Social Policy as Health Policy
JAMA. 2009;301(11):1166-1169 (doi:10.1001/jama.2009.320) Medical Practice; Health Policy; Medical Practice, Other; Public Health; PublicHealth, Other of the endocannabinoid system for the development of a novel Financial Disclosures: None reported.
Funding/Support: This article was written with the support of a Canadian Insti-
class of antidepressants. As mentioned, agents that increase tute of Health Research (CIHR) operating grant to Dr Gorzalka and a CIHR post- endocannabinoid neurotransmission produce antidepres- sant, antianxiety, and stress-reducing effects in preclinical mod- Role of the Sponsors: Beyond financial support, these agencies had no role in the
preparation, review, or approval of this article.
els.6-8 Conventional antidepressant treatments increase CB1 re-ceptor expression in limbic brain regions involved in REFERENCES
depression, such as the hippocampus and amygdala.13,14 Thus, 1. European Medicines Agency. The European Medicines Agency recommends
suspension of the marketing authorisation of Acomplia [press release]. http://www promote symptoms of depression, it follows that augmenta- .emea.europa.eu/humandocs/PDFs/EPAR/acomplia/53777708en.pdf. Posted Oc-tober 23, 2008. Accessed February 19, 2009.
tion of endocannabinoid/CB1 receptor activity could reduce 2. Sanofi-aventis is complying with the EMEA’s recommendation to temporarily
suspend the marketing authorisation of Acomplia in obese and overweight pa-tients [press release]. http://www.sanofi-aventis.ca/live/ca/medias Depressive illness is a devastating mental disorder for which /28852FA7-9BC8-44FB-AAC9-81ECE7EA5870.pdf. Posted October 23, 2008. Ac- the physical and financial burden is often underappreciated.
cessed February 19, 2009.
3. Zimulti Acomplia Report Web site. Pfizer kills diet drug otenabant after Sanofi
The World Health Organization currently ranks depression pulls plug on Acomplia. http://www.acompliareport.com/News/news-110608 as the fourth leading contributor to global morbidity, disabil- .htm. Updated November 6, 2008. Accessed February 19, 2009.
4. Pertwee RG. Ligands that target cannabinoid receptors in the brain: from THC
ity, and early mortality and predicts that it will become the to anandamide and beyond. Addict Biol. 2008;13(2):147-159.
second leading contributor by 2020.15 Accordingly, the search 5. Aso E, Ozaita A, Valdizan EM, et al. BDNF impairment in the hippocampus is
for novel treatments for depressive illness is a high priority, related to enhanced despair behavior in CB1 knockout mice. J Neurochem. 2008;105(2):565-572.
particularly considering that conventional treatments for de- 6. Kathuria S, Gaetani S, Fegley D, et al. Modulation of anxiety through blockade
pression are often suboptimal. The clinical and preclinical evi- of anandamide hydrolysis. Nat Med. 2003;9(1):76-81.
7. Patel S, Roelke CT, Rademacher DJ, Cullinan WE, Hillard CJ. Endocannabinoid
dence briefly reviewed herein demonstrates that endocan- signaling negatively modulates stress-induced activation of the hypothalamic- nabinoid signaling is impaired in depressive illness, pituitary-adrenal axis. Endocrinology. 2004;145(12):5431-5438.
8. Gobbi G, Bambico FR, Mangieri R, et al. Antidepressant-like activity and modu-
antidepressant treatments enhance endocannabinoid activ- lation of brain monoaminergic transmission by blockade of anandamide hydrolysis.
ity, and agents that pharmacologically potentiate endocan- Proc Natl Acad Sci U S A. 2005;102(51):18620-18625.
9. Justinova Z, Mangieri RA, Bortolato M, et al. Fatty acid amide hydrolase inhi-
nabinoid signaling may possess antidepressant properties. The bition heightens anandamide signaling without producing reinforcing effects in primates. Biol Psychiatry. 2008;64(11):930-937.
10. Hill MN, Patel S, Carrier EJ, et al. Downregulation of endocannabinoid sig-
symptoms of depressive illness in a significant proportion of naling in the hippocampus following chronic unpredictable stress.
participants in clinical trials argues that the endocannabi- Neuropsychopharmacology. 2005;30(3):508-515.
noid system is a critical regulator of emotion, mood, and stress 11. Hill MN, Gorzalka BB. Is there a role for the endocannabinoid system in the
etiology and treatment of melancholic depression? Behav Pharmacol. 2005;
responsivity in humans and that dysregulation of this system may be integral to the pathogenesis of mood disorders.
