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Population Health in America: A Q&A with Robert Hummer

September 19, 2019

Faculty Fellow Robert Hummer has co-authored a new book on population health.

Robert Hummer

Over the past 30 years, the life expectancy of people born in the United States has not kept pace compared to other large and wealthy countries. At the same time, socioeconomic disparities in health have increased, and disturbing differences in key measures of health and well-being have appeared with regard to certain racial/ethnic subgroups of the US population.

A new book coauthored by Robert Hummer, PhD, the Howard W. Odum Distinguished Professor in the Department of Sociology and a Faculty Fellow at the Carolina Population Center examines these trends and explains what factors influence them. Population Health in America (with Erin R. Hamilton, published in 2019 by the University of California Press) traces health and longevity patterns in the United States, weaving together demographic data with social theory to provide an in-depth historical and contemporary portrait of US population health.

Hummer and Hamilton challenge readers to examine current health policy priorities and to ask whether major shifts are needed. We recently spoke to Hummer, who was recently named the president-elect of the Population Association of America, about synthesizing the last few decades of population health research.

What’s different about this moment and why have these stories about population health been bubbling up recently?

I’ve been working on issues of population health in the United States for over 30 years now, but there’s never been nearly as much interest in the topic as there is at the present moment. I think there are probably four reasons for this.

First, over the last 5-10 years, researchers have finally collected and analyzed enough cross-national data to definitively show that the United States is the unhealthiest country of all of the wealthy democracies around the world. We live shorter and less healthy lives than any other high-income democracy in the world. This is not a good position to be in. As such, there is intense interest, at least among researchers, in explaining why the US is faring so poorly and in understanding what can be done about it.

Second, coinciding with the poor overall health of the country, researchers have also definitively documented growing inequalities in US health across socioeconomic status groups (e.g., by education and income) and across geographic boundaries (e.g., counties, states, regions); at the same time, racial/ethnic and gender inequalities in US population health remain stubbornly wide. Amazingly, and not in a good way, some groups of Americans – like low-educated women – are less healthy and living shorter lives than they did 50 years ago. Increasing realization of these growing and stubborn disparities has drawn more attention to this area of study.

Third, over the past decade or so, some core indicators of population health (e.g., life expectancy) have gotten worse among White Americans, who have always been the most powerful and privileged racial/ethnic group in the country. When such trends occurred among African Americans in the 1980s, there was unfortunately very little public attention or concern. But the recent worsening of population health among White Americans, especially those with less than a college degree, has raised both public and researcher attention to this area of study.

Finally, I think one positive trend has been that health issues in 21st century America are finally beginning to be understood as more than just issues that are pertinent to medicine and health care. Indeed, our country spends far more on health care and medicine per person than any other time or place in human history … and what has that incredible level of spending bought us? Not much.

Issues of population health are thus rightfully and increasingly being researched and taught in social science contexts, which arguably is where a substantial part of the attention (and resources!) should have been directed long ago.

It’s (long past) time that issues of income/wealth inequality, racism, sexism, corporate power, policies at all levels of government, childcare, preschool, educational equity, and civil rights are considered as critical determinants of population health – as strongly as, if not more so, than issues of health care and medicine.   

This is the culmination of many years of work for you. I’m curious what surprised you as you synthesized these health patterns and trends in the US population.

After doing this work for so long, no single bit of evidence surprised me when Erin and I wrote this book. But what was surprising, and what continues to be extremely disappointing, is our society’s lack of attention and concern to issues of population health when the evidence is so crystal clear that what we are doing as a society is not working.

The book discusses the broad policy options we have as a country:

  • We can either continue to spend ungodly amounts of money on healthcare and medicine, much of it very high-tech, to patch up our unhealthy folks until the next thing goes wrong…
  • Or encourage individuals to behave differently – don’t smoke, don’t overeat, get exercise, don’t do drugs, wear your seatbelt – without changing anything about our society itself to help make these things happen.
  • Or…follow the lead of some other countries and put in place ideas and structures that help lead to an overall healthier population while reducing disparities. The third option has typically not been the “American Way”; we’ve been far too focused on expensive technological fixes, medical innovations, and trying to change individual behavior and not nearly focused enough on how we can improve our society from the ground up to make it more healthy.

The disappointment for me, after putting all of this evidence together, was in the realization that we have plenty of resources available to be a much healthier society … but that we have not focused nearly enough on the collective good. In other words, we’ve got to steer this big ship in a much different way if we want to be a healthy society; right now, we are not a healthy society.

There are substantial racial/ethnic disparities in population health in the US. How has this changed over the past century? And can you talk briefly about some of the factors that account for these disparities?

This is a hugely important topic and one that we devote a chapter to in the book … although it is deserving of so much more… In this brief answer, I’ll focus on the disparity between African Americans and Whites.

But please note that there are very important disparities to consider for all racial/ethnic groups in our society. Indeed, largely because of their relatively small size and geographic dispersion, Native Americans in particular are not given nearly the attention in our book or in much of the population health literature that is deserved … and their overall population health has suffered greatly over the years due to their near genocide and continued exclusion and racism against them in American society.

