Why Our Greatest Health Concern Isn't Diet or Exercise -- It's Neighborhood

While we anxiously wait to hear how the Obama administration will tackle health care reform, are we missing the forest for the trees? Is it time for a complete overhaul of not just our dysfunctional system of medical insurance but what health economist Robert Evans calls our entire "repair shop" model of health? That idea is gaining traction among a growing number of public health advocates and policy makers.

Think of medical care as our bodies' repair shops, Evans says. It's where we go when our engines break down. The United States spends twice per person on those repair shops than the average rich country, patching up our engines so we can get back on the road of life. That's one of every seven dollars of our GDP. And rising. Yet our average life expectancy has fallen to 29th in the world. Costa Ricans live longer. Infant mortality? We're 30th. Chronic illness now costs American business more than $1 trillion a year in lost productivity.

So, why are our engines breaking down so often in the first place? Most point the finger at our bad driving habits: our fast-food diet, smoking, lack of exercise. All are important. But the new studies suggest there's something even more basic at work. And that's the condition of our roads.

Currently, the rich get the best roads: their jobs pay well and give them lots of power and control; they live in leafy neighborhoods with parks and green spaces and supermarkets filled with healthy, fresh foods; they send their children to well-resourced schools and take regular vacations. In sum, there's less stress placed on their engines.

Down the class pyramid, the roads we travel get bumpier, more twisted, pitted with potholes: the anxiety of living from paycheck to paycheck; fear of job loss, home foreclosures and downward mobility; speed-up at work; overcrowded and poor schools; worry about the kids' safety. Neighborhoods have few supermarkets or farmers' markets offering affordable fresh fruits and vegetables, only fast-food joints or mom-and-pops, and there may be little time to shop and cook anyway after hour-long commutes.

Traveling these unequal roads of life increases the wear and tear on the engines of the less affluent, especially poor people of color, increasing the risk for all the chronic diseases -- coronary artery disease, stroke, kidney disease, diabetes, asthma, even some cancers. Off to the repair shops we go -- if we can afford them.

The result? The rich live on average two years longer than the middle class, six years longer than the poor. Study after study shows that socio-economic status and neighborhood conditions are even stronger predictors of health than diet, smoking or exercise. The United States has by far the most inequality of all the rich countries, and the worst health. "Inequality is killing us on a grand scale," concludes the recent World Health Organization Commission on Social Determinants of Health.

The new model of health would have us tackle these unequal road conditions to lessen the stress and strain placed on our engines. Not only would that improve population health, it could relieve some of the demand on the repair shops and thus lower medical spending. A win-win.

We've done it before. Most of Americans' 30-year increase in life expectancy during the 20th century came not from medical breakthroughs but social reforms. The eight-hour work day, social security, sanitation codes, the right to form unions, civil rights, and environmental protections improved our health by improving our lives. Several of these "health" programs were initiated in the Great Depression.

But beginning in the early 1980s economic inequalities started widening, and so did our socio-economic and racial health gaps. By 2006 (the most recent figures available), aided by tax cuts for the rich, deregulation and cuts in social programs, the top 1% of Americans owned more wealth than the bottom 90% of us combined.