When we talk about what we need to do to make quality health care affordable and available to all, people (including card-carrying liberals like Barney Frank) tend to talk about the supposed need for medical malpractice reform, or about capping Medicare benefits or more comparative effectiveness research. But, in a nation where the top one percent earn twenty-four percent of the nation’s income and control forty percent of its wealth, no one seems to be talking about the effect that income inequality has on health care delivery and outcomes.
But that’s changing. Awhile back, I blogged about the new book “The Spirit Level,” about the negative effect that income inequality has on public health.
And recently a New Yorker article entitled “Poverty Clinic” drew more attention to cutting-edge research suggesting that poverty and trauma can, in and of themselves, cause poor health outcomes.
The new thinking traces its origins to a study commissioned by the Kaiser Permanente H.M.O. in the mid-1990s. The study measured patients’ so-called “Adverse Childhood Experiences” (ACE) scores and assessed the patients’ health. A lot of the circumstances that are factored into determining ACE score – such as growing up with parental divorce and family members with mental illness or substance dependency – also tend to disproportionately affect children living in poverty.
What the researchers found stunned even them.
Patients with high ACE scores grew up to be at very high risk for suicide, drug abuse, cancer and heart disease. The drug abuse and suicide didn’t surprise researchers that much. Initially researchers thought that the cancer and heart disease could easily be explained away too.
They hypothesized that the ACE scores/poverty of the patients was merely correlated with the heart disease and cancer and was not the cause of it. They imagined that poorer patients ate less healthy and their diet led to the cancer and heart disease problems.
But it turned out that it was more complicated than that. Researchers found that patients with high ACE scores who didn’t drink, who didn’t smoke and who were not overweight were three hundred percent more likely to suffer from heart disease. Childhoods filled with poverty and trauma were affecting patients’ health through some sort of causal mechanism that had nothing to do with unhealthy behaviors such as smoking or overeating.
The exact pathways by which childhood trauma lead to poor health are not well understood. But research shows that childhood adversity can actually alter the chemistry of DNA in the brain through a process called methylation. Childhood trauma can cause complex lifelong changes in endocrinology and brain chemistry.
As Dr. Vincent Felitti, one of the co-authors of the ACE study, points out, we spend billions of dollars each year on statins because we know that having a cholesterol reading above 240 doubles your chance of heart attack. But so does having an ACE score greater than 4.
So maybe, if we’re trying to reduce heart disease, we should be looking to reduce some of its root causes such as childhood poverty and its associated traumas.
Health care is not (solely) a budgetary issue. Addressing health care also means addressing other social issues, such as the poverty and inequality that many Americans are born into.

This blog in maintained by the Boston medical malpractice lawyers at The Law Office of Alan H. Crede, P.C.