Piketty & Public Health

by Anthony Robbins, MD, MPA

I first heard the name Thomas Piketty on a trip to France.  Now his immense book, Le capital au XXI^e siècle (Capital in the Twenty-First Century) sits on my bedside table (in both the original French and the English translation).  It is a best seller in the US and in France. I have read reviews (here, here), attacks, defenses, and other essays that take off from Piketty’s work. I even had the opportunity to hear him live, addressing a class at MIT.

Having learned Piketty’s major observations and arguments with the MIT students and followed the debate about his work, I sheepishly admit that I have barely cracked open the book. Perhaps I overestimated my capacity to read the book. Could a book so large and dense ever have been bedtime reading?

This has not stopped me from thinking, based on his methods and conclusions, Piketty might have something to offer us in public health.  He describes how over the last two centuries, as income flowed to the richest people, the distribution of wealth in industrial societies has become increasingly concentrated in a very small minority–increasing wealth inequality.  There was one brief period, from the 1940s to the 1980s, where wealth inequality declined, but Piketty suggests that this was an historical aberration, not the long-term trend.  He predicts increasing wealth inequality in the 21^st Century, a feature of capitalist economies, unless we do something about it.

Public health scholars have concluded that environmental factors–both the physical and social environments–affect health.  They have imported the word determinant from mathematics to describe these causal situations. They have also chosen to use the adjective “social”, although I don’t think they means to exclude physical exposures like housing and workplaces. And since the Report on the WHO Commission on the Social Determinants of Health, researchers are more attentive to what influences the health of populations.  This is a salutary trend, as it constitutes a countervailing force against the tendency to attribute health to medical care effectiveness and lack of health to medical care deficiencies–a very narrow view.

To study social determinants of health, most researchers have compared people exposed to different environments, often using income as a variable.  Because it is easier, these studies usually look at different populations at one time in history. The studies are cross-sectional, not longitudinal (over time).

If we adopted Piketty’s research strategy and focused on changes in health and in social determinants over time, would we be able to learn more about the causes of health inequality?  Surely more has changed over time than the medical care system. And just as Piketty urges policies that alter wealth directly, such as wealth taxes, to achieve a more equitable distribution of wealth, public health advocates would be advised to urge policies that attack the most unhealthy aspects of our societies’ environments.

Here I make a plea for public health leaders to avoid having public health get lost in the term health systems, where the public immediately thinks medical care.  Surely we must attend to workplaces and employment, housing and the living environment, and toxic and physical exposures throughout society.  These exposures are rarely spread evenly across the population.  Following changes over time in both health and exposures may encourage policies that bring more health in the future.  It may be a powerful antidote to the conventional thinking that usually attributes inequality in health to unequal access to medical care.

Anthony Robbins, MD, MPA is co-Editor of the Journal of Public Health Policy. He directed the Vermont Department of Health, the Colorado Department of Health, the U.S. National Institute for Occupational Safety and Health, and the U.S. National Vaccine Program.