Episode 253 – Death by Inequality with Stephen Bezruchka

Macro N Cheese – Episode 253
Death by Inequality with Stephen Bezruchka
December 2, 2023

 

[00:00:00] Stephen Bezruchka [Intro/Music]: About 25 years ago, I coined a term: Health Olympics. If health were an Olympic event and the race was how long you live, today, the United States wouldn’t be there for the final day’s event. It would have been disqualified in the trials.

The father of modern cellular pathology, Rudolf Virchow voiced around 1850 that all diseases have two causes, one pathological and the other political.

[00:01:35] Geoff Ginter [Intro/Music]: Now, let’s see if we can avoid the apocalypse altogether. Here’s another episode of Macro N Cheese with your host, Steve Grumbine.

[00:01:43] Steven Grumbine: All right, this is Steve with Macro N Cheese. My guest today is Stephen Bezruchka. He is faculty at the School of Public Health at the University of Washington in Seattle. He worked as an emergency physician for 30 years and also set up a teaching hospital in a remote district in Nepal, where he supervised the training of Nepali doctors.

His current work is making better known what produces health in a population and why the United States has worse health outcomes than some 50 other nations, despite spending almost half of the world’s health care bill. His book, Inequality Kills Us All: COVID 19’s Health Lessons for the World, was published by Routledge, and we will be discussing a lot of those issues in this conversation today.

So let me bring on my guest. Steven, welcome to the show, sir.

[00:02:35] Stephen Bezruchka: Thank you very much for having me.

[00:02:37] Grumbine: Absolutely. We were talking offline and my entire life has been one consistent journey of leaving the right side of the world and coming over to the left for justice and solving things like inequality. And as we also talked about, this show typically will revolve around the Modern Monetary Theory school of thought and showing the possibilities of how we can solve these problems using the public money for the good of the people. But you’ve been writing specifically about inequality in terms of outcomes and within impoverished communities and the impacts that inequality has on life expectancy, et cetera. Talk to me a little bit about this specialty and what got you so involved and interested in this space.

[00:03:28] Bezruchka: So inequality is a property of a group. A single person out in the middle of the ocean, there’s no inequality there. But put them together with others, in many animal species, a ranking occurs. In chimpanzees, for example, there’s an alpha, beta, gamma, delta. And in many other species, there’s a hierarchy. So, as a young lad, I grew up in a working class neighborhood in Toronto, and everybody was sort of the same.

There was no hierarchy or inequality amongst us. We all had homes, my father repaired shoes, we lived above the shoe repair store. And others on the street were similarly workers. Same thing in the high school I went to. And then I went to university, and there was a little bit of a hierarchy there, but not much.

And then I went to Harvard in graduate school, and suddenly there was a tremendous range of people at Harvard, Boston Brahmins, very upper class people. The surprising thing about these more well heeled people was that they dress down. My initial impression, when I went to an Ivy League school, was that everybody would be well dressed.

When I went to the University of Toronto, I wore a jacket and tie every day, but not at Harvard. They dress down. So I became aware of these differences that were really quite stark. And then I went to Nepal and spent a year there. There was a caste system there with very well defined situations that you were born into and couldn’t change through the luck of your birth.

Medical school followed, this time at Stanford, and I became aware that doctors had high status. And so one of the ways that I have changed my situation in life from being a shoe repairman’s son in a working class community, to having multiple degrees from prestigious institutions, I raised my status that way.

But deep down inside, I’m just a worker class dude. Well, that was sort of how I saw society. And then, being a doctor, I’ve worked in different circumstances and enjoyed some of the prestige that came with that. And along the way, working as an emergency doctor, the easiest diagnosis I could make in the emergency department was that somebody was dead.

Very hard to fake. So when that was the case, I just filled out a death certificate and sent it off along with the body to the morgue. So, I immigrated to the United States because I always thought things were better here than in Canada. Turns out that’s true, but to reflect upon it, the best things are better in the United States, but the worst things are also worse in the United States.

And one of the things I discovered in the 1980s was that the health status of the United States, how long people lived, was not very stellar. It wasn’t the best in the world. Actually in medical school in 1971, I wrote in my notes that in 1951-53, we had the lowest maternal mortality ratio of all countries, lowest number of deaths of women from childbirth related causes.

