THAT 50 percent OF
BRITISH ECONOMIC GROWTHS IN
1790 WAS JUST DUE TO BETTER
NUTRITION.
AND YOU THOUGHT IT WAS THE
STEAM ENGINE.

[Audience laughing]

John says SO, WHY DO I GO
INTO THIS?
BECAUSE WHEN YOU READ THE OP ED
IN THE STAR OR THE GLOBE OR THE
POST, YOU'RE ALWAYS READING
ABOUT HEALTH SERVICES.
YOU'RE ALWAYS READING THERE'S A
PROBLEM WITH HEALTH OUT THERE.
WE'VE GOTTA GET MORE HEALTH
SERVICES.
WE DON'T HAVE ENOUGH DOCTORS.
WE DON'T HAVE ENOUGH NURSES.
IT'S IMPORTANT TO REMEMBER IN
THE HISTORICAL BROAD SPAN OF
THINGS, THAT MOST BIG CHANGES
ARE NOT DUE TO MORE DOCTORS AND
MORE NURSES.
AND MANY PROBLEMS WE FACE
TODAY, SUCH AS THE EPIDEMIC OF
OBESITY AND OVERWEIGHT IN, IN
YOUNG PEOPLE, CANNOT BE HANDLED
BY DOCTORS AT ALL.
IT CAN ONLY BE CHANGED BY
SHIFTING CULTURE, WHICH WILL
EMBRACE PHYSICAL ACTIVITY AND
HEALTHIER FOOD HABITS.
DOCTORS CAN'T DO A THING.
SO, WHAT I NEED TO SAY TO YOU
THEREFORE IS THAT THERE'S A
NAIEVE VIEW OUT THERE, THAT
JUST LIKE THE THERMOSTAT IN
YOUR HOUSE WHEN THE HOUSE IS A
LITTLE COLD, YOU JUST TURN UP,
UP THE FURNACE.
THERE'S A NAIEVE VIEW THAT WHEN
THE HEALTH PROBLEMS OF THE
POPULATION ARE A LITTLE BIT TOO
MUCH, WE JUST TURN UP THE
HEALTH CARE AND GET A FEW MORE
DOCTORS AND NURSES AND THAT'LL
FIX IT.
THAT IS NOT THE WAY PEOPLE NEED
HELP WHEN THEIR ILLNESS STARTS
YEARS AND YEARS BEFORE THEY SEE
DOCTORS AND NURSES.
YOU CAN'T GET UPSTREAM WITH
ORDINARY CLINICAL CARE, NO
MATTER HOW WELL INTENDED.
IT'S GREAT FOR RESPONSE TO
ILLNESS.
IT'S VERY POOR AT CHANGING
CULTURE TO FIGHT SOMETHING LIKE
OBESITY, TOO MUCH SMOKING, TOO
MUCH DRINKING.
ALL THE OTHER PROBLEMS IN OUR
LIVES APOLLO HAS TALKED TO YOU
ABOUT TONIGHT.
SO, THIS NAIEVE MODEL, THE
THERMOSTATIC MODEL OF HEALTH
AND HOW TO FIX IT, HAS A FEW
PIECES OF EVIDENCE TO KNOCK IT
DOWN A LITTLE FURTHER.
PUT A FEW NAILS IN THE COFFIN.
ONE IS THIS LITTLE GRAPH, WHICH
SHOWS WHETHER CAUSES OF DEATH,
THE RATES OF DEATH FROM JUST
THOSE THINGS THAT MEDICINE CAN
STOP, MEDICINE CAN FIX, IS THE
WHY AXIS UP HERE.

A slide with a dot graph appears. It reads “Health Care Expenditure and GDP-Adjusted Mortality from Amenable Conditions 1980-1984.”

