[Paleopsych] SW: Class and National Health

[Premise Checker]

Public Health: Class and National Health
http://scienceweek.com/2004/sb041015-6.htm

    The following points are made by S.L. Isaacs and S.A. Schroeder (New
    Engl. J. Med. 2004 351:1137):
    1) The health of the American public has never been better. Infectious
    diseases that caused terror in families less than 100 years ago are
    now largely under control. With the important exception of AIDS and
    occasional outbreaks of new diseases such as the severe acute
    respiratory syndrome (SARS) or of old ones such as tuberculosis,
    infectious diseases no longer constitute much of a public health
    threat. Mortality rates from heart disease and stroke -- two of the
    nation's three major killers --have plummeted.(1)
    2) But any celebration of these victories must be tempered by the
    realization that these gains are not shared fairly by all members of
    our society. People in upper classes -- those who have a good
    education, hold high-paying jobs, and live in comfortable
    neighborhoods -- live longer and healthier lives than do people in
    lower classes, many of whom are black or members of ethnic minorities.
    And the gap is widening.
    3) A great deal of attention is being given to racial and ethnic
    disparities in health care.(2-5) At the same time, the wide
    differences in health between the haves and the have-nots are largely
    ignored. Race and class are both independently associated with health
    status, although it is often difficult to disentangle the individual
    effects of the two factors.
    4) The authors contend that increased attention should be given to the
    reality of class and its effect on the nation's health. Clearly, to
    bring about a fair and just society, every effort should be made to
    eliminate prejudice, racism, and discrimination. In terms of health,
    however, differences in rates of premature death, illness, and
    disability are closely tied to socioeconomic status. Concentrating
    mainly on race as a way of eliminating these problems downplays the
    importance of socioeconomic status on health.
    5) The focus on reducing racial inequality is understandable since
    this disparity, the result of a long history of racism and
    discrimination, is patently unfair. Because of the nation's history
    and heritage, Americans are acutely conscious of race. In contrast,
    class disparities draw little attention, perhaps because they are seen
    as an inevitable consequence of market forces or the fact that life is
    unfair. As a nation, we are uncomfortable with the concept of class.
    Americans like to believe that they live in a society with such
    potential for upward mobility that every citizen's socioeconomic
    status is fluid. The concept of class smacks of Marxism and economic
    warfare. Moreover, class is difficult to define. There are many ways
    of measuring it, the most widely accepted being in terms of income,
    wealth, education, and employment.
    6) Although there are far fewer data on class than on race, what data
    exist show a consistent inverse and stepwise relationship between
    class and premature death. On the whole, people in lower classes die
    earlier than do people at higher socioeconomic levels, a pattern that
    holds true in a progressive fashion from the poorest to the richest.
    At the extremes, people who were earning $15,000 or less per year from
    1972 to 1989 (in 1993 dollars) were three times as likely to die
    prematurely as were people earning more than $70,000 per year. The
    same pattern exists whether one looks at education or occupation. With
    few exceptions, health status is also associated with class.
    References (abridged):
    1. Institute of Medicine. The future of the public's health in the
    21st century. Washington, D.C.: National Academies Press, 2003:20.
    2. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment:
    confronting racial and ethnic disparities in health care. Washington,
    D.C.: National Academy Press, 2003
    3. Steinbrook R. Disparities in health care -- from politics to
    policy. N Engl J Med 2004;350:1486-1488
    4. Burchard EG, Ziv E, Coyle N, et al. The importance of race and
    ethnic background in biomedical research and clinical practice. N Engl
    J Med 2003;348:1170-1175
    5. Winslow R. Aetna is collecting racial data to monitor medical
    disparities. Wall Street Journal. March 5, 2003:A1
    New Engl. J. Med. http://www.nejm.org
    --------------------------------
    Related Material:
    SCIENCE POLICY: ON HEALTH CARE DISPARITIES AND POLITICS
    The following points are made by M. Gregg Bloche (New Engl. J. Med.
    2004 350:1568):
    1) Do members of disadvantaged minority groups receive poorer health
    care than whites? Overwhelming evidence shows that they do.(1) Among
    national policymakers, there is bipartisan acknowledgment of this
    bitter truth. Department of Health and Human Services (DHHS) Secretary
    Tommy Thompson has said that health disparities are a national
    priority, and congressional Democrats and Republicans are advocating
    competing remedies.(2,3)
    2) So why did the DHHS issue a report last year, just days before
    Christmas, dismissing the "implication" that racial differences in
    care "result in adverse health outcomes" or "imply moral error... in
    any way"?(4) And why did top officials tell DHHS researchers to drop
    their conclusion that racial disparities are "pervasive in our health
    care system" and to remove findings of disparity in care for cancer,
    cardiac disease, AIDS, asthma, and other illnesses?(5) Secretary
    Thompson now says it was a "mistake". "Some individuals," Thompson
    told a congressional hearing in February, "wanted to be more
    positive."