Further down, I wrote by 1966, that a dozen countries had achieved better levels than the United States. And that story has continued to repeat itself to the present. That is, we used to be one of the healthiest countries, measured by whether you’re alive or dead. Most of us would prefer being alive. We used to be one of the healthiest countries, and now some 50 other nations, people in those other nations, have longer lives, healthier lives, than we do. And this became my obsession in the 1990s. As I learned the facts, it’s very hard to fake a death, and so I trust the mortality figures that are collected,in rich countries. All rich countries record births and deaths, and in poor countries, there are very good estimates.

About 25 years ago, I coined a term, ‘Health Olympics.’ Suppose health were an Olympic event. Remember, countries compete in the Olympics. If health were an Olympic event and the race was how long you live, well today the United States wouldn’t be there for the final day’s event. It would have been disqualified in the trials.

Now, that flies in the face of ‘American Exceptionalism.’ We’re number one in everything, is the feeling here. We’ve won the most Nobel Prizes of any country. We have the most billionaires. We got to the moon and nobody else has been there. So people think everything is really top in the United States.

Well, I came to realize that this wasn’t true about our health. And so I had to figure out why. So, I went back to public health school in 1992 to Johns Hopkins, the largest public health school in the world. And there I was confronted with the studies that showed that social and political factors were the most important determinants of health. The most important factors producing health.

And as you sort of implied, before that, I used to think medical care was really important, but that was already waning. I also used to think personal behaviors were really important. I used to harangue my smokers for the habits that brought them into the emergency department. But I had to change my mind because of the data and what I learned.

And as Taylor Mali said, ‘changing your mind is one of the best ways of discovering whether you still have one or not.’ So, social and political factors matter most. We can dissect both of those. What political factors really matter? Well, in 1979, the first studies linking income inequality to mortality outcomes for countries appeared.

And they found a strong association. And these were followed by other studies, with a much larger number of them being reported in the 1990s. And one of them, written by Richard Wilkinson in the British Medical Journal really intrigued me. It showed that income distribution really patterned life expectancy among rich countries.

[00:11:56] Grumbine: Let’s break down those two factors. Let’s start with the income inequality. This country, the American exceptionalism, everybody can do great, the opportunities… we know that’s not the case. There’s just so much evidence. But the impacts of it, I don’t think people realize how the system is wired to keep them in the bottom.

What was it that you discovered about income inequality and its impact o

us?

[00:12:25] Bezruchka: Well, there was a correlation between more inequality… led to more mortality. In many different realms, many different outcomes, among many different countries. And the studies were done by many different investigators over different time periods. Well, does association lead to causation? That’s the question to be asked.

One can find associations between all sorts of relatively irrelevant factors. So then you have to ask the question, is this a cause and effect? So, the idea of inferring causality. Epidemiology is the science of looking at the various measures of health and trying to make sense out of them. So, epidemiologists, those who wear this occupational badge, are relatively loathe to infer causality.

But criteria were established in the 1950s for the discipline, about how to believe something causes something else. The criteria were well laid out in the 1964 US Surgeon General’s report, Smoking and Health. Back in the 40s and 50s, doctors used to recommend to patients that they [should] smoke, though we knew back in the 1920s that smoking was bad for you.

So, the Surgeon General’s report came out and said, ‘officially, smoking’s bad for you.’ you can download this off the internet. One of the chapters there is about how to show that smoking causes worse health. And the criteria were to have many studies by different investigators over different times, showing that more smoking led to worse health.

You needed a dose-response relationship, that’s another criteria. You had to make sure there weren’t other causes for worse health than smoking, that were more important than smoking. Specificity.

And finally, it had to make biological sense. That is, if you couldn’t establish the biology on how smoke inhaled into a person’s body produced more heart attacks and cancers, then you were not on firm ground. So, these criteria for the association between income inequality and health outcomes, end up being satisfied.

And research papers pointed that out as well, that is, more inequality causes worse health. So, it’s a pretty open and shut case. However, we think of health as something other than related to inequality. You mentioned your son has strep throat. So, he’s got a bacterial infection that has caused some inflammation in his throat and it needs treatment. Now the interesting thing is, and this hasn’t been studied for strep throat, but a common condition these days is congestive heart failure. And a study done among those 50 countries, showed that countries with more income inequality had worse outcomes for this common disease, congestive heart failure. So, while I initially laid out the study for being dead, mortality, it’s also true for diseases as well.