He continues MEANING THESE ARE CALLED
AMENABLE CONDITIONS.
JUST CONDITIONS THAT WE CAN
STOP PEOPLE FROM DYING FROM
WITH MODERN MEDICINE.
THE CAUSES OF DEATH FROM THOSE
DIVISIONS IN THESE COUNTRIES,
BEAR NO RELATIONSHIP AT ALL TO
THE U.S. DOLLARS PER CAPITA
SPENT ON HEALTH CARE.
YOU CANNOT BUY MORE HEALTH
STATUS FOR A POPULATION BY
BUYING MORE HEALTH CARE EASILY.
A LOT OF HEALTH CARE IS
WORTHWHILE, BUT IT IS FOR A
LEAD REDUCTION IN HUMAN
SUFFERING, AND RIGHTLY SO.
IT DOESN'T NECESSARILY CHANGE
OBJECTIVE MEASURES LIKE
MORTALITY MEASURES.
SO, IN OUR GROUP WE PUT
TOGETHER A LITTLE MORE
THOUGHTFUL APPROACH IN THIS
RATHER COMPLICATED PLUMBING
DIAGRAM AS WE CALL IT.
I'M NOT GONNA GO INTO IN
DETAIL.
I'LL JUST POINT OUT THAT IT, IT
MAKES A DIFFERENT AND MORE
COMPLEX ARGUMENT.

A diagram under the title “Population Health: Determinants” appears.

He continues IT SAYS, LOOK, PEOPLE HAVE A
SOCIAL ENVIRONMENT.
THEY HAVE A PHYSICAL
ENVIRONMENT, AND THEY HAVE A
BIOLOGICAL ENDOWMENT, WHICH IS
BOTH GENETIC AND WHAT HAPPENS
TO THEM IN THE WOMB.
THEY COME OUT OF THE WOMB.
THEY HAVE A BUNCH OF STUFF THAT
HAPPENS.
THEY HAVE RESPONSES.
THEY COME INTO ILLNESS.
THEY CAN RETURN TO HEALTH
STATUS AND FUNCTION.
ILLNESS PRECIPITATES HEALTH
CARE.
AND IN THE LONG RUN IF THEY
STAY HEALTHY, IT LEADS TO A
SOCIETY HAVING BOTH
PRODUCTIVITY AND WEALTH.
BUT IF THE SOCIETY STARTS TO
PUT TOO MANY RESOURCES INTO
HEALTH CARE, IT WON'T HAVE THEM
FOR SAY EDUCATION, HOUSING,
SOCIAL WELFARE, CHILD
DEVELOPMENT.
AND THAT IS THE POSITION THAT
OUR NEIGHBOURS TO THE SOUTH ARE
IN.
THEY ARE NOW SPENDING ALMOST
15 percent OF THEIR GROSS NATIONAL
PRODUCT, ALMOST THE HIGHEST IN
THE WORLD, ON HEALTH CARE.
THEIR HEALTH STATUS RANKS ABOUT
30TH IN THE WORLD.
PARTLY, THEY CAN'T INSURE IT
ALL, 40 MILLION AMERICANS.
PARTLY, THEY UNDER INSURE MANY
MORE THAN THAT, AND MOSTLY,
EVERYBODY'S FINGER'S IN THE
PIE, AND THE PIE HAS BEEN
SPOILED.
SO, THE TRUTH OF THE MATTER IS
THAT THINKING OF HEALTH CARE AS
AN ENGINE OF THE ECONOMY, AS
SOME SORT OF ORDINARY PRIVATE
SECTOR ACTIVITY IS VERY NAIEVE.
YOU CAN'T ALL GET RICH TAKING
CARE OF EACH OTHER WHEN YOU'RE
SICK.
THEY'RE WON'T BE ANYBODY TO DO
THE WORK.
HEALTH CARE IS A RESPONSE AND
IF WE INVEST TOO MUCH IN IT, WE
WON'T BE ABLE TO DO THE OTHER
THINGS THAT ANY SOCIETY SHOULD
DO.
THAT'S THE BOOK THAT WE WROTE,
PUBLISHED ABOUT EIGHT YEARS AGO
AND IT HAS ALL THESE ARGUMENTS
IN MORE DETAIL.
I WON'T GO INTO THEM RIGHT NOW.