12. Hill MN, Miller GE, Ho WS, Gorzalka BB, Hillard CJ. Serum endocannabinoid
content is altered in females with depressive disorders: a preliminary report.
On the basis of preclinical research and the adverse clini- Pharmacopsychiatry. 2008;41(2):48-53.
13. Hill MN, Ho WS, Sinopoli KJ, Viau V, Hillard CJ, Gorzalka BB. Involvement of
1 receptor antagonists, it can be antici- the endocannabinoid system in the ability of long-term tricyclic antidepressant treat- pated that inhibition of FAAH (or alternate pharmacologi- ment to suppress stress-induced activation of the hypothalamic-pituitary-adrenal cal means to enhance endocannabinoid neurotransmission) axis. Neuropsychopharmacology. 2006;31(12):2591-2599.
14. Hill MN, Barr AM, Ho WS, Carrier EJ, Gorzalka BB, Hillard CJ. Electroconvul-
will soon become a target for research and development on sive shock treatment differentially modulates cortical and subcortical endocan- the treatment of depression. It will be interesting to see if nabinoid activity. J Neurochem. 2007;103(1):47-56.
drugs that augment endocannabinoid activity will eventu- 15. World Health Organization Web site. Depression. http://www.who.int
/mental_health/management/depression/definition/en/. Accessed February 19,
ally provide a new option for the treatment of depression.
Social Policy as Health Policy
to restore economic stability, maintain public services, andpromote student and workforce education. Rarely, how-ever, do proponents of these efforts note their connection WHATHEALTHPROFESSIONALSMIGHTCALLSO- tohealth,anexusthatisrarelytheirfirstconcernorwithin cial issues—eg, the economy, jobs, educa- tion—now dominate the national agenda.
Families, businesses, and government are con- Author Affiliations: Virginia Commonwealth University Center on Human Needs,
fronting a recession, unstable financial markets, unemploy- ment, a housing crisis, environmental challenges, and other Corresponding Author: Steven H. Woolf, MD, MPH, Virginia Commonwealth Uni-
versity Center on Human Needs, 1200 E Broad St, PO Box 980251, Richmond,
global threats. Sweeping corrective measures are under way 1166 JAMA, March 18, 2009—Vol 301, No. 11 (Reprinted)
2009 American Medical Association. All rights reserved.
The health professions, for their part, deal little with so- the rate reported by the highest-income quintile.5 Black new- cial policy, focusing instead on health care issues, for un- borns are twice as likely as white newborns to die by age 1 derstandable reasons. Health care spending in the United year; their life expectancies are shorter than those of new- States now exceeds $2 trillion per year,1 surpassing the health care spending of any other country but producing inferior Social conditions such as education, income, and race/ results.2 Reforming health care to control costs and im- ethnicity are heavily interrelated but also exert indepen- prove access and quality is the priority of health policy mak- dent health influences: for example, upper-income blacks ers. This focus on health care comes naturally to physi- are unhealthier than upper-income whites.5 Examining dis- cians, who work largely in this area, and it resonates with parities through the lens of any one variable without ad- the public and their leaders, who view medicine as the front justing for others introduces confounding but may provide a better estimate of the benefits of correcting the package Health is much more than health care. Diseases are me- of social conditions for which these variables are proxies.7 diated by factors outside the clinical setting, such as per- For example, it is possible to estimate the number of deaths sonal behaviors (eg, smoking), obesity, and environmental that could be averted if blacks experienced the mortality rates exposures. Whereas health policy gives some attention to of whites, a conceivable outcome if the diverse causes of the public health issues, it deals little with the social context of disparity were rectified. Social change on this scale could life, which exerts profound influence on health.