So, we really are able to nail the coffin lid down pretty securely… with income inequality nails. The other criteria relates to the importance of early life. That is, as we go from the erection to the resurrection. First thousand days after conception is when roughly half of your health as an adult is programmed. That is, we have mechanisms to understand how the circumstances surrounding your early life program your biology and, in a sense, determine how long you live.

All of these factors that I point out, apply to populations, to groups. They don’t necessarily apply to individuals. So, we are talking about populations/groups, they can be cities, states, countries, neighborhoods. And it gets a little complicated at the neighborhood level. Early life lasts a lifetime, that is, the first thousand days from conception to when you’re blowing out two candles on your second birthday. In that period, roughly half of your health as an adult has been programmed. Doesn’t mean that some tragedy such as the death of Princess Diana meant she didn’t live a long life. As I said, it applies to groups, not to individuals. But, healthier societies privilege early life in some way. One way to consider that is one needs time to parent and resources to parent.

So that means that you have to have some money and you have to have some time, otherwise you can’t make the effort to parent a newborn child. So there are only two countries in the world, with populations of a million or more, who don’t give a working woman who’s pregnant paid time off after she has her baby.

One is, of course, the United States. We say we can’t afford it. And the other is Papua New Guinea, half of a big island north of Australia. Only two countries in the world. We are compromised in early life to not be able to raise healthy children. And as a result of that, we have higher child mortality, we have shorter lifespans.

And all the other countries in the world have a national policy of paid maternity leave. And they vary. There are about seven or eight U. S. states that have a pretty minimal policy of paid parental leave. And by minimal, I live in Seattle and Washington state has passed a 12 week paid family leave program paid for by a payroll tax.

And Pennsylvania, where you live, has not entered that elite group yet.

[00:20:17] Grumbine: No, indeed

[00:20:19] Bezruchka: But take a country like Sweden, much, much healthier than the United States. In Sweden, it is mandatory to take 444 days of paid parental leave at your full pay, and the father has to take 13 weeks, and the rest of it can be split. That’s full pay, 444 days, a year and a half. Then, for the rest of the second year, you can continue to have Optional leave at 70 percent pay, and most families take that. Then in your child’s third year, you can put your child in a Swedish government run daycare center that’s free. And to work in a Swedish government daycare center, you have to have an advanced degree in play.

Because what’s daycare? It’s socializing the kid, and you want experts. What are our requirements to work in daycare? Well, no recent sexual abuse of children and ability to work at a minimum wage. So once again, you get what you pay for. So many reasons why our health is so poor. One is the high inequality that we accept and the lack of attention to early life.

Sweden spends more government money on the first year of life than in any subsequent year,

[00:21:56] Grumbine: Smart people.

[00:21:57] Bezruchka: THe United States, if we look at our spending on childhood, it’s in the teenage years for remedial efforts. It doesn’t work.

[00:22:10] Grumbine: This is the kind of stuff that infuriates me as a guy that focuses on the public purse, the ability to do these great things. You’ve unearthed this stuff. This has got to be out there in a way that people know these things to be true. And yet nothing is done about it. But you see the evidence in the other countries where people are leading their best lives that are not stressed and are able to be with their children, give them what they need to make them lead happy, healthy lives.

And we don’t do that. What kind of perversion is that? It just seems so inexplicably horrible.

 

[00:22:46] Bezruchka: So a lot of it comes to our language and the words we use. Just think of, commonly you hear, we access health, pay for health, get health, insure health. It’s nothing of the kind. We access health care, pay for health care, get health care. So we conflate the terms health and health care, and we assume they mean the same thing.

So if you ask someone, do you want health or health care? They’re very confused. So we believe that it’s health care that produces health, and the evidence for that is very, very limited. So what do we do to change that? Well, trying to engage people in conversations about this is really very problematic.

We conflate the terms health and health care, and health care has relatively little to do with producing health. Studies on the impact of health care in averting death give it about 10 percent. About 10 percent of avertable mortality can be related to health care. Yet we spend 4. 2 trillion dollars on health care, and that represents almost half of the world’s total health care expenditure.

And as I pointed out, some 50 nations have better health measured by longer lives than we do. So, what else really matters? Well, if income inequality and support for early life matters much as I pointed out, then those choices are in the political realm. That is, how much inequality we decide to have in our society is a political choice.

