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The World Would Change Tomorrow

Posted on July 28, 2011

Interview with Jeff Ritterman, MD

I just retired from 30 years as a cardiologist at Kaiser Richmond, a span of time that started in 1981, right after my fellowship, and went to the end of November 2010. The last two years of my cardiology also overlapped two years on the Richmond [CA] City Council, which I’m still on.

When I was in medical school, people were starting to understand that disadvantaged living circumstances have a way of getting under the skin and causing premature morbidity and mortality. So I’ve always had that conception of disease and wondered in my own field of cardiology how it works that disadvantaged social circumstances can play a role in early heart disease and death. Richmond was a laboratory for that. We always in Richmond had a very high minority enrollment and a high enrollment of people in poverty.

The field of social epidemiology documents and gives the data for this. The most famous epidemiologist in that field is Michael Marmot. He’s probably going to win the Nobel Prize. When I started medical school in the ’70s, the conception of chronic disease was that it was the CEO who was under so much pressure in the company that the stress of that leads to a heart attack. It was Michael Marmot who showed in the famous Whitehall studies that actually it was the reverse: the lower down you were in the occupational scale, or in the social hierarchy, the more likely you were to have premature heart disease. And that didn’t only go for heart disease; it was true also for just about every disease you could think of.

Understanding this pattern led me to health advocacy and health policy work. It actually propelled me into running for municipal office. Now I’m trying to introduce the ideas in social epidemiology into health policy, which isn’t always easy to translate. That’s the challenge.

The low hanging fruit was really easy to go after. We had a failing grade from the American Lung Association for our anti-smoking ordinances which were really lax and non-existent. Now we have a very strict anti-smoking ordinance, including100% non-tobacco smoking in multi-unit dwellings. The scientific data is that the smoke comes through the walls and it creates secondhand smoke illness, so there was incontrovertible data. The epidemiology on that is incredibly solid. The amazing thing about it is that you begin to save lives basically within the first year once you adopt those kinds of ordinances. It’s not necessarily easy politically, because you get the homeowners and the apartment owners and the realtors and so on, who are generally anti-regulation, but there’s basically no redeeming factor here for tobacco.

We’ve also been educating the Richmond residents on the deleterious effects of rising income inequality. When a country is rich like our country, life expectancy no longer correlates with gross domestic product; it correlates with how equally the product is shared. The US is now the most unequal of the rich countries of the world, with the exception of Singapore. This is a greater public health menace than, say, cigarette smoke, I mean by three orders of magnitude, and yet it’s invisible.

Imagine a microbe that could do all this, that could decrease life expectancy, and adversely affects every social ill you can think about. The more unequal a country is, the more prisoners you have per capita, the more alcoholics you have, the more drug addicts you have, the lower your children score on math and science tests, the less trust you have between neighbors, the more teenage pregnancies you have, the more bullying in schools, the less recycling, the less innovation in industry, it goes on and on. You can’t believe the number of correlations with rising income inequality. I highly recommend that you review Richard Wilkinson and Kate Pickett’s book, The Spirit Level. The website is They have done incredible epidemiological research on this, and this is basically unknown. I try to bring that information into Richmond politics. There will be no way to improve health in this country without addressing this rising income inequality.

In the food and environmental world, we are trying to work toward supporting urban agriculture and moving us toward healthy diets. For example we have a very successful workforce development project in Richmond called Richmond Build. It can take a young man from the street, from a gang, and in 12 weeks teach him how to build a house and how to install solar panels so he can actually have a career. We found that when they were in that 12-week training period, they pretty much all ate Cheetos and drank jugs of cherry coke. We got a grant and we introduced healthy eating, active living information into the curriculum, so now we’re really trying to bring health education to a group that is on the bottom of the socioeconomic totem pole.

What advice do you have for healthcare professionals doing advocacy work for the first time?

I believe you can do a lot of good in the office one-to-one. I dedicated a lot of my life to doing that. But to make a difference in the health of a population, changing policy is a lot more effective. Taking lead out of gasoline is an obvious example. If you look at any of the environmental health data on lead, the lead levels track more closely than anything else with getting lead out of gasoline. So there are huge benefits to getting involved on the policy level.

Politicians don’t really have the credibility that doctors have. In some ways my credibility as a politician is predicated on my credibility as a doctor. That’s really why I was elected. I’ve been a cardiologist in the same community for 30 years, and that’s how people knew me. If I took care of your mother, you didn’t care what my position was on the casino or this or that, you knew that you trusted me and that I took good care of your mother and so you voted for me. We all love our families; we all want our children to be healthy. In the end we can bring that knowledge and that honesty into the public arena in a way that nobody else can and we can thereby change the world.

Right now a big issue in California is the soda tax, and we don’t have one. There’s a perfect nexus between childhood obesity and sugary drinks. We have the science, but we don’t have the political will. What if every pediatrician demanded it? The world would change tomorrow. That’s our challenge.


Mary Saunders said ..

If every pediatrician demanded a tax, it would not change things. What are you thinking? If people could have access to fresh fruit they grew themselves without poisons, we would have change. We must have kids growing things. Search Hood River Middle School farmers market and community-supported kitchen.

August 24, 2011

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