yield immense gains, exceeding the modest benefits from As is demonstrated by the current recession, socioeco- incremental advances in medical care. If blacks had the same nomic pressures can affect health more deeply than any- mortality rates as whites, 5 lives would be saved for every thing physicians do. Along with restricting access to care (eg, making insurance and treatments unaffordable for pa- However, several caveats apply. First, social change im- tients, employers, and government), the economy intro- proves health, but not directly and not without comple- duces priorities in daily life that compete with the pursuit mentary efforts by clinicians, business, and government. In- of good health. Portion size, the timing of medications, and adequate education and inadequate income are predisposing scheduling a colonoscopy recede in priority when pay- factors but not direct causes of disease, like obesity or car- checks, homes, or savings are endangered. Many individu- cinogens, which require mitigation by other means for so- als will forego their daily workout to take a second job. Low cial change to fully confer health benefits. A college educa- incomes force other unhealthful choices: families replace tion can impart the knowledge to make healthier choices fresh groceries with fast foods, seniors endure cold tem- but cannot bring supermarkets to a neighborhood or re- peratures to lower heating bills, and students leave college move tobacco and alcohol advertising. Good jobs enable to defray tuition. Stress, along with its physiological ef- households to obtain health care and contribute taxes for fects, can induce cigarette, alcohol, and drug use and fo- public schools, but other factors influence the quality of pa- ment abusive behaviors. Desperate persons commit vio- lent injuries or homicide to steal what they need; they may Second, evidence of an association does not constitute even commit suicide. Perfecting health care is a half an- proof that social change will improve outcomes or to what swer if the living conditions that cause disease prevail.
degree. Although the inference makes sense, associations The degree to which social conditions affect health is il- can have other explanations, such as reverse causality (eg, lustrated by the association between education and mortal- illness limiting educational and employment opportunities).9 ity rates. In 2005, the mortality rate was 206.3 per 100 000 Longitudinal data suggest that exposure to socioeconomic for adults aged 25 to 64 years with some education beyond disadvantage precedes higher morbidity and mortality rates high school but was twice as great (477.6 per 100 000) for later in life,10 but prospective studies are needed to clarify those with only a high school education and 3 times as great the effect size and effect modifiers of social policies.
(650.4 per 100 000) for those with less education.3 An on- Third, social change is immensely difficult. The humani- line calculator has been devised to allow users to estimate tarian impulse to help the needy does not always lend itself how death rates would change if states or counties experi- to effective policy. Policy makers have struggled for gen- enced the health gains associated with higher education rates.4 erations to identify effective models for improving educa- In New York, for example, the death rate in Bronx County tion, incomes, and social justice. Some programs, such as would be 9.5% lower if the proportion of adults with some Social Security and early childhood education, have pro- college education (43%) equaled that of Queens County duced measurable benefits,11,12 but other initiatives have man- aged only to attenuate poverty, homelessness, and other so- Equally dramatic disparities affect poor and minority popu- cial ills. Programs that could do more for the needy have lations (eg, blacks, Hispanics), who endure worse health and often foundered because of inadequate resources and ideo- die younger than affluent persons and non-Hispanic whites.
The orders of magnitude are striking. More than 30% of those Times have changed, however. The recession, having put living in poverty report poor to fair health, almost 5 times financial markets and much of the population at risk, has 2009 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1167
produced an economic emergency. The government has re- ships, resources, and working conditions. Health policy mak- acted boldly, mobilizing billions of dollars to rescue major ers need systems to monitor social policies with health im- industries and help the public cope with increasingly dire plications and to pursue implementation with leaders in other circumstances. The size of the rescue effort signals a will- fields. Many health agencies cannot take up social issues with- ingness of society, at least temporarily, to invest in the com- out broadening jurisdictional boundaries. For example, a mon good: to help families meet expenses, remain em- senate health committee must be willing to examine the ployed, keep their homes, and attend school as well as to health consequences of a minimum-wage bill, not just re- maintain the essential services and commerce on which com- For practitioners, integrating social change into patient This domestic reform initiative should not lose sight of care requires more than a social work referral. It entails es- health as a potential consequence and a selling point. At a tablishing social milestones (eg, getting a job, graduating) time of tight budgets, aid programs are typically defended as explicit goals for patients and coordinating with other dis- on economic grounds: the aid will increase consumer spend- ciplines and community partners (eg, schools, social ser- ing, mobilize revenue, counteract recessionary forces, spur vice agencies, employers) to find solutions. Although fund- technological innovation, and help workers compete against ing and infrastructure are essential for such collaboration, overseas economies. Health should be added to this list of much can be accomplished by leveraging existing tools and benefits, not only for its intrinsic value to society but also resources. For example, electronic medical record tem- for the economic leverage that health commands: if wide- plates can be redesigned to enable clinicians to monitor so- spread socioeconomic distress persists, the resulting dete- cial conditions as another “vital sign.” Health systems and rioration in population health could affect workforce pro- safety-net agencies can work together to develop a stream- ductivity, disease burden, demands for health care, and lined, electronically linked system that enables clinicians to costs—none of which employers and government can afford.
refer needy patients with the click of a button and to keep Household income and education are therefore impor- each other informed as patients reach health or social mile- tant health levers, but the same is true for some transpor- tation, housing, agriculture, and other nonhealth policies.