A book cover reads “Why Are Some People Healthy and Other Not? The Determinants of Health of Populations.”

He continues UM, THE SECOND BASIC THEME IS
THAT THERE ARE THINGS ABOUT
WHOLE SOCIETIES, WHICH
POWERFULLY DETERMINE THE HEALTH
OF THEIR CITIZENS.
WHICH YOU CAN'T CHANGE, JUST
BECAUSE YOU MIGHT WANT TO BE
DIFFERENT.
YOU WERE BORN INTO A SOCIETY
AND IT'S ON A DIFFERENT
TRAJECTORY.
I DON'T THINK IN THE MIDDLE OF
AN IRAQI WAR, I NEED TO TELL
YOU HOW THAT'S OBVIOUS.
BUT I WANT TO GIVE YOU SOME
NON-WAR, NON-FAMINE EXAMPLES.
EASTERN EUROPE IN THE LAST 20
OR 30 YEARS AND JAPAN, AND
THESE ARE MOVING IN OPPOSITE
DIRECTIONS.

A slide reads “Changes in Life Expectancy since World War II: Eastern Europe, Japan.”

He continues FIRST, JAPAN.
JAPAN FINISHED WORLD WAR TWO
WITH HEALTH STATISTICS THAT
LOOKED LIKE A MIDDLE INCOME
COUNTRY.
PRETTY POOR.
LIFE EXPECTANCY IS ONE OF THOSE
MEASURES.
IT'S HOW MANY YEARS ON AVERAGE
PEOPLE BORN AT A GIVEN POINT
WILL LIVE.

Now, he shows a colourful line graph.

He continues AND PEOPLE BORN AT THIS POINT,
1960, JAPAN IN THE GREY LINE,
WAS WORSE THAN ANY OF THESE
WESTERN INDUSTRIALIZED NATIONS.
AND THEN, SOMETHING HAPPENED IN
THIS POST WAR PERIOD.
IT TOOK OFF LIKE A RABBIT, AND
THE REST OF THE COUNTRIES LOOK
LIKE TURTLES.
AND NOW THEY CAN NEVER CATCH
UP, BECAUSE THE DIFFERENCE OF
LIFE EXPECTANCY BETWEEN
JAPANESE AND THE REST OF US
IS THE EQUIVALENT OF
ELIMINATING ALL OF CANCER AND
HALF OF HEART DISEASE.
IT'S, IT'S ONLY THREE OR FOUR
YEARS, BUT ONCE YOU'RE UP TO
HAVING MOST PEOPLE LIVE NEAR
80, IT'S VERY TOUGH TO GET
FURTHER GAINS.
AND WHAT'S HAPPENED THERE, THEY
DON'T HAVE A CLUE ABOUT.
THE JAPANESE HAVE NO RESEARCH
TO TELL US THE ANSWER.
THEY DO NOT KNOW WHY THEY ARE
LIVING SO LONG.
THERE ARE MANY THEORIES.
YOU CAN THINK OF SOME YOURSELF.
DIET.
A LOT OF THINGS.
OKAY?
BUT THE BOTTOM LINE IS NONE OF
THESE SEEM TO EXPLAIN IT.
AND THE HYPOTHESIS THAT'S
ARISEN IS THAT IT'S JUST THEIR
WEALTH.
SINCE THE POST WAR PERIOD, THEY
HAVE GONE FROM THE MIDDLE
INCOME STATUS TO THE, ONE OF
THE WEALTHIEST NATIONS IN THE
WORLD, AND MAYBE WEALTH MAKES
HEALTH.
WELL, WE KNOW THAT ISN'T THE
EXPLANATION BECAUSE CAREFUL
WORK OVER MANY YEARS HAS DRAWN
UP THE RELATIONSHIP BETWEEN
WEALTH, THAT'S PER CAPITA
INCOME OF A COUNTRY.
THIS IS AT THE LEVEL OF THE
WHOLE COUNTRY, AND THE LIFE
EXPECTANCY, AND AROUND 1900 IT
LOOKED LIKE THIS, AND THEN
ABOUT 1930 IT LOOKED LIKE THIS.