And how we structure early life is another political choice. So, if we ask people, public opinion polls, to rank eight factors in what produces health, they rank health care number one and politics number eight. And these are consistent in many countries, so it’s not just the United States that thinks that health care is so important, and politics is not.

However, if we go back to the ancient Greeks, they recognized that health was related to politics. The father of modern cellular pathology, Rudolf Virchow, voiced around 1850 that all diseases have two causes, one pathological and the other political. And our longest lived state, Hawaii, the healthiest state in the country, the Department of Health in Hawaii also points out that political factors are the most important determinants of health.

[00:26:14] Grumbine: As you pointed out, the other portion being political, we have not had healthcare in this country; real genuine healthcare, to demonstrate that health is a priority for this country in any way. And the Affordable Care Act may have been the single greatest cash grab for industry ever. It didn’t provide people with affordable health outcomes.

It provided them with a bunch of bills to pay and diminished care. Looking at care in this country, you’ve got to have an advocate. You’ve got to have somebody that’s taking care of you because this system is designed to block you from getting served. What is the political calculus that created this?

[00:27:01] Bezruchka: Well, first of all, the word health system is used incorrectly. It should be health care system. And our health care system, we should call profit care. Working as an emergency doctor in Seattle in the early 1980s, we were asked by the hospital to bill for our services, separately from the hospital, and we were the first group to do that.

And so a company stepped in and said, we will create your bills for you from your records, and then we’ll take a percentage of the bill we create as our fee. So what happened was, every day a nurse would come in, go through the records and create a bill, and that would be sent to the patient. We were then told, look, if you examine more systems, if you took a bigger history, we could bill for more, and you’d be paid what you’re worth.

I still remember that phrase, you’d be paid what you’re worth. So we were incentivized to do more to make more money. Well, that was in the early 1980s. We’ve made a huge advance in the business of billing, and incredibly extravagant billing. Back then we used to hand write records and they would go into a file.

Now all these records are electronic and the two companies that do most of the electronic record keeping are designed for billing. And so that further enhances the profits made by… well, doctors don’t make the huge profits they used to, or the huge incomes… well, they make too much, but it is the hospital administrators.

It is the healthcare insurance companies. It is now the private equity funds that are buying up hospitals and practices and separating them into ones that are very profitable and driving the others into bankruptcy and selling them off. That’s really what’s happening to healthcare in this country and literally it is killing us.

[00:29:38] Grumbine: It’s unconscionable. Is there no one in power aware of this or is it by design?

[00:29:47] Bezruchka: Well, by design. We have a system of lobbying that takes this very sophisticated lobbying industry and it puts incentives into the government system to make sure that whatever legislation is there is crafted to enhance profits. At the University of Washington, our Department of Global Health gets students from all over the world.

And when they arrive, they often speak about the horrible corruption in their country. And then I explain our lobbying system to them and ask them what this is, and they always reply, oh, that’s corruption. The only difference is that it is legal in the United States. It is legal to have an industry to corrupt.

We have registered lobbyists in DC. Remember, that’s your favorite place. And each elected official has half a dozen lobbyists assigned to make sure they do the right thing.

[00:31:09] Intermission: You are listening to Macro N Cheese, a podcast brought to you by Real Progressives, a non profit organization dedicated to teaching the masses about MMT, or Modern Monetary Theory. Please help our efforts and become a monthly donor at PayPal or Patreon, like and follow our pages on Facebook and YouTube, and follow us on TikTok, Twitter, Twitch, Rokfin, and Instagram.

[00:32:00] Grumbine: It’s just appalling. It’s funny you say it’s my favorite place. I grew up in Washington, DC and my entire youth and teenage years and even into my forties, I lived in the nation’s capital and Southern Maryland, suburban Maryland, through the Beltway region. And there was just a lot more opportunity there to have jobs, to find work to make changes, if you wanted to make changes.

In more rural areas, like where I’m at in Pennsylvania, the opportunities simply aren’t there like they were in the Wash- Met region. When I think about Washington, DC, I also now in my fifties, think about it as an opportunity for activism and being away from there has definitely impacted some of my reach to be able to impact… Anyway, moving forward. Everything you’ve just laid out here is terrifying. Everything from the design of the system is intended to enhance profit and to clip away anything that is not profitable. So these areas of health that aren’t earning a profit are just simply eliminated.

[00:33:13] Bezruchka: Healthcare, healthcare, healthcare.