    3) But when word that DHHS officials had ordered a rewrite first
    surfaced in January, the department credited Thompson for the
    optimism. "That's just the way Secretary Thompson wants to create
    change," a spokesman told the Washington Post. "The idea is not to
    say, `We failed, we failed, we failed,' but to say, `We improved, we
    improved, we improved.'" According to DHHS sources and internal
    correspondence, Thompson's office twice refused to approve drafts by
    department researchers that emphasized detailed findings of racial
    disparity.(5) In July and September, top officials within the offices
    of the assistant secretary for health and the assistant secretary for
    planning and evaluation asked for rewrites, resulting in the more
    upbeat version released before Christmas.
    4) After unhappy DHHS staff members leaked drafts from June and July
    to congressional Democrats (and to the author), Thompson released the
    July version. For all who are concerned about equity in American
    medicine, issuance of the July draft was an important step forward.
    The researchers who prepared it showed that disparate treatment is
    pervasive, created benchmarks for monitoring gaps in care and
    outcomes, and thereby made it more difficult for those who deny
    disparities to resist action to remedy the problem. And therein lies
    the key to how the rewrite came about -- and to why the episode is so
    troubling.
    References (abridged):
    1. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment:
    confronting racial and ethnic disparities in health care. Washington,
    D.C.: National Academies Press, 2003
    2. Health Care Equality and Accountability Act, S. 1833, 108th Cong.
    (2003) (introduced by Sen. Daschle)
    3. Closing the Health Care Gap Act of 2004, S. 2091, 108th Cong.
    (2004) (introduced by Sen. Frist)
    4. National health care disparities report. Rockville, Md.: Agency for
    Health care Research and Quality, December 23, 2003
    5. Bloche MG. Erasing racial data erased report's truth. Los Angeles
    Times. February 15, 2004:M1
    New Engl. J. Med. http://www.nejm.org
    --------------------------------
    Related Material:
    ON THE COSTS OF DENYING HEALTH-CARE SCARCITY
    The following points are made by G.C. Alexander et al (Arch Intern
    Med. 2004;164:593-596):
    1) Scarcity is increasingly common in health care, yet many physicians
    may be reluctant to acknowledge the ways that limited health care
    resources influence their decisions. Reasons for this denial include
    that physicians are unaccustomed to thinking in terms of scarcity,
    uncomfortable with the role that limited resources play in poor
    outcomes, and hesitant to acknowledge the influence of financial
    incentives and restrictions on their practice. However, the denial of
    scarcity serves as a barrier to containing costs, alleviating
    avoidable scarcity, limiting the financial burden of health care on
    patients, and developing fair allocation systems.
    2) Almost two decades ago, Aaron and Schwartz(1) published The Painful
    Prescription: Rationing Hospital Care, in which they examined the
    dramatic differences in health care expenditures between the US and
    Great Britain. Their examination highlighted the role of rationing
    within the British system and explored the difficult choices that must
    be made when trying to weigh the costs and benefits of many health
    care services. They noted that British physicians appeared to
    rationalize or redefine health care standards to deal more comfortably
    with resource limitations over which they had little control.
    3) Since that time, physicians in the US have been under increasing
    pressure to acknowledge and respond to scarcity.(2-4) To begin to
    learn more about how they respond to these pressures, the authors
    conducted exploratory interviews with physicians faced with scarcity
    on a daily basis: transplant cardiologists involved in making
    decisions about which patients to place on the organ waiting list;
    pediatricians who frequently prescribe intravenous immunoglobulin
    (IVIg), a safe and effective medical treatment that has been in short
    supply(2); and general internists who make cost-quality trade-offs on
    a daily basis. The interviews were conducted in confidential settings,
    included open-ended and directed questions, and were recorded and
    transcribed for subsequent analysis. During these interviews, the
    authors were struck by the vehemence with which the physicians they
    interviewed denied scarcity or, more commonly, the constraints that
    scarcity imposes on their practice. The authors were left with the
    impression that physicians' awareness of scarcity and its consequences
    lies under the surface.
