[Paleopsych] SW: Class and National Health
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Wed May 25 18:44:58 UTC 2005
Public Health: Class and National Health
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.
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
SCIENCE POLICY: ON HEALTH CARE DISPARITIES AND POLITICS
The following points are made by M. Gregg Bloche (New Engl. J. Med.
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
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
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
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
ON THE COSTS OF DENYING HEALTH-CARE SCARCITY
The following points are made by G.C. Alexander et al (Arch Intern
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.
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:
Archives of Internal Medicine http://pubs.ama-assn.org
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
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
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.
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