[00:33:15] Grumbine: Healthcare. Yes, thank you so much. I need to be corrected because we’re not saying these things in the correct fashion.

[00:33:22] Bezruchka: Yeah.

[00:33:23] Grumbine: And by not saying them correctly, I think we just aid and abet the folks that are pilfering us for profit, killing us for profit, so to speak.

[00:33:32] Bezruchka: Yes.

[00:33:33] Grumbine: Let’s go to COVID 19. One of the things that is quite clear in the world stage is that patents played a huge role in terms of getting people necessary medication for those that were willing to take the vaccine.

The vaccine was not available for some countries around the world. They just simply withheld that support, people died in crazy numbers. So on a global scale, we can see the impact of inequality. But what lessons did you glean based on your understanding of the perverse incentives within the system from the COVID crisis?

[00:34:11] Bezruchka: So let’s back up and recognize that the United States has had the most deaths of any country in the world from COVID. Last count is 1.1, 1.2 million deaths. That’s one in 300. And if you take rates, so divide by the population, we may not be number one, but we’re certainly in the top 10 countries in high rates of death from COVID. So, studies appeared beginning in 2020 looking at US state deaths from COVID, and found a strong relationship with income inequality. Similarly, there were studies looking at 84 countries around the world, again, finding the link between income inequality in that country and COVID death rates. So, I think there really is an important case to be made that a lot of why we did so poorly has been linked to our high levels of inequality. These days, I like to speak of our wealth pump. That is, from 1980 to 2020, over that 40 years, roughly $50 trillion has been taken from the bottom 90% and given to the top 1%. $50 trillion.

Most of us have a hard time imagining a sum of money of that amount. So how could we represent that? Suppose we take freshly minted hundred dollar bills. It’s our largest currency and freshly minted, they stack as tightly as can be. And stack them from the ground up to reach 50 trillion. How high would that stack go?

Almost to the moon. 170, 000 miles. That’s how much the rest of us have given to the richest over the last 40 years, and we seem to have done it willingly. How did we do it? Well, we decided to not tax the rich people. The rest of us should pay much more tax, and that is evidenced by the fact that who pays the lowest rate of combined federal, state, and local income tax?

The richest 400. And the number is 23 percent. Back in the 1950s, when we were one of the healthiest countries in the world, the richest 400 paid 70 percent of their income in taxes. In fact, in 1942, during the presidency of Franklin Delano Roosevelt, I like to show my students the front page of the New York Times with the lead headline 25,000 Income Limit Asked by President.

So FDR wanted 100 percent tax on all incomes above 25, 000. That’s equivalent to about $450,000 now, and many of us could live on that if we had to, and there was widespread agreement that this was a good idea. That tax rate didn’t pass Congress. In 1944, a 94% highest marginal tax rate passed, almost 100%.

And in 1946, that was raised to 96%. We’re talking about the highest marginal tax rate. If you’re making a million dollars, how much of the next dollar you made went to the government? And in the 1950s, the highest marginal tax rate was 91%. So it’s as American as apple pie to tax the rich back then. And somehow we now don’t want to tax the rich.

We want them to pay the least amount of taxes. And the ideology was, if we let the rich make as much money as possible, they’ll invest it and create jobs for us, the so called trickle down Reaganomics idea. Well, of course, that hasn’t happened. And so we have a situation of inequality in this country that, again, is, let’s call it a violent force.

[00:39:08] Grumbine: Yes.

[00:39:09] Bezruchka: Frederick Engels, in the 1840s, wrote a piece calling what we do to make the poor poorer, murder. Social murder.

[00:39:22] Grumbine: Austerity is social murder.

[00:39:24] Bezruchka: Yes.

[00:39:25] Grumbine: Yes, indeed.

[00:39:26] Bezruchka: And then in 1969, Johann Galtung, in an article in the Journal of Peace Research, coined the term “structural violence.” That is, we think of behavioral violence, there’s a rocket landing in Gaza or somebody pulled a trigger and there’s a bullet hole and somebody falls over dead.

Behavioral violence. But the deaths from social murder or structural violence are far, far higher than they are from the behavioral form. So I liken social murder or structural violence as the presence in our society of an invisible, odorless, highly toxic, lethal gas that kills us from the usual disease conditions we die from. And we’re totally unaware of it.

[00:40:22] Grumbine: My tagline is “austerity is murder.”

[00:40:25] Bezruchka: Yes.