For researchers, the opportunity to study ties between so- Studies known as health impact assessments document the cial policy and health and to engage coinvestigators from health consequences of nonhealth policies.13 Programs with other disciplines is frustrated by limited funding and pub- seemingly no health connection, such as roadwork, can be lication opportunities. No agency or foundation provides a transformed into health policies, as when planners include home for studying the interconnections between social con- bicycle lanes and sidewalks to promote exercise.
ditions and health. Most of the centers at the National In- If health pertains to those who shape social policy, the stitutes of Health are organized by body systems. Of the many obvious corollary for health leaders is to use social policy funders concerned with health or social policies, few en- for health purposes. Although many physicians have lim- tertain proposals about the interconnections, and only a ited interest in social issues, those who establish health handful of journals publish such results. Reviewers in aca- policy should take the broad view. If the profession’s mis- demic medicine—eg, study sections, manuscript review- sion is to optimize health, then all effective options ers, tenure committees—include few experts on social poli- should be considered, not just clinical tools (eg, drugs, cies, data sources, and the analytic methods such data require.
diagnostic tests), especially when other tools work better.
More conducive conditions are necessary to foster robust For example, no diabetes drug is associated with a 3-fold difference in mortality rates, as applies to education: The health consequences of social policies warrant greater among adults aged 40 to 64 years, diabetes mortality attention from the health policy community. At a moment rates are 21.42 per 100 000 for college graduates and of prominence for social policy, the nation is being recon- 67.30 per 100 000 for those with only a high school edu- figured to overcome unprecedented challenges. Sweeping cation.14 Arguably, organizations and endocrinology soci- decisions are being made that will affect living conditions, eties devoted to optimizing diabetes outcomes should and resulting health outcomes, for many years. This is the promote education reform as avidly as they emphasize wrong time for the health professions to keep their dis- disease management and health care reform.
tance from these issues. Not recognizing the imprint of so- Systems must change before social issues can be inter- cial conditions on health is problematic at any time—but woven into health policy. The first hurdle is attitudinal: health officials, organized medicine, disease-related groups, caredelivery systems, and academia must embrace the tenet that Financial Disclosures: Dr Woolf’s work for the Virginia Commonwealth Univer-
sity Center on Human Needs is supported by the W. K. Kellogg Foundation (grant
social change is a legitimate tool for improving health. That P3008553) and the Robert Wood Johnson Foundation (grant 63408). The online commitment would change the job description for health calculator discussed in this Commentary was developed by Dr Woolf and col- policy makers, practitioners, and researchers, who cannot leagues for the Robert Wood Johnson Foundation Commission to Build a HealthierAmerica, with support from Robert Wood Johnson Foundation grant 58974 to meet expectations without new collaborative relation- the George Washington University Department of Health Policy.
1168 JAMA, March 18, 2009—Vol 301, No. 11 (Reprinted)
2009 American Medical Association. All rights reserved.
Keck W, eds. Principles of Public Health Practice. 3rd ed. Clifton Park, NY: Del-mar Learning; 2009.
1. Hartman M, Martin A, McDonnell P, Catlin A; National Health Expenditure Ac-
7. Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why
counts Team. National health spending in 2007: slower drug spending contrib- both matter. Health Aff (Millwood). 2005;24(2):343-352.
utes to lowest rate of overall growth since 1998. Health Aff (Millwood). 2009; 8. Woolf SH, Johnson RE, Fryer GE Jr, Rust G, Satcher D. The health impact of
resolving racial disparities: an analysis of US mortality data. Am J Public Health.
2. Commonwealth Fund Commission on a High Performance Health System. Why
Not the Best? Results From the National Scorecard on U.S. Health System Per- 9. Goldman N. Social inequalities in health: disentangling the underlying mechanisms.
formance, 2008. New York, NY: The Commonwealth Fund; July 2008. http://www Ann N Y Acad Sci. 2001;954:1180-1239.
