0 Justice, Social Justice, Health, and Health Care, Part III

Health Disparities

Etiologic Agent
# deaths per year
Tobacco use
Microbial agents
Toxic Agents
Sexual behaviors
Motor vehicles
Illicit use of drugs*
What are some of the components of the social determinants of health? They include, certainly, housing, food, warmth, education, the overall treatment of women and especially the education of women. There is evidence that greatest determinant of the quality of a society, and especially its economic standing, is related to the education of women. Let us take the example of “food deserts”. 2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle. There are food deserts not far from me in Kansas City, KS. In a community called “the Argentine”, largely populated by Mexican Americans, it can take more than two hours on 3 buses to reach the supermarket. It could be faster to walk, but hard to carry back groceries. In fact, the inability to carry much on any one trip can lead to fresher food, but this requires availability of stores. In an article in the NY Times (July 31, 2011), Russell Shorto describes “The Dutch way: bicycles and fresh bread”; riding bicycles everywhere not only provides great exercise, but the limited carrying capacity means that the bread – and other food – is fresh daily.

The unequal distribution of the social determinants of health is a major cause of health disparities, as demonstrated in the slides from Dr. Jones, and in a few from Dr. Woolf.  The latter shows us a list of the 9 most common etiologies of death, from tobacco use (400,000 deaths per year) through illicit drugs (20,000, and not including the use of “licit”, legally prescribed, drugs). Seen this way, by root cause (that is “tobacco”, “diet and activity”, “alcohol”) as opposed to medical diagnosis (like “heart disease”, “cancer”, “liver disease”) we get a clearer picture of the true role of social determinants. Only one on the list, (#4, microbial agents) is even considered part of “traditional” medicine. Dr. Woolf also demonstrates the tremendous impact that education has on health with data from the University of California San Francisco (UCSF) Center for Health Disparities that show that 26.7% of those with less than a HS education describe themselves as having “fair” or “poor” health, compared with 5.8% of college graduates, a five-fold difference! The racial and gender difference in age-adjusted mortality rates is also dramatic; the death rate for black males is coming down, but still far exceeds white males and black and white females (and, although the rates for women are lower than for men, they are much higher for black women than for white women).

In a provocative “thought experiment” published in the American Journal of Public Health, “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”[1], Dr. Woolf and his colleagues demonstrate that even if we attribute all current and recent reduction in mortality to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this graphic.

The County Health Calculator produced by Woolf and colleagues from Virginia Commonwealth University, and available free on line,  allows one to look at the socioeconomic status (measured as percent of people with income s >200% of poverty) and education (measured as percent of people with at least some college) for every state and county, and compare it to the other states or counties within a state. A neat “slider” feature allows you to change these rates (e.g., make the rate the same as the best or worst) and see what the change in deaths would be. For Harris County, Texas (Houston) , if 5% more people attended some college and 5% more had an income higher than twice the federal poverty level we could expect to save 1,200 lives, prevent 12,200 cases of diabetes, and eliminate $97.8 Million in diabetes costs every year.

Bradley and Taylor, in an Op-Ed piece in the NY Times, To fix health care, help the poor”, NY Times, (12/8/11) cite their research challenging the simplicity of the notion that the US spends far more per capita on health care than other developed countries. While true on its face, the US spends far less on social services that might decrease the need  for health care; when lumped together, the difference decreases, although the US stands out as being one of very few countries where almost all health+social services spending is on medical care. [2]

A major way to address social determinants and health disparities is the implementation of “health in all” policies, for such things as
·         Land use (what is the density? Are there open spaces? How is space used?)
·         Built environment (are distances to schools and shopping walkable? Are there facilities for exercise?)
·         Transportation (can people get to the store or the park?)
·         Agriculture (what about antibiotic and drug use in raising livestock? How about the conditions of farmworkers, including exposure to pesticides?)
·         Environmental Justice (are there toxins in the environment? Lead? Who is exposed to “brownfields” and do their children have higher rates of cancer? )
·         Health policies (smoking in public places)
·         Taxes (do these encourage or discourage the building of a healthful society?)

Although these areas are outside of traditional medicine, physicians can be involved in addressing them; they are (like Dr. Henry A. Withers, for whom this lecture is named) community leaders who have great moral authority.