[00:40:25] Grumbine: And that has been my chief moniker for years. And I get these wealthy people that disagree. They don’t realize that this is a structural, purposeful, intentional strategy. And we have an author on named Clara Mattei [Episodes 198 & 222] she wrote a book called The Capital Order and it described the huge knee jerk reaction to the Bolshevik revolution in 1917.

That set off all the capitalist forces around the globe, basically to crush any kind of social movement that empowered workers. And that really became an institutionalized way of dealing with insurrection was to discipline labor through austerity measures. Now they’re just trying to make sure that wealth maintains its station and doesn’t allow for their demise while we pay the ultimate price with our lives.

I’m so intrigued by the fact that you brought up Engels and the social murder construct. What would you tell people that are struggling with that idea that these economic elements are not some benign ideological gentlemen’s disagreement. People are dying. What are your thoughts on the origins of social murder and the blase acceptance of it today?

[00:41:53] Bezruchka: Well, the difficulty is trying to communicate to those who accept the idea, those who even think it’s one of the wonders of modern society, that they are affected by it. Remember the title of my book, Inequality Kills Us All. There’s nobody in this country that can say ‘the concepts of austerity, social murder, structural violence don’t impact me.

I see my doctor, I don’t smoke, I exercise, I meditate.’ That’s not enough. You are harmed by these forces in our country, and to evidence that… again, I, as an emergency doctor, death was the easiest diagnosis and so mortality figures are my measure of health. And so one way to look at this is to notice that the oldest old person at any one time is never in the United States.

If we were such a healthy country, surely one of us would someday be the oldest person. Doesn’t happen here. They’re mostly in Japan. Japan, of course, is the longest lived country. It has been since 1978. We destroyed Japan in the Second World War. We firebombed Tokyo. We’re the only country to have dropped two atomic bombs, killing hundreds of thousands. .

So at the end of the Second World War, Japan’s life expectancy was estimated to be around 25 years. Really, really low. Then, what did we do? The Allies occupied Japan, and the head of the occupation was a five star general, Douglas MacArthur. We sent him there, well, he went there, and he set up shop across from the Imperial Palace and, with a bunch of Americans,

during the occupation, had three basic ingredients to give to Japan that made them the healthiest country in the world. First thing he did was write Japan’s constitution. He did the equivalent of cutting and pasting from existing constitutions around the world. And one element in the constitution is article nine, which says Japan shall never maintain a standing army. It will resolve all disputes peacefully, never go to war. Once you put something into the Constitution, it’s hard to change. The United States would now like Japan to have an army and wage war in the South China Sea, but the Japanese people are comfortable with no military. I think of the MacArthur medicine as having three ingredients. They’re all D’s. Demilitarization. The second D was democratization. Japan was not a democracy before the war, and so he wrote the clauses in the Constitution for everyone to have the right to vote, including women. He put a labor organizing clause into the Constitution. Everyone shall have the right to organize and bargain collectively in Japan.

Now, Japanese unions are organized in the workplace, vertically, everyone from the sweeper to the CEO organizes together. Our unions here are horizontal, all the educators organize or the autoworkers or Starbucks employees. But in Japan, it was the sweeper in Sony up to the CEO. He put a public health clause into the Constitution, Article 23, the government is responsible for the health of the people.

Those aren’t the exact words, but that is the intent of Article 23. He also legislated a maximum wage in Japan in 1946. No one shall make more than 46,000 yen. An American general put a maximum wage as a law in Japan. So we have demilitarization, democratization, now decentralization. Japan, before the war, was run by 13 huge conglomerates, Zaibatsu.

MacArthur in his memoirs wrote you can’t have such concentrations of wealth and power and have a democracy. So he broke up the Zaibatsu. The other part of Japan was it was a rice farming economy. And, again, there were 37, 000 landowners, kosakumin, that owned the land farmed by 50 million peasants. And, again, MacArthur said, you can’t have such concentrations of land ownership and have a democracy.

So he bought the land from the landowners at a fixed price per acre and sold it to the tenants at the same price and gave them a 30 year low interest loan to pay for the land. And in the ensuing year, 94 percent of the land in Japan changed hands. And historians call it the most successful land reform program in history.

And Japanese abhor loans, so most of them had paid off the loan in a year or two. So demilitarization, democratization, and decentralization. And what followed were the most rapid declines in deaths ever seen on the planet, before or since. So much so that by 1978, Japan had the highest life expectancy, a position that it continues to enjoy to the present.