A slide displays a line graph. A low red line reads “About 1900,” a higher yellow line reads “About 1930,” a much higher green line reads “About 1960” and the highest blue line reads “About 1990.”

He continues MEANING, IT'S, IT IMPROVED, BUT
IT STILL FLATTENED OUT.
IT FLATTENED OUT.
ABOUT THE SAME, THESE ARE IN
CONSTANT DOLLARS, BROUGHT TO
THE SAME CONSTANT DOLLARS.
SO, WHAT HAPPENS YOU SEE IS
THAT IT MATTERS A LOT, YOUR
LIFE EXPECTANCY GOES UP A LOT
WHEN YOU'RE IN A COUNTRY THAT'S
STILL CLIMBING FROM VERY, VERY
POOR.
UNTIL YOU REACH ABOUT, NOW,
THAT WOULD BE MORE LIKE 10,000
OR 15,000 U.S. DOLLARS PER YEAR
IN CURRENT DOLLARS.
AND THEN WHEN YOU REACH THAT
PER CAPITA INCOME LEVEL
YOU CAN'T BUY MORE LONGETIVITY
WITH WEALTH.
IT FLATTENS OUT.
IT MAKES SENSE, DOESN'T IT?
YOU KNOW, THERE'S A LIMIT.
SO, IF IT'S NOT THEIR WEALTH,
COULD IT BE THE WAY THE WEALTH
IS DISTRIBUTED?
NOW, THIS SUBTLE IDEA COMES
FROM A BRITISH GUY, RICHARD
WILKINSON, WHO WROTE A BOOK,
AH, AND HE SAID, LOOK AT THIS.

A dot graph under the title “Relation between life expectancy and percentage of income received by least well off 70 percent of families” appears.