    4) The authors conclude: Physicians' limited time and energy will
    never suffice to fulfill the almost limitless needs of their patients.
    Similarly, the limited resources available to health care in the US
    guarantee that difficult choices must and will be made regarding the
    distribution of health care. Physicians are in a privileged position
    to help develop policies that promote fair allocation of health care
    resources. However, to do so, they must examine their own practices
    and those of the health care systems in which they work. Denial of the
    impact of scarcity limits physicians' abilities to play an active role
    in reshaping policies on a local and national level.
    References (abridged):
    1. Aaron HJ, Schwartz WB. The Painful Prescription: Rationing Hospital
    Care. Washington, DC: Brookings Institution; 1984
    2. Tarlach GM. Globulin goblins: shortfall in immune globulin supplies
    looms. Drug Topics. 1998;142:16
    3. Pear R. States ration low supplies of 5 vaccines for children. New
    York Times. September 17, 2002:A26
    4. Morreim EH. Fiscal scarcity and the inevitability of bedside budget
    balancing. Arch Intern Med. 1989;149:1012-1015
    5. United Network for Organ Sharing. Data. Available at:
    http://www.unos.org/data/default.asp?displayType=USData.
    Archives of Internal Medicine http://pubs.ama-assn.org
    --------------------------------
    Related Material:
    HEALTH CARE AND RURAL AMERICA
    The following points are made by S.J. Blumenthal and J. Kagen (J. Am.
    Med. Assoc. 2002 287:109):
    1) Poverty, a major risk factor for poor health outcomes, is more
    prevalent in inner-city and rural areas than in suburban areas. In
    1999, 14.3 percent of rural Americans lived in poverty compared to
    11.2 percent of urban Americans. Irrespective of where they live,
    persons with lower incomes and less education are more likely to
    report unmet health needs, less likely to have health insurance
    coverage, and less likely to receive preventive health care. When
    combined, these variables raise the risk of death across all
    demographic populations.
    2) Many of the ills associated with poverty, including lower total
    household income and a higher number of uninsured residents, are
    magnified in rural areas. In addition, rural communities have fewer
    hospital beds, physicians, nurses, and specialists per capita as
    compared to urban residents, as well as increased transportation
    barriers to access health care.
    3) The highest death rates for children and young adults are found in
    the most rural counties, and rural residents see physicians less often
    and usually later in the course of an illness. People in rural America
    experience higher rates of chronic disease and the health-damaging
    behaviors associated with them. They are more likely to smoke, to lose
    teeth, and to experience limitations from chronic health conditions.
    While death rates from homicides are greater in urban areas, mortality
    rates from unintentional injuries and motor vehicle crashes are
    disproportionately more common in rural America.
    J. Am. Med. Assoc. http://www.jama.com
    --------------------------------
    Related Material:
    ON HEALTH OF THE GLOBAL POOR
    The following points are made by P. Jha et al (Science 2002 295:2036):
    1) Improvements in global health in the 2nd half of the 20th century
    have been enormous but remain incomplete. Between 1960 and 1995,
    life-expectancy in low-income countries improved by 22 years as
    opposed to 9 years in high-income countries. Mortality of children
    under 5 years of age in low-income countries has been halved since
    1960. Even so, 10 million child deaths occur annually, and other
    enormous health burdens remain.
    2) In 1998, almost a third of deaths in low- and middle-income
    countries were due to communicable diseases, maternal and perinatal
    conditions, and nutritional deficiencies: a death toll of 16 million,
    equivalent to the population of Florida. Of those deaths, 1.6 million
    were from measles, tetanus, and diphtheria, diseases routinely
    vaccinated against in wealthy countries.
    3) Of the half million women who die annually due to pregnancy or
    childbirth, 99 percent do so in low- and middle-income countries.
    Approximately 2.4 billion people live at risk of malaria, and at least
    1 million died from malaria in 1998. There are 8 million new cases of
    tuberculosis every year, and 1.5 million deaths from tuberculosis.
    4) On the basis of current smoking trends, tobacco-attributable
    disease will kill approximately 500 million people over the next 5
    decades. Over 20 million people have died already of HIV?AIDS, 40
    million people are infected currently, and its spread continues
    unabated in many countries. The burden falls most heavily on poor
    countries and on the poorest of the people within those countries.
    5) Of the 30 million children not receiving basic immunizations, 27
    million live in countries with GNP below $1200 per capita. In India,
    the prevalence of childhood mortality, smoking, and tuberculosis is
    three times higher among the lowest income or educated groups than
    among the highest.
    Science http://www.sciencemag.org