And one of the important things to recognize from this is these political forces put in place trumped personal behaviors. And what do I mean by that? Well, today, three times as many men smoke per capita in Japan as in the United States. The United States has some of the lowest rates of smoking cigarettes of certainly all the rich countries, and Japan has the highest.

So there’s something about the political policies put in place that means you can smoke in Japan and not pay the same price in poor health that you do here. Put that in your pipe and smoke it.

[00:49:33] Grumbine: Yeah, no kidding. When I think about the taxes that we have in this country. Taxes at the federal level are not a funding operation, but when it comes to behavior modification, the Pigouvian taxes, the sin taxes, they’re used to do social engineering. The idea within the MMT community is tax the bad, not the good.

Without the fundamental underlying investments in infrastructure and the political will to ensure every person in this country has the best life possible; they’re able to get whatever they need in a manner that is commensurate with the ailments or issues they have… none of that is there. We celebrate our greatness.

While Japan, a tiny island nation, takes care of its people, it makes no sense to me at all how we allow this to happen. What do you think it would take in the United States for us to make it right? I no longer believe in the standard electoral system. I’ve begun to really dig into the structural issues as it pertains to democracy in America.

And we live in an oligarchy. We do not live in a democracy. This concept of a Republic is alluring, but in reality, we live in a capital driven elitist oligarchy that doesn’t care whether we live or die as long as we can be controlled for our labor. Whatever it is that the haves want, and they just expect us to be there for them.

What in your mind will it take for us to fix this? I’m on board for reviving the tactics of the civil rights movement and radical class struggle unions, because I don’t think that you’re going to get it at the ballot box. And to me, it seems like an impossibility to overcome a system that was designed by the very people profiteering from the system, your thoughts.

[00:51:42] Bezruchka: Yeah, many places to go there. First of all, we don’t have a democracy. That’s been very clear for a long time. If we applied for membership to the European Union, we’d be turned down because we don’t have proportional representation. Wyoming has the same two senators that California does. And the populations are 30, 40 times different. We also have the electoral college, so somebody can become president without gaining the popular vote. So, in many ways, this is not a democracy. The main issue at work is that people are not aware of the mortal facts, the killer facts that I presented here. Suppose people knew that we were dead first. Most people would prefer to live a longer, healthier life than a shorter, sicker one. But they don’t realize that by living in the United States, their chances of doing that are marginal. So, what’s it going to take to make people aware of these ideas? To begin with, it’s very hard to change adult beliefs. We tend to we have our own thoughts that have been instilled in us earlier in life. I once asked a grade 8 student in a class how he came to know something was true. There was a long silence. Finally somebody raised his hand and he said, if our parents tell us when we’re very young, if our teachers and friends reinforce that, and if we’ve experienced it, then we know it to be true. So exposure in early life is really, really important. And it’s hard to get the parents to mouth what I’ve been saying because they don’t necessarily know it. But you can put it into school curriculums. So we have developed school curriculums down to grade five. You can introduce all the ideas that I presented here in the lower grades and then as students advance in their learning, hopefully they will understand some of these ideas. Now, this is a real challenge because I’ve tried to get school boards to modify their curriculums to have these ideas in them, and that’s not very easy. There are a variety of ways of sidelighting these ideas so they’re not so stark.

You have to take the SAT test, Scholastic Aptitude Test, to get into college. Suppose the questions about US health were on the test, then we would have to have preparatory courses so students could answer those questions. Same thing with the Medical College Admission Test or the Law School Admission Test.

Suppose questions were there about US health status compared to other countries, then that might get into the curriculums as well. Even schools of public health do not teach US health status in comparison to other countries. That’s a striking lapse. Even people who graduate from schools in public health often don’t know what I’m talking about.

So, presenting these ideas in early life is critically important as a part of the educational system. Another thing would be to recognize that Americans like to be number one. I remember in 1957 Russians launched a satellite, Sputnik, into space and we were caught totally off guard. And the satellite was broadcasting signals to the earth and we were totally shamed by this.

And so, what was our response? We set a goal to land a human on the moon by the end of the next decade. We told the world, this is what we’re going to do. And then the media reported progress towards that goal, the various test flights and so on. And then when we landed on the moon, we broadcast that to the earth in real time.

