Over the past few decades, as factories have closed as those jobs have become increasingly more automated or sent overseas, hospitals have remained in urban centers. Many of those institutions now serve the same economic function of early industry leaders. In my hometown of Pittsburgh, for example, the University of Pittsburgh Medical Center now occupies the Steel Tower, once owned by U.S. Steel — illustrative of the city’s new “eds and meds” economy. However, at the same time that medicine has emerged as the driving force in our economy, our average life expectancy (at least for some of us) has decreased.
Like many U.S. cities, Pittsburgh has a health system that controls vast economic, human and intellectual resources, and links Pittsburgh to national and international flows of money, ideas and people. Our hospitals are also charities, free to pursue their missions without the pressure of providing dividends to investors. Pittsburgh’s hospitals have the potential to help make our cities truly livable. And yet thus far, they have not.
So, what’s wrong? The problem is that the medical industry — which now accounts for about 17 percent of GDP — is focused on medical care, when it should be focused on health. It’s estimated that top-flight medical care accounts for only about one tenth of our health outcomes. The rest is accounted for by so-called social determinants of health. A long bout of unemployment or the presence of lead paint are better predictors of poor health and early death than is proximity to life-changing medicine. And the biggest predictors of all? Income and wealth. The engine at the heart of Pittsburgh’s economy may be healthcare, but we have not focused its vast resources and creativity on solving the problem that most affects our health. The story is similar in cities across the country.
Anyone who has ever tried to get by without enough money can tell you why income is a critical social determinant of health. Apart from the direct effects like food insecurity, every other critical social determinant of health — such as safe housing, educational achievement, and job opportunities — is also closely tied to income. Conversely, increasing wages has been shown to improve psychological well-being and job satisfaction, improve delay-of-gratification ability, and increase the opportunity costs of engaging in unhealthy habits.