He continues IF YOU PUT THE LIFE EXPECTANCY
OF A COUNTRY, AND THESE ARE ALL
WESTERN NATIONS.
OKAY?
YOU PUT THAT AGAINST THE
PERCENTAGE OF ALL THE SOCIETY'S
INCOME THAT'S RECEIVED BY THE
LEAST WELL OFF 70 percent.
SO, THAT MEANS THAT COUNTRIES
THAT ARE VERY EGALITARIAN AND
EVENLY DISTRIBUTED INCOME ARE
UP HERE.
NO SURPRISES THERE, NORDIC
COUNTRIES.
AND COUNTRIES THAT HAVE VERY
INEGALITARIAN, SKEWED INCOME
DISTRIBUTIONS, WHERE A FEW
PEOPLE HAVE A LOT OF THE
INCOME, IT'S DOWN HERE, THAT
THERE'S A KIND OF A
RELATIONSHIP.
AND HE BUILT A THEORY AROUND
IT, WHICH SAYS THAT THIS IS BAD
FOR PEOPLE'S PSYCHOLOGY.
IT'S SUBTLE, BUT IT'S BAD FOR
THERE TO BE BIG DISPARITIES,
BECAUSE PEOPLE SEE THEM.
AND NOWADAYS, THEY SEE THEM
MORE THAN EVER BECAUSE OF MEDIA
AND SO FORTH.
AND IT HAS A SUBTLE EFFECT ON
THEM.
WE'LL TALK MORE IN THIS LECTURE
IN A FEW MINUTES, ABOUT SUBTLE
EFFECTS MEDIATED BY THE
ENDOCHRINE IN THE IMMUNE
SYSTEMS, WHICH START IN OUR
BRAINS, BY OUR PERCEPTIONS.
SO, THIS IDEA HAS GARNERED A
LOT OF ATTENTION.
BUT WHAT'S NOW TURNING OUT TO
BE THE CASE ON RECENT RESEARCH
IS THIS IS MOSTLY DRIVEN BY
DATA FROM THE UNITED STATES.
AND NEW INFORMATION FROM
AUSTRALIA, CANADA AND THE
STATES SHOWS THAT, THAT
EQUALITY OF INCOME
DISTRIBUTION, WHICH IS DOWN
HERE.
THIS IS THE PERCENTAGE OF
INCOME EARNED BY THE BOTTOM 50 percent
OF A POPULATION IN INCOME.
AND THIS IS THE RATE OF DEATH
AMONG PEOPLE 25 TO 64.
SO, THEY DIED EARLY.
SO, IT'S, IT'S DEATH THAT
MATTERS A LOT.
AND WHAT YOU SEE IS THAT IN THE
UNITED STATES IN PURPLE,
THEY'VE MAPPED THE CITIES OF
THE UNITED STATES HERE.
THE SIZE OF THE CIRCLES IS
RELATED TO THE NUMBER OF DEATHS
FOR THE SIZE OF THE POPULATION.
THERE'S A STRONG RELATIONSHIP,
WHEREBY THE VERY UNEQUAL CITIES
IN INCOME DISTRIBUTION HAVE
ABOUT TWICE THE DEATH RATE OF
THE EQUAL CITIES, THE CITIES
WITH EQUAL INCOME.
NOW OF COURSE, THESE AREN'T
JUST RANDOMLY SCATTERED OVER
THE AMERICAN ATLAS.
THESE ARE, THESE ARE CITIES,
LOWER AND SOUTH CAROLINA, NEW
ORLEANS, LOUISIANA, PINEBLUFF,
ARKANSAS, AUGUSTA, GEORGIA,
MONROE, LOUISIANA, BRYAN,
TEXAS, THEY'RE CITIES OF THE
OLD SOUTH.
THEY'RE CITIES OF AN EX-
SLAVEHOLDER PLANTATION ECONOMY,
WHICH STILL HAS PROFOUND
INEQUALITIES OF ALL SORTS.
SO, WE HAVE TO BE CAREFUL IN
EXTRAPOLATING.
SO, THAT'S WHY CANADIAN
RESEARCHERS DID THIS ANALYSIS.
AND WHAT THEY SHOWED IS THAT
FOR CANADIAN DATA IN RED, AND
AUSTRALIAN DATA IN GREEN,
THERE'S NO RELATIONSHIP AT ALL.
AND THOSE CITIES ARE ALL
SITTING DOWN HERE AT LOW DEATH
RATES, BY COMPARISON WITH THE
AMERICANS.
AND AT RELATIVELY EGALITARIAN
INCOME DISTRIBUTIONS, BECAUSE
THEIR TAX SYSTEMS FAVOUR THAT.
SO, WHAT WE NOW THINK IS THE
AMERICANS HAVE AN EXTREME
OUTLIAR SOCIETY.
WHERE EXTREMELY UNEQUAL,
UNEQUAL INCOME DISTRIBUTIONS
ARE ASSOCIATED WITH EXCESS
MORTALITY, BUT PROBABLY BECAUSE
OF THE WAY THE SOCIETY WORKS.
AND THE SUPPORT OF EVIDENCE IS
IN THESE INTRIGUING
QUESTIONNAIRE RESPONSES FROM A
NATIONAL AMERICAN SURVEY.
THIS IS STATE LEVEL DATA, WHERE
THEY HAVE TAKEN A MEASURE OF
INCOME AND EQUALITY.
IT'S A DIFFERENT ECONOMETRIC
MEASURE.
ECONOMISTS UNDERSTAND THESE
THINGS.
BUT BASICALLY IT WORKS LIKE
THIS.
REALLY EQUAL STATES IN EQUAL
INCOME DISTRIBUTION ARE ON THE
LEFT.
NEW HAMPSHIRE, WISOCONSIN,
UTAH, MINNESOTA.
THEY'RE LILY-WHITE STATES.
RIGHT?
THERE'S VERY FEW MINORITIES
THERE.
AND THEN OVER HERE, WE HAVE THE
REALLY UNEQUAL STATES WITH A
HIGHER ROBIN HOOD INDEX.
OKAY?
AND THIS IS THE PERCENTAGE OF
PEOPLE RESPONDING ON A SURVEY,
THE DIFFERENCES BETWEEN STATES
HERE, TO THE QUESTION, MOST
PEOPLE WOULD TRY TO TAKE
ADVANTAGE OF YOU, OF YOU IF
THEY GOT THE CHANCE?
THEY ANSWER, YES.
AND THE DIFFERENCE IN
LOUISIANA, ALMOST HALF THE
POPULATION BELIEVED THAT, AND
IN NEW HAMPSHIRE, A LITTLE OVER
TEN PERCENT.
HAVE YOU EVER BEEN IN NEW
HAMPSHIRE?
NO WONDER.