[1] Woolf SH, Johnson RE, Phillips RL Jr, Philipsen M.“Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”, Am J Public Health. 2007 Apr;97(4):679-83. Epub 2007 Feb 28.PMID:17329654
[2] Bradley E et al, “Health and social services expenditures: associations with health outcomes”. BMJ Quality and Safety 2011 Oct 20(10):826-31.

0 Justice, Social Justice, Health and Health Care: Part II

This is the second of what will be 4 parts comprising the Henry A. Withers lecture I gave at the University of Texas-Houston Department of Family and Community Medicine. When they have all been posted, I will attach them as a "GoogleDoc".

The Social Determinants of Health

A key measure of Social Justice are the Social Determinants of Health, and manifests, in the negative, as health disparities. Some of the most important  work on disparities was done by the British physician, Julian Tudor Hart. Practicing in the Welsh coal-mining town of Glyncorrwg, Tudor Hart was able to identify who got sick from what, and as the physician for this community, he could identify how it related to their economic and social standing. As an epidemiologist he gathered this data in the pre-computer era, and then expanded it by looking at access to health care across Britain. The result was a 1971 article in Lancet called “The Inverse Care Law”,[1] in which he demonstrated with empiric data that “the availability of health care services is inversely proportional to the need for it.”

A corollary of this law is that the “higher” the level of medical involvement, in terms of both complexity and cost, the lower the overall impact on the health of the population, as demonstrated in this graphic from Dr. Steven Woolf. The greatest determinants of health of the populations are those that come before medical care. This incontrovertible truth is integrally tied to the concept of social justice. The role of social determinants in the health of the population and the production of health disparities was developed as an outstanding cartoon by Camara Phyllis Jones and colleagues, “Addressing the social determinants of children’s health: a cliff analogy.[2]

A link to a powerpoint presentation of these, developed by Neal Palafox and colleagues at the University of Hawai’i Department of Family Medicine, can be found here, and is definitely worth reviewing. In brief, it pictorially demonstrates that all people are at risk for injury or illness, but some live a little closer to the “edge,” which puts them at greater risk of falling off. The same is obviously true for populations who live “closer to the edge”, who are at higher risk for disease – because of genetic risks, environmental risks, and behavioral risks – but also because they have less money, or social support, or greater stress in their lives. Things that, at the best of times, mean they are just able to get by and keep from falling off.
So, what can we do?

·    We can pick up the person, or people, who “fall off the cliff”, who get sick. This is known as “tertiary prevention”, because the bad thing has already happened and we are hoping to prevent complications, prevent it from getting worse. This is where we spend almost all of our “healthcare” dollars.

·    Or maybe we can put up a safety net. You’ve heard of “safety net clinics” and “safety net hospitals”. This can be thought of as a form of secondary prevention – they have already fallen, their high blood pressure or diabetes has become uncontrolled and they are at risk for something really bad, but we intervene. In the nick of time.

·   Or we could actually put a fence up on the edge of the cliff, preventing people from falling off. This is a kind of “primary prevention”.

But there is something else that might even be more effective. We can move these people further from the edge. This “pre-primary” prevention actually involves intervening on the core risk factors for health – addressing the social determinants of health. It is not a major component of our current medical model.

This is what health disparities are about. They are about differences that we could control. About some people living closer to the edge. And maybe the ambulance doesn’t come as quickly; that is, high tech medical care is less available. Or there is no safety net. And not even a fence, primary prevention. All these three are characteristics of access to medical care. Social determinants address health disparities by asking the questions that Dr. Jones asks:  why are there differences in who is found at different parts of the cliff, and why there are differences in resources along the cliff face?

Earlier I mentioned the work of John Rawls, and tried to distinguish between the concepts of intrinsic equality (as in the Declaration of Independence, “All men [sic]  are created equal”), and people actually being equal in all things (including intelligence, wealth, physical ability, genetics, etc.) I noted Rawls speaks of distributing societal goods equally, which is a different thing. I also noted that the principle of “justice” in medical ethics, which I said implies that people with the same conditions be treated the same. This concept is equity. What is the difference between equality and equity? Which should we strive for?

