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ScienceWeek
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.
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
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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
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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
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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
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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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