[Audience laughing]

John continues THEY'VE GOT
NOTHING TO WORRY ABOUT ANYBODY
TAKING.
IT'S A BEAUTIFUL STATE.
IT'S A BEAUTIFUL STATE, BUT
THEY'RE SO TRUSTING.
SO, THE POINT IS THIS SOCIETY,
THESE SOCIETIES ARE INCREDIBLY
DIFFERENT.
THEY'RE ABSOLUTELY DIFFERENT,
IN ONE COUNTRY, BUT TOTALLY
DIFFERENT.
AND THIS IS THE, THIS IS THE
REAL CLINCHER.
THE DEATH RATES IN THESE STATES
VARY IN PRECISE RELATIONSHIP TO
THE SAME QUESTION.
MOST PEOPLE WOULD TRY TO TAKE
ADVANTAGE OF YOU IF THEY GOT
THE CHANCE?
HERE'S, LOUISIANA, MISSISSIPPI,
ARKANSAS, MARYLAND, TEXAS, AND
I ADMIT NEW YORK.
THEN NORTH CAROLINA PARDON ME,
THEN CALIFORNIA IN THE MIDDLE,
AND THEN WE HAVE THE LILY-WHITE
STATES DOWN HERE.
SO, THE TRUTH OF THE MATTER IS
THAT SOCIETAL CULTURE AND
ECONOMIC SOCIAL STRUCTURES HAVE
A LOT TO DO WITH THE PATTERN OF
MORTALITY, AND EQUALITY IS ONE
OF THE INDACIES THAT TELLS US
ABOUT THAT.
WE HAVE A SAD SOCIETY, TO KIND
OF REACT TO THE JAPANESE STORY,
AND THAT STORY IS THE STORY OF
THE EASTERN BLOCK NATIONS,
BEFORE, BOTH BEFORE THE IRON
CURTAIN FELL AND THE
DISSOLUTION OF THE SOVIET, THE
OLD SOVIET UNION, AH, BUT EVEN
NOW MORE SINCE.
AND I'LL UPDATE YOU.
THESE DRAFTS ARE A LITTLE OLD.
BUT IT'S HARD TO GET CURRENT
DATA.
I CAN TELL YOU FROM PEOPLE I'VE
SPOKEN TO ABOUT THE MOST RECENT
SITUATION.
OTHER COUNTRIES IN WESTERN
EUROPE WERE DOING FINE
THROUGHOUT THIS PERIOD, BUT AS
EARLY AS THE 60S AND 70S, THE
OLD EASTERN BLOCK NATIONS WERE
FAILING TO SHOW CONTINUOUS
INCREASES IN LIFE EXPECTANCY
THAT WERE NORMAL IN WESTERN
DEMOCRACY.
AND INVESTIGATORS WEREN'T SURE
WHAT WAS GOING ON, BUT THEY,
THEY, THEY SAW SOME TANTALIZING
EVIDENCE THAT IT WAS MOSTLY
MIDDLE-AGED MEN DYING
PREMATURELY.
A LOT OF IT WAS CARDIOVASCULAR
DISEASE, AND IT WASN'T CLEAR
WHAT ALL THE FACTORS WERE.
SO, FURTHER RESEARCH HAS SHOWN
THAT IT'S PARTICULARLY THOSE
WHO ARE SOCIALLY ISOLATED WHO
HAVE THE INCREASED DEATH RATE.
SO, THIS IS A NORMAL GRAPH.
IT ALWAYS GOES UP LIKE THIS.
OF COURSE THE RISK OF DEATH
AGAINST AGE, THAT'S WHAT LIFE'S
ABOUT, UNFORTUNATELY.
BUT LOOK WHO'S GOT THE EXCESS
DEATH RATES.