The Declaration of Independence, for example, also states that all men [sic, again] are entitled to “life, liberty and the pursuit of happiness”. It doesn’t guarantee happiness, but suggests some degree of equity, of equality of opportunity. What about when people start, as the folks on the cliff do, from such different places? What are the implications? For example, we have all heard politicians rail against inheritance taxes as “death taxes”, but what does it say about someone who is raised with all the advantages of money – good food, education, support, tutoring – but still cannot compete with a person raised with nothing? Are inheritance taxes good or bad? For myself, I’d say it depends on what we are going to spend the money on. Bombs? Feeding people? Bailing out banks? Housing people?

A key concept, going back to Rawls, is that the exception to the general rule of distributing all social goods equally is when not doing so is to the benefit of the least advantaged. This is also the basis for why for it is a different thing for the underprivileged or oppressed to band together to relieve that oppression or lack of privilege than it is for the privileged or oppressors to band together to maintain it. This is the flaw of the concept of “reverse discrimination”. Is it discrimination if we take away all of the advantages that one group had that another did not? I suppose that it is still a matter of perspective. While I do not know the source of this quotation, I believe it speaks very well to the issue of perspective: “If you’ve spent your whole life with the wind at your back, a calm day seems unfair!”

(to be continued)

[1]Tudor Hart J, The inverse care law”, Lancet. 1971 Feb 27;1(7696):405-12.
[2]Jones CP, Jone CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228

0 Justice, Social Justice, Health and Health Care: Part I

I was recently honored to be invited by the Department of Family and Community Medicine at the University of Texas Health Science Center in Houston to give their annual "Withers Lecture", which is named for and supported by the family of Henry A. Withers, MD, a family physician and Houston civic leader. My topic was Social Justice and Health. I am "serializing" the talk in this blog, with the first part today. For those who prefer looking a powerpoint slides, they are attached under "Links to documents in Google Docs" in the navigation bar on the left.


“Justice” is most commonly thought of in terms of courts of law, epitomized by a blind goddess holding a scale – and often a sword. Thus justice can be seen – and is seen by many – as punishment for crime s or transgressions. The rule of law may be necessary for a civilized society, but legal decisions, even in country such as ours, are not always just: think of the death sentences overturned by new DNA evidence, of the cases right here in Texas where a person was convicted of a capital crime while their court-appointed attorney dozed through the trial. Justice is, perhaps, in the eye of the beholder.

In the field of medical ethics, justice is one of the four key principles, but probably the least discussed. We often hear student groups discuss the relative implications of “non-maleficence” (do no wrong) and “autonomy”, as, for instance, when a person wishes a costly intervention that physicians believe will not help and may hurt (the fourth is "beneficence", do the right thing). But “justice” refers to the concept that people with the same conditions should have the same treatments available.  What, then, is “social justice”?

Also known as “distributive justice”, the term social justice was popularized by the philosopher John Rawls in the 1970s, although obviously the concept has been in existence, in one form or another, for centuries. In “A Theory of Justice”, Rawls writes:
“All social primary goods – liberty and opportunity, income and wealth, and the bases of self-respect – are to be distributed equally unless an unequal distribution of any or all of these goods is to the advantage of the least favored.”[1]
While this seems pretty expansive, as it says “distributed equally”, the inclusion of the phrase “to the advantage of the least favored” suggests that things are not completely equal because there are people who are least favored. For example, even in a much more equal society, some people may be suffering from physical or mental challenges that require them to utilize more resources. From a medical perspective, we have to consider whether  people who advocate for the disabled, or the expenditure of large amounts of money for the diagnosis and / or treatment for those who are close to them may see it as their individual “right”, but do not necessarily support other people having the same rights.

A somewhat earlier authority, Franklin Roosevelt, said that "The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough to those who have too little." This does not suggest that everything be divided equally, but makes a different moral claim: that what we do as a society (and it is fine to read “government”) should be to help those who need the help most rather than those who need it the least. Often in history, including today, that concept is rejected by many. In any case it is clear that, today in US, we do not have a system of social justice such as that described by either Rawls or Roosevelt; rather We have a system in which the most privileged exert great influence, and (mostly seem to) use it to increase their privilege. More modern discussions of social justice and medicine can be found in the many writings of Paul Farmer, including Pathologies of Power and Partner to the Poor: A Paul Farmer reader, and in the online journal Social Medicine, published by the Department of Family and Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine.

