The Social Side of Health

When it comes to health and longevity, the United States ranks near the bottom among the richest countries. Dismal health statistics have generally been blamed on poverty, racism, blocked access to medical care, and poor lifestyle choices. But many experts are now exploring the effects of social status, organization, and interconnectedness.

America is among the most affluent countries in the world, but money doesn't necessarily buy health. According to the United Nations's 2005 Human Development Report, the U.S. life expectancy at birth of 77.4 puts it behind 28 countries, including Costa Rica, which has a gross domestic product per person that's a mere one-quarter of that of the United States.

To explain differences in the overall health of a population or nation, experts often trot out factors such as people's access to medical care, personal habits such as diet and exercise, environmental exposures, and level of education. Although these issues clearly play a role in chronic disease and longevity, many experts are now shifting their focus to a previously underappreciated element: how societies are organized. Epidemiologist Michael Marmot of University College London, who pioneered this idea, will discuss "The Social Determinants of Mortality and Longevity" in an upcoming SAGE Crossroads Web cast.

Decades ago, researchers studying animal behavior observed that an individual's position in the social hierarchy can affect his or her health. For example, in groups of free-ranging monkeys, members of low-ranking families do not live as long as those of higher social rank--largely because they have less access to the resources necessary for survival and reproduction, such as food, shelter, and mates, says Carol Shively, a medical researcher at Wake Forest University in Winston-Salem, North Carolina.

Shively studies small groups of cynomolgus macaques in captivity and finds that subordinate monkeys are treated more aggressively, receive less grooming, and spend more time alone and on alert than the more dominant animals. That social exclusion translates into ill health: Those of low rank get sick more often, don't grow as fast, and die more often from all causes than do monkeys at the top of the hierarchy. They also show all the signs of being stressed, such as suppressed immunity, reduced fertility, and altered brain chemistry. When fed a typical fatty American diet, subordinate monkeys develop greater amounts of the bad kind of blood cholesterol than do high-status animals, says Shively. "There are incredibly far-reaching differences between high-ranking and subordinate animals in their behavior and health," she concludes.

And the same appears to be true for people. In everyone from Swedish academics to Taiwanese seniors, epidemiologists find that individuals at the top of their group's social class live longer and healthier lives than do those in the middle, who in turn fare better than the unfortunate folks at the bottom. "There's an acquired biology produced by social position," says Alvin Tarlov, a physician and health policy expert who recently retired from Rice University's James A. Baker III Institute for Public Policy in Houston, Texas. "The lower one's position, the greater one's vulnerability to disease."

Researchers have found that most people intuit their social position based on their level of education, income, and family characteristics. For working-age men in many countries, status strongly reflects occupation, says Johannes Siegrist of the University of Dusseldorf's Institute for Medical Sociology in Germany. Other groups might define status differently. "People tend to have a sense of where they stand, but it differs by culture," says Nancy Adler of the University of California, San Francisco's Health Psychology Program. For instance, Taiwanese seniors give top honor to those who have many sons.

Some of the strongest evidence supporting the effect of status on health has emerged from Marmot's Whitehall studies. He and his colleagues at University College London looked at all major causes of death in British civil servants and found a clear health gradient that mirrored job status. The lowest-ranking individuals--those who perform, say, custodial work--reported feeling that they had little control, and they suffered more coronary heart disease, absences due to sickness, back pain, and mental illness than program managers, data analysts, or other high-ranking individuals. Standard behavioral risk factors--such as smoking, exercise, and obesity--accounted for only a third of the differences. Moreover, all of the workers were middle-income and had the same health insurance.

Not even the ultrarich are immune to status syndrome, it seems. A study of 1650 Hollywood actors and actresses found that those who won Academy Awards lived on average 4 years longer than did those who were nominated but did not win. This dramatic boost in longevity might be explained biologically, says Donald Redelmeier, an epidemiologist at the University of Toronto, who led the study. Once a performer has an Oscar on the mantelpiece--which represents the ultimate in peer approval--he or she views all of life's stresses (paparazzi, talk show appearances, crashing the Rolls Royce) as less disturbing. And the sense of accomplishment, says Redelmeier, "changes your immune system, your hormones, your blood lipids, and it buffers you against work stress." Yet he can’t rule out a behavioral explanation. Winning the award might cause a performer to hire an entourage to keep him or her exercising, sleeping, and eating well.

Whether due to biology, behavior, or both, status syndrome seems to permeate all walks of life. Although it cannot be eliminated, public policies that reduce psychosocial stress might soften its effects, suggests Marmot.

Take Japan, a country that remains the world leader in longevity. Marmot believes the population enjoys protective benefits from its high degree of social cohesion: People trust each other, encourage working in groups, and show tremendous loyalty even in how they run their businesses. These "Asian values" appear to flatten out the social hierarchy and lower stress for all.

In the United States, sociologist Robert J. Sampson of Harvard University sees something similar. Comparing neighborhoods in Chicago, Sampson finds that the healthiest communities have extensive social connections that provide members with a sense of control and support that allows them to work together to solve problems.

Being disconnected can have dire consequences. Consider, for example, New Orleans, where many residents became trapped in a public health nightmare when Hurricane Katrina struck. Says Sampson, "There was strong evidence beforehand that Louisiana had low levels of cohesion and trust, which might explain some of the behavior before, during, and after the hurricane." Perhaps in the aftermath of this disaster, researchers and policy experts will find it easier to grab the bullhorn and call out for more attention to the social side of health.

Karen F. Schmidt is a freelance writer in California who enjoys her freedom from a workplace social hierarchy.