Whether it is ascertainable as fact or merely an impression, recent findings from the legendary Whitehall studies in the U.K. strongly suggest an interest in the quality of human relationships in society relative to health that is all but unimaginable in the United States. The New World is trying to get a grip on racial, ethnic, gender, and income disparities that are grossly inequitable. But as to more finely calibrated differences in status and power, the last word belongs to Jimmy Carter. The normal expectation in the U.S. is that life is unfair. Get over it.
The new Whitehall findings themselves, while poignant, are unsurprising. In a population of about 8,300 British civil servants, during an 11-year study period, those who reported that they often had a feeling they were being treated unfairly — controlling for a range of other health, psychosocial, and demographic risk factors — were significantly more likely than others to suffer fatal and nonfatal heart attacks and angina. Those with strong feelings of unfairness were 55 percent more likely to experience these coronary events than those who reported fair treatment.
The authors of the study observed that the sense of unfair treatment “seems to be connected with a threat or an attack to an individual’s dignity.” The 20-year Whitehall project has focused on the effects of relative social position on health, as opposed to absolute income levels; many of the studies have shown those effects to be substantial. In that same vein — predictably — the recent “Unfairness and health” report in the British Medical Journal finds that such feelings are more prevalent at the lower end of the socioeconomic ladder. We’ve known for a long time that poverty is bad for your health. What’s new here is evidence of how insidious and cruel the mechanisms of that association are.
Interest in social inequality and health in the U.S. is multifaceted and growing. Health Affairs has published a steady stream of research on racial and ethnic disparities, including a thematic issue on the subject in 2005, with another special issue planned for next year. Class and income disparities were examined in one of the 2005 papers and in a thematic issue on nonmedical determinants of health in 2002. More recently, Bob Hurley and colleagues took a look at economic disparities in a Health Affairs Web Exclusive last December. As is well known, public- and private-sector efforts to reduce disparities began in earnest under former Surgeon General David Satcher and have been pursued further by the National Institutes of Health, the Institute of Medicine, the Agency for Healthcare Research and Quality, the foundation community. and many others; they are now being studied extensively in academia, with cumulative results that can be described as mixed, at best.
But can anyone imagine the U.S. health policy community taking on the issue of fairness? To be sure, the recent Whitehall study does not represent a major policy initiative in the U.K. “Consistent with the hypothesis suggesting that fairness is a fundamental aspect of human behaviour, social relations and the organisation of society, the frequency with which people experience unfairness may influence their physical and mental health,” the BMJ authors conclude. Their underwhelming recommendation is that “future research is needed to investigate the societal, relational and biological mechanisms that may underlie the effects of unfairness on health and heart disease.”
But in the national homeland of rugged individualism, does anyone even care?