GDP has Immense Consequences for Health Equity: Why Doctors Should Care

Natalia Khosla ‘22 is a MS 4 at the University of Chicago Pritzker School of Medicine. She can be reached at nkhosla@uchicago.edu or natalia.khosla@uchospitals.edu.

During one of my medical rotations, my team and I were taking care of a patient stuck in a vicious cycle: a 68-year-old with heart failure, obesity, osteoarthritis, anxiety, and recurring urinary tract infections. This was her third hospitalization in a month for heart failure exacerbation due to discontinuing her diuretic medication. It was a repeating cycle: she could not walk much because of her knee pain, so she laid in bed, passing bowel movements into a diaper, resulting in frequent urinary tract infections. She thought her diuretic was causing the urinary tract infections, so she would stop her pill, triggering water overload, and bringing her back to the hospital with heart failure exacerbation. She had recently been moved in with her son’s family due to alleged difficulties living alone, and was no longer on the Pace bus route that took her to church and bingo, where she used to meet her friends. She hadn’t seen them in weeks, and her anxiety and mood were reflecting it. This worsened her forgetfulness and apathy about leaving the bed. My incredible team integrated the physical and psychosocial elements of our patient’s life, identified this cycle, and found a way to mobilize her disability insurance to cover a Pace bus pickup in front of her house. She would be able to go back to church and bingo.

From our perspective, we had clearly enabled someone to live more fully, which would have positive effects not just for her physical and emotional health, but for her community as well. But in the eyes of our economic measures what we had done for our patient was “spending” on social care services, not investing in human life. Gross Domestic Product (GDP), the most widely used indicator of the “health” of the economy, makes massive assumptions about what does and does not add value to society: assumptions that are embedded in the language itself.

It approximates the value of all goods and services within a fixed period in a country by summing expenditures in an economy: consumer spending, government spending, investment, and net exports. Transactions in the social sector are termed “government spending,” whereas transactions in the private sector are “investments.” Government spending includes social services provided to the public, such as the Pace bus, or goods like infrastructure and roads. Transfer payments through welfare programs only become investments if they are spent on capital to invest in corporations. GDP does not take into account, for example, that by enabling our older patient to participate more fully in her multiple social units—family and community—we had invested in arguably the most impactful type of capital: human capital. GDP does not consider the increased time and mental sanity that our investment bought her, however these positive externalities provided social good not only to her but to the rest of society as well. This results in metrics that severely underestimate the return on investment of social, public health, and cultural interventions, as Bobby Kennedy famously said, GDP “measures everything except that which makes life worthwhile”. It’s no wonder that our resource allocation is not maximizing human wellbeing: the US ranks low in worldwide measures of happiness, social cohesion, mental health, and physical health among OECD countries despite ranking high in GDP. If our metrics don’t value human life, then our resulting policies will not either.

The impacts of this lopsided narrative of value extend beyond bad storytelling: the consequences are dire particularly for those already marginalized. When an economic downturn hits, governments make cuts to social spending, yet maintain private investment. For example, at the beginning of the COVID crisis the government allocated a two trillion dollar relief package for the airline industry that had been engaging in share buybacks to boost their own stock prices without adding any value since their last bailout in 2001. Meanwhile, Ohio, Missouri, Indiana, and a number of other states cut government services, including a $210 million cut to Ohio state Medicaid.

Sectors that contribute more to GDP growth end up receiving more investment. These include finance, real estate, and insurance, which currently account for the greatest portion of GDP growth at 21%. However, most benefit only the 14% of Americans who invest in the stock market and represent the wealthiest 10% of the country. During the COVID crisis we’ve hailed “essential workers,” yet we slashed their feeble safety nets while the already wealthy experienced notable growth of their wealth. Because GDP only measures wealth and economic growth it does not take into consideration the equitable distribution of this wealth.

The biased narrative of GDP also has immense effects on racial inequity. Poorer and Blacker communities are already unlikely to receive government and private investment, and GDP further portrays communities funded by social aid as spenders, not creators, thereby further deterring investment and widening racial gaps. GDP is far from gender-neutral: women of color and immigrant women are particularly hard hit because they are more likely to do unpaid, domestic labor which is not included in GDP, as it is expected to be “free” and “natural.” In OECD countries, even when women are the primary breadwinners they bear two to three times more domestic work than men. GDP tells a profound story about who and what creates value, and therefore in whom we should invest or disinvest, but these subjective definitions  systematically undervalue the poor, nonwhite, nonmale, and other non-dominant groups in society, while overvaluing their richer, whiter, and male counterparts. This drives disparate health outcomes, and therefore is in the purview of physicians.

Public and private partners across the globe are starting to recognize the dangers that GDP creates and new metrics are already being developed. For example, in Spain the Prosperity & Inclusion City Seal & Award (PICSA) index has been used to categorize cities by inclusive prosperity (GDP per capita), social inclusion (health access), and spatial inclusion (housing access). Tellingly, the richest 10 cities in the world did not make the top 20 cities ranked by the PICSA index due to non-inclusive prosperity. Scales like the PICSA index indicate how much information is being left out of GDP, and optimistically, that better and more inclusive metrics are possible.

We cannot fix a problem that we cannot measure. We need to improve on and implement more measures like the PICSA that reflect what we value as humans and that don’t privilege certain bodies over others. The healthcare community in particular, as the group charged with caring for human wellbeing, should be leaders in this movement. Recent figures estimate that medical care determines only 10-20% of people’s health, the rest is determined by the social and economic conditions around them. Healthcare is one of the few major industries where strategic planning is done largely without the input of those on the ground, which is particularly detrimental given that only people working at the front lines can understand such a complex system.

Healthcare and the GDP have more crosstalk potential than it seems at first glance. The medical community, public policy makers, and private actors have an opportunity to bridge intellectual silos and create novel measures of humanity that capture its complexity and actually improve health, happiness, and equity. We need to measure the work we did that day with our patient as an investment in human wellbeing and acknowledge it as a benefit to society. We must align our measures with the reality that we know to be true: that human capital is the most valuable investment we can make, above all others.