Sapolsky, Chapter 17

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Sapolsky, Chapter 17

• The view from the bottom

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Rudolph Virchow

• Typhus outbreak in 1847.
• Disease is as much about appalling living
  conditions as it is about microorganisms.
• Doomed European revolutions of 1848.
• Political machinery subjugated those in appalling
  living conditions.

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Pecking orders among beasts with tails

• Baboons Ranks can be changing, hereditary,
  situationally dependent or coalitional.
• Confrontation anything from menacing scowl to a
  bloody fight.
• Subordinates full of physical and psychological
  stressors, lack of control or predictability, few
  outlets for frustration.

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Pecking order among hens Resources, no matter
how plentiful, are rarely divvied up evenly.
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Physiology of subordination

• Glucocorticoids
• High basal levels
• Smaller slower responses to a real stressor
• Slow recovery
• High BP
• Sluggish R to real stressor
• Sluggish recovery
• Suppressed levels of good cholesterol

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Physiology of subordination

• Testosterone more easily suppressed by stress
• Fewer circulating white blood cells
• Also less insulin-like growth factor-I
• Helps heal wounds
• promotes neuron growth in hippocampus cortex
• Comparable situation in many species.
• Its not just that bad physiology ? subordination

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Some species subordinance does not ? stress R.

• Marmosets
• Cooperative breeders
• Relaxed waiting strategy
• Wild dogs, dwarf mongooses
• Dominance requires frequent fighting ? high GCs

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Wild dogs Dominance requires frequent fighting.
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Social factors

• Monkey culture w/ high rates of reconciliation.
• Drought ? so much time looking for food ? no time
  for harrassment.
• Rats outlet for frustration gnaw on wood
• Unstable dominance hierarchy ? high GCs in
  dominant animals
• Personal experience how often attacked.
• Personality

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Social support networks

• Encounter stressor with other people
• Friends help strangers make things worse.
• Baboons
• Low ranking males have high GCs.
• All in unstable social groups have high GCs.
• Low ranking males less stress if they groomed
  females or played with kids.

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Baboons grooming
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Do humans have ranks?

• Executive stress syndrome
• People at top give ulcers, rather than get them.
• Middle management get ulcers responsibility w/o
  control.
• People belong to a lot of different ranks.
• Spin inside our heads
• Runner 5 vs runner 5000 in marathon

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Poverty Physical stressors

• Physical labor
• Hunger
• Uncomfortable living conditions
• Little medicine

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Poverty Psychological stressors

• Lack of control, predictability
• Series of temporary jobs
• Uninteresting work
• Lack of outlets social support
• Crime-riddled neighborhood
• Jogging could be a hair-raising stressor!
• Lack of time for social support

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SES gradient

• Biggest factor in all of behavioral medicine
• True even though diseases have changed
• 510-year difference in life expectancy in some
  countries
• Direction of causality? (Elderly nuns)
• A few exceptions
• Melanoma, some autoimmune diseases, hospitalism
  in babies in the 1930s

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Puzzle of health care access!

• Fewer check-ups, less care if sick
• But socialized medicine in Britain
• Gradient has gotten worse
• Poor people had more cardiovascular disease,
  despite making more use of medical resources.
• Gradient every step makes a difference.

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Michael Marmot

• Mortality rates within British civil service
  system
• All have adequate pay and access to medical care.
• Control for smoking and other health risks still
  have 4-fold increase in mortality, comparing
  highest lowest rungs.

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Michael Marmot

• Greatest gradient diseases most sensitive to
  stress
• Heart disease, hypertension, psychiatric
  disorders
• Access-proof diseases (juvenile diabetes,
  rheumatoid arthritis) gradient still there.
• Access does make some difference
• US has a worse gradient than Sweden.

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Risk factors

• More likely to drink excessively smoke
• Smoking becoming low SES activity
• Eat unhealthy diet
• Dont exercise
• Dangerous neighborhoods
• More likely to get mugged
• More likely to be obese less likely to use seat
  belts or helmets crowding

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Risk factors

• Less education
• Dont know cigarettes, drugs are harmful
• Dont know women should have Pap smears.
• Dont know they should wear seat belts, bike
  helmets
• Dont understand how body works or instructions
  from physician.
• But these risk factors still account for only
  1/3 of SES gradient.

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Risk factors

• Countries differ in wealth
• US most expensive health system in the world
• But 1960 US was 13th in life expectancy.
• In 1997 25th in life expectancy!
• 10 countries are happier than the US.
• Mostly in countries with social welfare.
• Least happy former Soviet Union.

