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Caring for Health: Expanding the Policy Dialogue

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Is health care reform the full answer to improving the health of Americans? Since good health entails much more than just having high quality health insurance, what other issues do President Obama and other policymakers need to consider? The current government and media focus on health care provides an opportunity for us to look beyond the narrow lens of health insurance options, to the full range of potential policy solutions. Thus far, the focus has been narrowly on the government's role in regulating or providing health care for more people. This is of course an urgent need for millions of people. Yet, health insurance should not be the only topic up for national discussion. And while Obama talks often about individual responsibility, asking Americans to take steps to improve their own health by not smoking, eating less junk food, working out, etc., we all know it is not that easy. In their new book, Gender and Health: The Effects of Constrained Choices and Social Policies, Dr. Chloe E. Bird and Dr. Patricia P. Rieker argue there are a whole host of issues to be examined between the two bookends of individual choice and health insurance.

In my conversation with the authors, they argue that to address the question of how to improve health "We must consider why men die prematurely while women live longer but with more health problems. Moreover, why don't Americans live as long as men and women in other industrialized countries?" In short, they are trying to advance research and policy on health in part by extending the dialogue. The authors are interested in understanding gender disparities in health, and as a result of years of research, conclude that approaches which focus on simply biological or social forces alone are inadequate. According to Bird, "it is not simply that both biology and society play a role, but they interact, and so unless we are using an interdisciplinary approach that takes all factors into consideration, we cannot create better solutions and policy responses." They develop the sociological notion of "constrained choices" to highlight the ways in which the individual decisions we make in our daily lives are constrained in various ways by law and policy (consider Family Medical Leave; social security; Medicare); government regulation (of alcohol and tobacco, for example); family responsibilities (the presence of children or responsibilities for eldercare); work (choice of occupation, work related stress, work hours, the flexibility to adjust one's schedule, etc.) and the local communities we reside in (environmental pollutants, parks and recreation opportunities, etc.). These contextual factors can and often do vary for men and women. While it is more obvious how family responsibilities, for example, impact women and men differently, also consider, for example, that the availability of safe park areas where one can walk or jog is more important to women's ability to exercise and spend time outdoors. Bird and Rieker highlight the ways in which all of these factors differentially impact men and women and the interacting biological and social factors involved.

Throughout their text, they examine what they refer to as "constrained choices" at three levels: national social policy; community; and work/family levels, all of which shape our individual lives and enhance or limit our "choices."

For example, there is ample evidence now that stress impacts health. Yet this has only just begun to inform the ways in which we think about how the communities we live in impact health. At the community level, decisions are made daily which impact health, such as regulations regarding where people can smoke in public, to the availability of public transportation or affordable housing. This issue hit home for me the other day as I sat in rush hour traffic that doubled my usual commute time to work. I could feel my level of stress rising. Bird's and Rieker's arguments fresh in my mind, I started reflecting upon the variety of factors involved, including the location of workplaces relative to housing, public planning and urban sprawl, the lack of public transportation opportunities, the numbers of other cars on the road, the inflexibility of most people's work hours resulting in more cars on the roads at specific hours, etc. These factors all interact to impact my commute, which then interacts with my own biological responses and lack of learned mechanisms for dealing with stress. The issue clearly cannot be reduced to one of individual choice regarding health.

The authors focus on four of the most prevalent conditions in which there are large gender gaps--cardiovascular disease, immune function and disorders, depressive disorders, and substance abuse disorders. One of the more interesting issues for me was the comparative discussion of men and women's mental health. For years, professionals believed that women suffered disproportionately from mental illness; however, over the past fifteen years researchers have found that they suffer similar rates of psychological disorders. It is in the manifestations of the problems that we observe differences. Women are more likely to be diagnosed and treated for depression and anxiety disorders, whereas men are more likely to abuse alcohol and drugs. In this and many other areas the authors identify, research integrating both biological and psychiatric factors with environmental and social factors hold promise for interpreting these gender differences.

Bird and Rieker move us beyond the stereotypes about men and women's bodies and minds. They argue that examining the ways in which specific biological differences interact with the daily lives of men and women that are constrained in gender-based ways, can help us to improve both women's and men's lives. They draw upon the basic feminist sociological insight that while biological sex differences between men and women are very small, and men's and women's bodies are far more similar than they are different, we live in a gendered society, where our daily lives, experiences, responsibilities and opportunities are shaped at every level by gender, whether consciously or not.

Although it varies slightly from one year to the next, we are 26th among nations in terms of life expectancy from birth. In the U.S. the life expectancy for women is 79.8, and for men, 74.2. Understanding both the differences among nations, and the gender gap, requires that we examine both biological and social factors. Wealth, income, and education levels all play a role, and the interaction among these is complicated. Bird and Rieker "examined the Nordic countries and countries such as France where they have free day care, free higher education, pensions that allow people to stay home with their children and still get income. Lo and behold, people in these countries do live longer. It's pretty clear that those non-health policies make it easier for people to make healthy choices." According to Rieker "such cross national comparisons underscore the irony of the U.S. focus on individual choice and responsibility for health, because as a nation we fail to address and rectify the larger constraints that produce barriers to opportunities, and impediments to choice, for both men and women."

Clearly the discussion needs to be expanded beyond the tired reduction of health to questions of individual choice and health insurance. Providing universal health coverage is essential, but there are many, many other social policy avenues to pursue if we seek to improve the health of our citizenry. Further, as Bird and Rieker demonstrate, it is time we move beyond stereotypes of feminism, and recognize that a feminist perspective-- which brings gender into the analysis-- is about enhancing the lives of both women and men.

Gender and Health: The Effects of Constrained Choices and Social Policies by Chloe E. Bird and Patricia P. Rieker, Cambridge University Press, 2008.

Sloan Work and Family Research Network Interview: http://wfnetwork.bc.edu/The_Network_News/52/

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