Dr. Tony Iton: ‘What’s in the way of the American dream right now?’

6 min read

What you’ll read about: The faltering American dream. How ‘short-termism’ in politics and business encumbers progress in thinking about health as a means to participation in the economy and society.

The U.S. has a life expectancy problem that’s threatening the notion of the American dream and more money spent on health care services won’t fix it.

The U.S. outspends on health care and underspends on social services compared to more than 30 countries, per Organization for Economic Co-operation and Development data. Despite the outsize spending on health care, the U.S. life expectancy in 2015 was 79.3 years — wedged at 31st between Costa Rica and Cuba, according to the World Health Organization.

It’s a spending imbalance that Dr. Tony Iton, senior vice president of healthy communities at The California Endowment, pegs to earlier deaths because of what he calls the “broken social contract,” or a deterioration in the support or structure in the communities in which people live. Around the country — and Tennessee — people find it harder to get around, save money, attain education and skills and live healthy.


White Americans — traditionally the group with the longest life spans, most education and greatest wealth — are dying earlier, a stark change that surprises citizens and researchers alike, said Iton, who kicked off a new speaker series hosted by NashvilleHealth and Metro Public Health Department in Nashville on March 2.

“What surprises (people) the most is the sort of severity of the mortality — the premature death problem facing white, working class populations. It also surprises people like me who do research,” Iton said. “We have this way of understanding the way patterns of health kind of manifest themselves across communities — and this defies those patterns and that’s what’s hard for people to understand.”

Dr. Tony Iton

Iton digs into life expectancy by zip code in partnership with health departments around the country, and the results are startling. Everywhere he and the teams looked, they found life expectancy can vary from neighborhood to neighborhood by 12 to 30 years. The Shelby County Health Department found a discrepancy of 13 years.

People in one part of town might have decades less to live, work and contribute.

There’s no pill, he said, to fix what’s plaguing communities.

“The initial response is often shock, and sometimes horror, and people basically trying to argue that the data is somehow not real but the data is very real. It’s overwhelmingly available through multiple sources,” said Iton. “We need new explanations and I think this notion of a social compact has provided a unifying explanation of this very surprising data.”

Do you think there’s resistance in hearing that the U.S. or local communities are not doing as well as people seem to think they are? There’s the nationalism and local pride that can that can make it hard for people to see the numbers. 

I think there’s a lot of denial and while it does hit people hard sometimes to see stuff they didn’t expect it also tends to galvanize action, which is what’s most critical to get people sort of looking at the true numbers and results and figure out what is it going to take to turn this around.

The media has now picked up on at least the white mortality aspect of it so people will have a hard time figuring a way around this data.

It is very real and it’s real despite the investment in health care in places like Nashville where you have a lot of health care institutions.

You’re seeing worsening health status as opposed to improving health status. 

How do you try to talk to people about embracing a social compact? In places like Tennessee there will be resistance to social services. 

There’s one thing to understand: if you can help people to think about this differently sometimes you can make progress. And you know our dominate narrative is that health care equals health.

The more health care you have the healthier you are — and that was actually true at one point in the 19th century when the major killers of Americans were infectious diseases. Health care was about trying to intervene in things that happened to you out of the blue. Getting tuberculosis. Getting a sexually transmitted disease. Getting gastrointestinal disease. You needed to get to a doctor and the doctor would give you an antibiotic or a pill or do surgery and then you either die or you were cured.

There was a correlation between access to health care and health status but in the 20th and 21st centuries, the U.S. has made what’s called the ‘epidemiological transition’ where the causes of death stopped being acute, episodic events like you know infection, and it becomes chronic disease which is much more about lifestyle.

Our health care system is not really designed to essentially address lifestyles because lifestyle has much more to do with outside the doctor’s office than what happens inside the doctor’s office.

In our minds, our narrative hasn’t caught up with the epidemiology, it hasn’t caught up with the patterns of disease. We still think health is health care, when in fact health has much more to do with how we design communities and how much time people spend in cars, what they are eating, how they are interacting with people, whether they are socially isolated and whether they are feeling stressed and those things can’t be treated by a health care intervention. They can only be treated by redesigning the environments in which people live

Fundamentally, the public doesn’t really understand how that change manifests itself in terms of health.

It also strikes me that you don’t see results as quickly if you’re investing in social services whereas you can see whether someone lived or died from an infection —

Or a heart attack.

How do you try to educate the public or policy makers to go in for the long haul?

That is a challenge because our politics are short-term politics. People are up for re-election every couple of years so they need to show results within the time they were in office and that’s one of the big challenges. Corporations have to show quarterly profits. So we have ‘short-termism’ as a general problem.

But we don’t have a hard time in thinking about investments in education as paying off over the long-term. That’s never been a challenge for us. We recognize education is an investment.

What we’re trying to do is transition our thinking around health to make it more aligned with how we think about education than how we think about health care.

We think about health care as just you know having an insurance card and having access to an expert. Whereas when we think about education it’s more of a lifelong kind of cycle of acquiring knowledge and skills that allow you to participate more effectively in the economy. We need to think about health in the same way we think about education.

How do you explain this problem to, say, someone out on the sidewalk?

The way I approach this problem with people is talk about the American dream. The fact that our data suggests that the American dream is actually dying, and this is a problem not just for us but for our children and people care about their children and their children’s future. Then I tie it to health — that not only is it about economic and social mobility, it’s also about health, and how long people will live.

The thing about health is that people feel, and they may have political agendas around education, they may have some about land use, but they generally feel like health is a value that everyone should support and espouse. Health helps people enter this conversation without having necessarily an agenda.

I think that on the streets you want to talk about the American dream. You want to ask people if they still believe in it. How does it manifest in their lives, in their children’s lives — and then talk about what’s in the way of the American dream right now?

Do we really have the kind of supports that we need in order for people to be able to pursue opportunity? Really at the end of the day what I’m talking about is opportunity. I’m not talking about health in the traditional sense.

Health and opportunity are perfectly correlated: the more opportunity people have, the better health they have. So if we can talk in terms of opportunity, which translates a lot of technical information into something people understand — the American dream — you can actually get people to understand this much more effectively.

Posted in Q&A