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Risk factors

• STRESS!
• Strongest gradients are for diseases most related
  to stress
• Heart disease
• Diabetes
• Metabolic syndrome
• Psychiatric disorders
• Health care access, risk factors ruled out as
  major factors. Whats left? Sunspots?

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Being poor vs. feeling poor

• Once basic needs are met, if EVERYONE is poor,
  then NO ONE is poor.
• But its never the case that EVERYONE is equally
  poor
• Problem is feeling poorer than those around you.

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Being poor vs. feeling poor

• Subjective SES ladder w/ 10 rungs where are
  you, re. how well youre doing?
• Correct for cultural distortions
• Lake Wobegone eff. in European Americans
• Chinese-Americans rate themselves lower.
• Subjective SES as good or better than actual SES
  at predicting health
• Cardiovascular metabolic measures, GCs,
  childhood obesity

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Poverty vs. poverty amid plenty

• Greater income inequality ? worse health.
• Least egalitarian state (LA) had 60 higher
  mortality rate than most egalitarian state (NH)
  (even before the hurricane).
• Canada (objectively poorer, but more egalitarian)
  has better health than the US.
• Little or no relationship btwn. inequality
  health in much of Europe (social welfare).

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Poverty vs. poverty amid plenty

• USA top 1 of SES ladder controls 40 of
  wealth
• Huge effect of subjective SES.
• Even after controlling for race.
• Comparison w/in local communities most
  predictive,
• But TV, movies, news, etc., expand our world.

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Poverty vs. poverty amid plenty

• Problem 1 Does effect of inequality reflect
  fact of greater total poverty?
• NO Control for absolute income effect still
  there.
• Problem 2 Asymptote each step upward gets
  smaller.
• Country w/ greater inequality must have more in
  the lower steps.
• Still cant explain all of the health problems.

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Same asymptote, different starting points
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Poverty vs. poverty amid plenty

• Problem 3 if you take some from wealthy give
  it to poor (Robin Hood index)
• You should make rich a little less healthy, but
  the poor a lot more healthy.
• In fact in more egalitarian societies BOTH RICH
  AND POOR have better health than in less equal
  societies with same average income.
• Therefore, inequality itself is the problem.

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How does inequality ? poor health

• Social capital
• Volunteerism, organizations (feel a part of
  something bigger than themselves)
• Dont feel need to lock doors
• Try to prevent crime against others
• Trust, reciprocity, lack of hostility,
  organizations for a common good
• Kawachi income inequality ? less social capital
  ? worse health

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Aaron Antonovsky poor tend to be ignored.
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How does inequality ? poor health

• Trust requires reciprocity
• Reciprocity requires equality.
• Hierarchy ? domination, not equality.
• Qn what do you think?

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How does social capital ? health?

• Less social isolation
• More rapid diffusion of health information
• Social constraints on unhealthy behaviors
• Less psychological stress
• Organized groups demanding public services
• BUT Can be problem if group demands rigid
  conformity.

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How does lack of social capital ? poor health?

• Income inequality better predictor of crime
  than poverty per se.
• More crime, more gun ownership
• Displacement aggression
• Not against wealthy, but other have-nots

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How does lack of social capital ? poor health?

• How do you improve social capital and health?
• Spend money on public goods.
• Public transit
• Safer streets
• Better public schools
• Universal health care
• Cleaner water air

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How does lack of social capital ? poor health?

• BUT the bigger the distance between rich poor,
  the less benefit the rich feel from public
  expenditures.
• Secession of the wealthy
• Rich have more money to ? political opposition.
• Bad effect on social capital

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How does lack of social capital ? poor health?

• US vs. Canada
• More inequality worse health in US
• Compare only groups with similar INCOME equality
• Still get worse health in the US
• Less social capital.

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How does lack of social capital ? poor health?

• Over last 25 years in US poverty income
  inequality have steadily risen.
• Every measure of social capital has declined
• Trust, community and voter participation.
• Poverty poor health of the poor not just about
  having too little money
• Graduate students have very little money, but
  have better health real plan to advance.
• Stress lack of social capital more important.

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How does lack of social capital ? poor health?

• Humans worse than monkeys baboons re social
  inequality.
• Agriculture is the villain!!
• UNEQUAL stockpiling of surplus resources ?
  stratification of classes.
• What do you think?

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Summary

• Subordinate animals numerous health problems
• Stress is the cause, not v.v.
• Exceptions
• Cooperative breeders
• Drought (or war w/ common enemy)
• Unstable hierarchy
• Personality

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Summary

• Humans Poverty ? both physical psychological
  stressors.
• Not just lack of access to medical facilities.
• Were worse than monkeys at this.
• Agriculture ? stratification of society.
• Unequal stockpiling of resources