The Social Determinants of Survival

I’ve been thinking about the various circumstances that have worked in my favor.

Let’s start with the global. I have benefited from living in a high-income country. According to the World Health Organization, residents of high-income countries get a life expectancy bonus of 23 years in comparison to residents of low income counties.  The average life expectancy in low-income countries is just 57 years, while in high-income countries it is 80 years. No doubt many factors are at work there. Generally, early childhood health is much better in high-income countries and that has long term effects. Even still, expensive and technologically complicated treatments, requiring a high degree of advance training, such as stem cell transplants, are likely to be more readily available and more successful in high income countries. A person living in, say, Malawi would be less likely to survive.

I also live in a country in which it is considered a matter of justice that everyone is covered by medical insurance that provides for very high quality treatment. A person living in the United States might be excluded from the life-saving treatment due to insurance that does not cover it, too high a co-payment, or lack of insurance altogether. Poor people covered by Medicaid and seniors covered by Medicare who suffer from myelofibrosis only became covered for a transplant in in January of 2016. A person’s access to life-saving treatment is far less secure in the US.

I’ve benefited by being of European descent. It turns out that race matters in finding a matched unrelated donor. Whether a potential donor is a match depends upon genetics. People who share a common ancestry are more likely to be a match. There are over 20 million people registered around the world as possible donors, around a half of them in the US. Campaigns to register people in African and Asian countries have not taken off to a similar degree. And in the US the history of unjust medical “experimentation” on African Americans is an obstacle to people’s willingness to participate in registry efforts. Additionally, people of African descent are by far the most genetically diverse group because of the long history of human movement out of Africa and into all the regions of the world. So, not only are there fewer donors of African descent, the genetic profile of a donor is less likely to match the person in need. I can only imagine the heartache of being denied access to a transplant because no donor can be found. I had a perfectly matched unrelated donor. Had I been of African descent that would have been far less likely.

I’ve emphasized on several occasions how little success is a matter of a patient’s own efforts and how much of it depends on the vagaries of complex biochemical processes, in particular the disease's response to therapy, as well as the skill and experience of the doctors and care staff. That’s is one reason to reject the attitude that an individual has “beaten” cancer. Survival is in large part a matter of good biochemical fortune. It’s more like a gift than an accomplishment. But the language of “gift” might suggest that it’s just a matter of charity. The social determinants of survival are matters of policy. We survivors have had the good fortune not only of biochemistry, but of favorable social circumstances. That’s an issue of justice. Better science can improve biochemical fortune across the board. Better politics can reduce health disparities.






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