I'm OK -- You, Maybe Not So Much

It is widely agreed that competition, or lack thereof, in health care is a problem.  The Wall Street Journal recently showed how Viagra and Cialis prices seem to move -- up, of course -- in lockstep.   USA Today found Walgreens charging 1237% more than Costco, for the same drug.  Economists like Martin Gaynor have been discussing problems with competition in health care for years.  The Harvard Business Review just published a lengthy article on the problem.

But, it turns out, we may be ignoring an important competition that has real impacts on our health: with each other.

We've been becoming increasingly aware that there are numerous social determinants that have dramatic impacts on health (e.g., Healthy People 2020 and the RWJF).  Where you live, how much you make, how much education you have, what your family situation is -- all are closely correlated with your health.  But so is where you stand in the social pecking order.

It isn't the kind of thing that can be easily tested in a blind clinical trial, so researchers did the next best thing: they studied its impact in monkeys.  Macaques, to be more exact.  In a paper published in Science, researchers from Duke, Emory, and the University of Montreal found that social status alters the immune function.

The researchers studied 45 female macaques, all with the same access to resources (and care).  They broke the group into 9 subgroups, allowing for different dominance patterns, and measured the resulting immune responses in each macaque.  Lower status individuals showed a higher ongoing inflammatory response, indicating higher levels of stress.

An inflammatory response is, of course, how the body deals with infections, but when the immune system works too hard for too long, it can attack the body's own cells, leaving it at higher risk for a variety of illnesses, such as heart disease.  And the increased inflammatory response in the lower status individuals didn't even serve its intended purpose; the higher status macaques still had a stronger anti-viral immune response.

What made the study especially powerful was that the researchers didn't just have to observe the response among a fixed set of status levels, as they might with human subjects.  They mixed and matched the sub-groups, creating new status levels.  Once previously low status macaques achieved high social status, their immune response changed accordingly.

As one of the lead researchers said: "There was nothing intrinsic about these females that made them low status versus high status. But how we manipulated their status had pervasive effects on their immune system.”

In a press release, another of the researchers summed up:

In short, two individuals with access to the same dietary resources and the same health care and exhibiting the same behaviours have different immune responses to infection depending on whether they have a high or low social status

This isn't about macaques, or monkeys, of course.  The chair of clinical microbiology at the University College London (who was not involved in the research) told BBC News: "All the evidence is showing the findings are terrifically applicable to humans."

One of the researchers further noted: "Some of the diseases that we know about that show the strongest social gradients in health in humans are in fact diseases that are closely associated with inflammation."  We're already seeing the health impacts of our social status; we're just not doing much about them, at least not intentionally.

There's a lot of "blame-the-victim" that is sometimes done to explain away poor health, The researchers beg to differ.  As one told BBC:

It suggests there's something else, not just the behaviours of these individuals, that's leading to poor health.  We know smoking, eating unhealthily and not exercising are bad for you - that puts the onus on the individual that it's their fault.  Our message brings a positive counter to that - there are these other aspects of low status that are outside of the control of individuals that have negative effects on health."

It's not always our fault.

The researchers made a point of stressing the plasticity of the immune response.  One told The New York Times: "I think there’s a really positive social message.  If we’re able to improve an individual’s environment and social standing, that should be rapidly reflected in their physiology and immune cell function."  Status is not necessarily fixed, either in time or place.  As an accompanying editorial suggested: "Think of a mailroom clerk acquiring prestige as the captain of the company softball team."

We've known for some time that income and other kinds of social inequality has measurable impacts on health.  Many have probably suspected that social status inequality might have the same kind of impact.  This research helps solidify those suspicions.

Of course, there is a lot we don't know from the new findings.  The researchers haven't yet confirmed that similar impacts happen with male macaques (although one might hypothesize that the effect is even greater).  We don't know how having varying levels of social status in different parts of our lives might mitigate how having low social status in only some of them.  We don't know if there is a pharmacological solution that might mimic the effect of higher social status, or if there might be behavioral training that could do so.

In short, it is like a lot of health care.  Much of the medical care we give to people may not be necessary, and can be even harmful.  We focus too much on medical treatment, not enough on behavioral change, even less on underlying social conditions, and virtually none on social status.  

The big takeaway is that we're not doomed to health based on the social status to which we were born, or have achieved.  In the words of one of the researchers, "But the hopeful message is how responsive [immune] systems are to changes in the social environment. That's really different than the  possibility that your social history stays with you your entire life."

There will probably always be at least some social inequality.  Even if we magically took away all income inequality, there would most like still be some social inequality.  We are, after all, primates, and primates tend to form hierarchies.  But, as one of the researcher hoped, "It's a hard problem that might never be fixed, but it might be possible to make it less worse."

Sometimes "less worse" is all we can hope for.