In terms of African Americans and Whites, it is clear that both groups experience much more favorable population health – longer lives and healthier lives – than they did a century ago. Moreover, because of the horrific conditions within which the African American population lived in the 1800s and early 1900s, improvement in African American population health since then has been especially steep. That’s the good news.

On the flip side, African Americans still live, on average, about 4 years less than Whites and experience much earlier bouts of disease and disability than Whites. We borrow from other scholars in the book and note that the life expectancy difference equates with a large airplane full of African Americans crashing and dying each and every day; where is the outrage?

The reasons for Black-White disparities in population health are quite well documented. In the book, we discuss how racism – especially as it operates in institutions such as educational systems, the labor market, the real estate market, the criminal justice system, government representation, inheritance laws, and more – has always caused pronounced disadvantages for African Americans in US society and continues to do so until this very day.

While Americans have generally become better (at least until the 2.5 years of the Trump presidency) at treating individuals in other racial/ethnic groups in humane ways, the structure of racial inequality built into our society – institutional racism – continues to operate in such ways that population health among African Americans suffers in profound, and very human, ways. We are far from a society of racial equity.

What are the big picture takeaways for policymakers who could change things at a structural level?

I’ll note a few big-picture takeaways here – two of which are focused on things we need to not do and two focused on areas we should improve upon.

First, we cannot spend our way out of this population health mess, especially with medical technology and pharmaceuticals, much of it high-tech. That’s the approach we’ve taken and it is easy to see that it doesn’t work.

Second, we can no longer focus on our mantra of “individual responsibility” … e.g., don’t do drugs; exercise 30 minutes a day; quit smoking; don’t eat fatty foods. That’s also what we’ve done and it’s also easy to see that it doesn’t work. Individual choices are hugely constrained in our society, especially for people who are not financially well off or in other ways are not powerful.

Third, it is clear that we need to reduce inequality in our society in all of its forms – income, wealth, educational, racial, ethnic, immigrant, religious, gender, sexual orientation, gender identity, etc. – if we are going to improve population health. Our health disparities are enormous; it is not at all surprising that groups who have fewer resources in American society tend to have worse health. Policymakers need to focus serious and sustained attention, and not just lip service, on reducing/eliminating such inequalities.

As one easy example, it is a travesty that wealth inequality in US society is as extreme as it has ever been, with vast wealth concentrated in the hands of just the top one percent or two of American individuals; at the same time, close to 20% of our children live in poverty. This is SO morally wrong, and it also has real consequences for our population health. Thus, inequality in all of its forms need to be given serious, sustained, and aggressive attention in the coming decades.

Finally, related to the focus on inequality is a greater focus on social policy that works for the greater good … for the collective. Our kids would be healthier if they all had access to high-quality and affordable childcare and preschool; similarly our children would be healthier and would have healthier futures if they all had access to high quality public schools, no matter where they lived.

Our communities would be healthier if we had zoning laws in place and housing programs in place so that we did not live in income- or racially-segregated neighborhoods. Our adults would be healthier if all of our workers earned a living wage with health care and retirement benefits. And so on.

As a nation, we have shifted away from this collective orientation toward one based on individual responsibility and reliance on technology, the free market, and medicine to solve our problems … but that approach does not work when resources are so incredibly unequally distributed and power is in the hands of a small subset of (wealthy, White, male) individuals. Thus, our social policy regime also needs to shift in major ways and at all levels – local, state, and national – to create a healthier society.    

What has been most enjoyable in putting this book together?

First, it has been a joy to work with Erin on the book; she’s really smart, a great writer, and a hard worker. Second, it has been enjoyable (although intimidating) to read and try to package together evidence from such a huge body of literature. We probably cite a few hundred papers and books in our book; but there are thousands and thousands of sources we could have included and simply could not given the relatively small space we had to work with.

While a bit intimidating and frustrating, it was also enjoyable to find such concern about the current state and future prospects of American population health being expressed in fields all over the scientific map. Such interest and widespread scientific work provides some hope for the future that policymakers will eventually use the evidence to help create a much healthier society than we have now.

Finally, it was enjoyable to give students draft chapters along the way and get their reactions. It has been a joy to watch lightbulbs go on among some students who have read pieces of the book, many of whom have never been exposed to material such as this and find it both tragic and challenging at the same time.

You mention student readers –What do you want students to come away with after reading the book?

Three things:

First, our society as currently structured is not conducive to favorable population health. The evidence is clear; substantial change is needed.

Second, the solution to the mess we’re in is not to focus on individuals behaving in more healthy ways; as college students and faculty, we are in the most privileged positions possible to enjoy good health and many of us (including myself) have a hard time with healthy behavior. The solution is not telling people to stop doing unhealthy things or to build a few sidewalks and farmer’s markets and everything will be ok. Those are “feel-good” things that have very little if any impact on population health.

Third, the solution is to look at the evidence we’ve amassed as a field of study – international comparisons, trends across time, disparities across groups – and critically assess what actually needs to be done to get things fixed. It’s a big challenge and, based on the evidence, it is going to involve aggressive, sustained, and in some ways radical changes in our approaches to social policy, the economy, and eliminating inequality.  

Robert Hummer is the Howard W. Odum Distinguished Professor, Sociology and a Faculty Fellow at the Carolina Population Center. Population Health in America (co-authored with Erin R. Hamilton) was published in July 2019 by the University of California Press.