Well, suppose we recognize that our life expectancy now is where it was in 1996. That is, we’ve seen a decline in length of life to where it was 26 years ago. When the Soviet Union collapsed in 1991, Russia’s life expectancy fell. And in the ensuing years now, it is close to where it was when it fell. We don’t want the United States to repeat that same trajectory.

So, it could be a wake up call to point out to Americans that we’re dead first. The media would have to do that. And then we have to set a goal to become one of the healthiest countries in the world. Another tactic, wild and crazy ideas, our Constitution requires a State of the Union address. And in all the State of the Union addresses recently, State of the Union is always strong.

Suppose in January the President would say, ‘The State of our Union is very sick. We die younger than people in some 50 other nations, and we need to do something about that.’ Then the media would pick that up, and boy, we’d have a field day wanting to right that. I have a whole host of ways in which we need to… inform the American public of the sad state of our health.

[00:58:27] Grumbine: For me, I think the single biggest factor besides messaging is the concept of public and private and the mass privatization that the neoliberal era has brought to us. There’s just been such a history of an attack on our wellbeing by both parties. It’s not a partisan issue. It’s a functional requirement for a neoliberal capitalist society to place profit over people. As your final words, where do we go from here with all the work and all the research you’ve done, what do you think is our next steps? Give us a message of hope on how we can go forward.

[00:59:10] Bezruchka: Well, as individuals, we have to take whatever opportunities we have to spread the word and change policy. So, I teach courses at the University of Washington. I returned from the American Public Health Association conferences in Atlanta, where I moderated a panel discussion on our declining health. I write articles, books.

I belong to the Washington Physicians for Social Responsibility, and we have an Economic Inequity Health Task Force. So I use whatever avenues are open for me to get the word out and to work on policy changes. And I think it starts with trying to develop elevator speeches, short little statements that you practice and get good at, that you can engage other people with.

And so, I tell my students to practice developing a 10-20 second elevator speech, and then when a marketing call comes on your phone around dinner time that’s being recorded for quality assurance purposes, they won’t hang up, and so you can practice your speech. And you can try and engage the caller in that as well.

As I said, they won’t hang up. And so a lot of the lines that I use here, I have practiced in the various opportunities that I have open to me. So we got to get good at communicating, and then we need to mobilize, we need to use whatever organizations. My last statement as moderator at the public health meeting’s panel discussion was we have to organize or die.

It’s that simple because we are dying. And the way out of it is to work together and recognize the power of the people is greater than the power of the people in power. It’s just as, as you pointed out, with neoliberalism, the goal in the privatization and then Modern Monetary Theory, it’s all designed to make us think we have no power.

But mashed together, our power is far, far greater than that of the people in power. It’s using whatever strategies we have to work together that’s going to matter most.

[01:01:50] Grumbine: Thank you so much. This was fantastic. I really appreciate your time. Stephen, tell our listeners where we can find more of your work.

[01:01:59] Bezruchka: Well, I have a website, stephenbezruchka.com, and there I have material about the book. This will probably be linked to from the media about the book. A whole host of things to do. And contact me. My email is S as in Sam, A as in Albert, B as in boy, E as in egg, Z as in zebra, at uw.edu, SABEZ@uw.edu. And I’ll answer emails.

That’s something I learned from Noam Chomsky. You write him a letter, he writes you a letter back and emails are the same.

[01:02:45] Grumbine: Fantastic. Thank you so much for your time, sir. My name is Steve Grumbine. I’m the host of this podcast, Macro N Cheese. We are part of Real Progressives, which is a 501c3 nonprofit. We survive by your donations and good news, it’s the fourth quarter. And for those of you who are looking for a tax break while we’re trying to change the world, You need a tax write off.

We need some money to keep thriving and producing content for you. Please consider becoming a donor. It’s at patreon.com/realprogressives and you also can come to our website, realprogressives.org and go to the get involved and donate and please become a contributor. If you’re interested in volunteering, we need your help.

For my guests, Steven Bezruchka

[01:03:34] Bezruchka: Thank you very much.

[01:03:36] Grumbine: and myself, we are out of here.

[01:03:45] End Credits: Macro N Cheese is produced by Andy Kennedy, descriptive writing by Virginia Cotts and promotional artwork by Andy Kennedy. Macro N Cheese is publicly funded by our Real Progressives Patreon account. If you would like to donate to Macro N Cheese, please visit patreon.com/realprogressives.