A line graph under the title “Mortality change among married and divorced men, Poland 1970 and 1988” appears on screen.

He continues IN 1970, BEFORE THE
BREAKDOWN IN POLISH SOCIETY,
THIS IS JUST AN EXAMPLE OF
POLAND, THESE WERE ALL SIMILAR.
BUT AFTER 18 MORE YEARS OF
SOCIETAL BREAKDOWN AND
DIFFICULTIES, FORTUNATELY,
THEY'RE COMING OUT OF THOSE
NOW.
BETTER IN POLAND, THAN SOME
OTHER COUNTRIES, AH, IT'S THE
DIVORCED MEN.
NOW, YOU CAN ALSO POINT OUT
THAT DIVORCED MEN ARE MOST
LIKELY TO BE THOSE WITH HEAVY
DRINKING PROBLEMS AND SO FORTH.
AND THERE WAS A PROBLEM IN THIS
SOCIETY AND STILL IS, IN ALL
SLAVIC SOCIETIES IN THE LAST 30
YEARS OF UNCONTROLLED,
ALCOHOLIC, BINGE DRINKING.
BUT THE ANSWER TO THE QUESTION
IS WHAT MAKES PEOPLE BEHAVE
THAT WAY?
AND SOCIAL SCIENTISTS WHO HAVE
GONE AND LOOKED AT THE
SITUATION BELIEVE THAT IT'S
BECAUSE WHEN A SOCIETY NO
LONGER REWARDS HARD WORK, WHEN
IT NO LONGER REWARDS TALENT,
AND IT STOPS FUNCTIONING AND
PAYCHEQUES DON'T ARRIVE.
AND YOU MUST STAND IN LINE FOR
EVERYTHING, AND PEOPLE BEGIN
TO, TO GET SPECIAL PRIVELEGES
IN WAYS THAT AREN'T FAIR, THAT
THE WEAKER SEX, MEN, CAN'T
HANDLE IT.

[Audience laughing]

John says THEY, THEY JUST
DON'T DO VERY WELL.
WOMEN BUILD SOCIAL NETWORKS
THAT ARE LARGER THAN THEY'RE
WORK, AND A FEW RELATIVES.
BUT MEN AREN'T TOO GOOD AT
THAT, AND THEY BASICALLY DIE
YOUNG.

A slate pops up. It reads “For more information about Mini-Med School at the University of Toronto visit us on the web at: www.tvo.org.”

The end credits roll.

Mini-Med School Producer, Wodek Szemberg.

Executive Producer, Rudy Buttignol.

Logos: CEP Local 72 M and Canadian Media Gold.

A Production of TVO Ontario.

Copyright The Ontario Educational Communications Authority 2003.

Watch: What Determines Health - Part 1