.commonwealthfund.org/publications/publications_show.htm?doc_id=692682. Ac- 10. Turrell G, Lynch JW, Leite C, Raghunathan T, Kaplan GA. Socioeconomic dis-
advantage in childhood and across the life course and all-cause mortality and physi- 3. National Center for Health Statistics. Health, United States, 2007: With Chart-
cal function in adulthood: evidence from the Alameda County Study. J Epidemiol book on Trends in the Health of Americans. Hyattsville, MD: National Center for Community Health. 2007;61(8):723-730.
Health Statistics, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf. Ac- 11. Smolensky E, Danziger S, Gottschalk P. The declining significance of age: trends
in the well-being of children and the elderly since 1939. In: Palmer J, Smeeding T, 4. Robert Wood Johnson Foundation Commission to Build a Healthier America.
Torrey B, eds. The Vulnerable: America’s Young and Old in the Industrial World. Education and health calculator. http://www.commissiononhealth.org/Calculator Washington, DC: Urban Institute Press; 1988:29-54.
12. Garces E, Thomas D, Currie J. Longer-term effects of Head Start. Am Econ
5. Braveman P, Egerter S. Overcoming Obstacles to Health: Report From the Rob-
ert Wood Johnson Foundation to the Commission to Build a Healthier America.
13. Cole BL, Fielding JE. Health impact assessment: a tool to help policy makers
Princeton, NJ: Robert Wood Johnson Foundation; 2008. http://www understand health beyond health care. Annu Rev Public Health. 2007;28:393- .commissiononhealth.org/PDF/ObstaclesToHealth-Report.pdf. Accessed Febru- 14. Miech RA, Kim J, McConnell C, Hamman RF. A growing disparity in diabetes-
6. Woolf SH, Phillips RL Jr. Social determinants of health: their influence on
related mortality: U.S. trends, 1989-2005. Am J Prev Med. 2009;36(2):126- personal choice, environmental exposures, and health care. In: Scutchfield FD, Action on Health Disparities
in the United States
Commission on Social Determinants of Health
countries (such as the United States) that can be dramatic.
Within the Scottish city of Glasgow, there is a 28-year gap in life expectancy between the richest and poorest areas;among the poorest, male life expectancy is 8 years less than HEREARE2TRUISMS.RICHCOUNTRIESHAVEBETTER theaveragelifeexpectancyinIndia.3Thegapinlifeexpec- health than poor countries, and medical care im- tancy between men in Washington, DC, and in suburban proves health. Consider, then, the case of the Maryland is 17 years.3 Rich countries have no cause for com- United States, which is among the richest coun- placency. The CSDH was oriented to countries at low, me- tries in the world and spends more than any other country on medical care, US $6350 per person in 2005.1 Does the The gap between top and bottom highlights the magni- United States then have the best health? Not quite. Life ex- tude of the difference in health outcomes but the CSDH em- pectancy from birth to age 65 years is one useful measure phasized the graded relation between socioeconomic posi- of premature mortality: the United States ranks 36th in the tion and health, the social gradient that exists within world for men and 42nd for women.2 If not by greater na- countries.6 A previous comparison of men and women aged tional income or more spending on medical care, how should 55 to 64 years demonstrated the social gradient in health the task of improving health in the United States be ap- and showed higher illness rates in the United States than in proached? Pay attention to the social determinants of health.
England,7 consistent with shorter life expectancy to age 65years in the United States. At every point along the scale of Commission on Social Determinants of Health
income or education, the health of Americans was worse than Because of concern with global health inequity the director- general of the World Health Organization established the Author Affiliations: International Institute for Society and Health and Depart-
Commission on Social Determinants of Health (CSDH) in ment of Epidemiology and Public Health, University College London, London, En- 2005. The CSDH produced recommendations, based on evi- gland. Dr Marmot was chair of the World Health Organization Commission onSocial Determinants of Health, 2005-2008. Dr Bell is a senior research fellow at dence, about what could be done to further the cause of health University College London and was a member of the Commission on Social De- equity.3 The CSDH highlighted inequities between coun- tries—life expectancy at birth in Zambia (41.2 years) is half Corresponding Author: Michael G. Marmot, FRCP, Department of Epidemiology,
University College London, 1-19 Torrington Pl, London, England WC1E 6BT (m
that of Japan (82.4 years)4—but also health inequities within 2009 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1169

Source: http://www.yale.edu/bioethics/contribute_documents/SocialPolicyasHealthPolicy-JAMA3-18-09.pdf

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