On the Social Contract, Part 1

          Recently, I suggested that the social contract underlying “Big Medicine” has broken. One statistic often produced to support the complaint that spending all this money isn’t working are mortality statistics. Medicine has not ignored the issue, but much attention has
been focused on the wealth-disparity in the US compared to Europe, and the impact of associated “diseases of despair:” suicide, drug abuse, and alcoholism.

            “Researchers studying US mortality data from 1999 to 2015 note a precipitous rise in “deaths of despair,” defined as mortality resulting from suicide, drug overdose, and alcohol-related liver disease, especially among working-class midlife adults with low
educational attainment. It is theorized that the long-term labor market decline has weakened family structures, limited access to high quality health care, reduced participation in social organizations, and caused loneliness and loss of future- oriented hope, particularly for those lacking college degrees in post-industrial service- and knowledge-based economies. In turn, these phenomena may trigger
physical, emotional, cognitive, and behavioral changes (eg, chronic pain, anxiety, or depression), increasing likelihood of self-harm and substance-use illnesses for working-class Americans. Risk of converting to despair-related mortality is further increased by distal factors, such as access to handguns, inexpensive alcohol, and
prescription or nonprescription drugs (eg, fentanyl, oxycodone). In 2017, researchers documented 158,000 annual despair-related deaths, with the crisis contributing to downward trends in US life expectancy from 2015 to 2017—the longest sustained decline since 1915 to 1918.” 1

          Implicit, but not often stated directly, is the converse proposition, that wealthy, well- educated do much better than elsewhere, but the median and mean are reduced by the
wealth disparity.

          Recently, Machado and associates published a detailed retrospective analysis of the association between wealth and mortality in the United States and Europe. 2 This study examined mortality in adults 59-85 from two large databases, one in the US and the other in Europe. Cox proportional hazards models were constructed as patients were sorted into quartiles based on wealth (not including housing,) that was normalized to the country of
residence. Of the 73,838 people included, 13,802 (18.7%) died over a mean follow-up of 10 years. Variables that were adjusted in the model included age, marital status, educational level, residence, current smoking status, and presence of previously diagnosed long-term
conditions. Their bottom-line conclusions? Mortality was worst in the poorest quartile in the US and in all three European regions: northern and western, southern, and eastern. Second, mortality in the richest US quartile was poorer than the richest quartile in all three
European regions and about the same as the poorest quartile in north and western Europe.

1 George DR, Snyder B, Van Scoy LJ, et. al. Perceptions of Diseases of Despair by Members of Rural and Urban
High-Prevalence Communities. JAMA Netw Open. 2021(July 23);4(7):e2118134.
doi:10.1001/jamanetworkopen.2021.18134.
2 Machado S, Kyriopoulos I, Orav J, and Papanicolas I. Association Between Wealth and Mortality in the United
States and Europe. N Engl J Med 2025(Apr 3);392(13):1310-1319. doi. 10.1056/NEJMsa2408259.

          In some of the detailed sub-analyses, baseline wealth increased across all age groups in the US and decreased in Europe; smoking decreased and education increased with increasing wealth. Previously diagnosed medical conditions were lowest in the US (30.3%, range
27.3% in the South to 36.3% in the West) and highest in northern and western Europe, (48.0%). Interestingly, their sensitivity analyses did not show a major impact of previously diagnosed conditions, self-reported health, or wealth including housing, on observed
mortality.

          Critics of big medicine can be expected to use these data to say the American people aren’t getting their money’s worth from us. Many have their own pet culprits: vaccines, fluoride, food dyes, seed oils, etc. From having lived in Europe for three years a long time
ago, and from more recent visits, I am struck by two things: first we Americans are much more obese than Europeans, and second much of their built environment is conducive to walking, as opposed to riding in an automobile. Much of western Europe, where I had my
first-hand experience, had been damaged/destroyed by WWII, and while many rebuilt along traditional lines, some, like Frankfurt, took a modern (American) approach, although they did include more public transportation. If this makes a difference, I haven’t seen the
data.
            “The [US] Community Preventive Services Task Force (CPSTF) recommends built environment strategies that combine interventions to improve walking or bicycle transportation systems with land use and environmental design interventions to increase physical activity. These strategies involve creating or changing environmental characteristics in a community to make physical activity easier or
more accessible. Interventions to improve walking or bicycle transportation systems include things like improving street connectivity and sidewalk or trail infrastructure.
Land use and environmental design interventions include things like increasing access to parks and other public or private recreational facilities.” 3

          The website includes an assessment of progress toward increasing physical activity by adults and adolescents, and the proportion of adults and adolescents who walk or ride bicycles to get places. The current report card: “little or no progress.”

          The article by George and associates asked: What do people living in communities with high prevalence of diseases of despair (suicidality, drug abuse, and alcoholism) believe is driving the crisis, and what are their potential solutions? “In this qualitative
study, 60 participants from 3 communities identified factors associated with despair- related disease, including financial distress, lack of infrastructure or social services, deteriorating sense of community, and family fragmentation. Intervention strategies
included building resilience through community-level coordination and state investments in social services and infrastructure.” But that does not seem the direction of public policy.

So, what now —a pill to get us out of the drive-thru lane and out of our cars?

12 May 2025

3 Guide to Community Preventive Services. (2016). Physical activity: Built environment approaches
combining transportation system interventions with land use and environmental design. Retrieved 12 May
2025 from https://www.thecommunityguide.org/findings/physical-activity-built-environment-approaches.

Further Reading

Humility
A new paper found literature supporting a pivotal role for physician humility in five domains: learning and professional growth, preventing and managing error, tolerating uncertainty, trust, and teamwork and communication. Three other studies from the same journal show how this might work in practice.

Measuring Social Determinants of Health
We can define poverty and discrimination in medical terms and in terms of impact on individual health, but does it help or distract from our historic task of trying to improve physical and mental health in ill or injured patients? I don’t know, but I fear it only serves to make a difficult task impossible.

Paying for What We Don't Want
Do you believe the proverb "you get what you pay for"? What if you pay for what you don't want?

Seasons
Seasons are a part of life and we seem to be in both astronomical and sociological winter, so we should expect hazardous driving conditions in both areas.

Social Determinants of Health
Social determinants of health trump many medical therapies, but can changes be made that result in better health?