What are human rights? The most authoritative modern definition is that of the UN Universal Declaration of Human rights, passed in 1948. Article 25 states that:
“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

According to the UN Association of Canada (UNAC), while “originally the Universal Declaration was conceived as a statement of objectives to be pursued by Governments, and therefore it is not part of binding international law…. it is still a potent instrument used to apply moral and diplomatic pressure on states that violate the Declaration’s principles…. in 1968, the United Nations International Conference on Human Rights agreed that the Declaration ‘constitutes an obligation for the members of the international community to protect and preserve the rights of its citizenry.’”

So, then, how is social justice related to health, health care, and medicine? In 1978, the World Health Organization issued the “Declaration of Alma-Ata” (now called Almaty, it was then but is no longer the capital of Kazakhstan which was then but is no longer part of the Soviet Union!). It defined “health” as ““...a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity…” and asserted that it “… is a fundamental human right...” This has been an important cornerstone statement for the development of health care and primary care for the last 40+ years. Primary Health Care, which was also defined at Alma-Ata, is integrally tied to the definition of health:
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”
Note here that health care is not limited to medical care, and that it is to be “universally” accessible. This statement makes an effort here to account for the different economic ability of different countries. I once heard a presentation on the Mexican health care system, which seems structured to provide universally accessible care, but does not always achieve this goal.  I concluded that in Mexico, they have the desire to provide universal access, but not the resources, while in the US we have the resources but not the desire. Under a social justice framework, this is far less defensible.

In 1848, the Prussian government sent a young physician named Rudolf Virchow to investigate an outbreak of typhus in the coal-mining region of Upper Silesia. His conclusion, that the social and economic situation of the residents was the main cause, is one of the first clear discussions of the social determinants of health; though he is famous for advancing the Cell Theory and his name is attached to dozens of medical eponyms (Virchow’s node, Virchow cells, Virchow’s autopsy, etc.), he may be best known as the “Father of Social Medicine”. In his report he observes that:
“The physicians are the natural advocates of the poor, and social problems fall to a large extent within their jurisdiction,” and that
“Medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time.”

Of course, today we see much less typhus, but we still see much disease that results from social conditions. And typhus itself is not completely gone. In the 1983 Gregory Nava film El Norte”, one of the lead characters, after finally reaching Los Angeles at the end of a long and grueling journey from Guatemala, dies of typhus contracted when she was crawling through sewers. Would she have gotten typhus if she had not been crawling through sewers? Unlikely. The “medical” question of “why” she got typhus would be that she was bitten by a rat-flea carrying Rickettsia typhae. But we must ask the next question, “where was she that she got bitten by a rat-flea?” and in discovering that it was in a sewer we must ask “why was she crawling through a sewer?” Finally, our question must be “what is wrong with a situation in which a person crawling through a sewer infested with rats, fleas, and Rickettsia typhae is better than the alternative?

{to be continued}

[1] Rawls J. A Theory of Justice. Belknap Press. Cambridge MA. 1971. P. 303.

0 Specialty Hospitalists: what is best for the patient?

In a “Viewpoint” article in JAMA, April 25, 2012, John Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists: analyzing an emerging phenomenon”.[1]They describe the progression of the hospitalist model – doctors who just care for patients in the hospital, rather than seeing them also in the office from general medical care to specialty care. They note that in recent years hospitals have hired physicians in a variety of specialties, including neurology, orthopedics, obstetrics/gynecology and others, to take care of patients, particularly at night or in emergency situations, so that other doctors to not have to come in to do so.

An argument in favor of this arrangement is that these physicians are present for urgent events (e.g., the neurology stroke specialist who is there right away to care for a person who comes to the emergency room with an acute stroke) and that they may have specialized knowledge that a more “general specialist” doesn’t. In a useful “box”, the authors summarize the criteria that might be applied to deciding if a specialty hospitalist is a good idea. These include the number of inpatients who might require their services, the urgency of the need for those services (is it a matter of minutes that may save a life?), whether the other specialists are so tied up in the operating room or office that they could not respond promptly, and if there so much “sub-specialization” that many doctors in that specialty would not be capable of addressing the needs that arise in the hospital.

I have previously written about “generalist” hospitalists, (Hospitalists, Dec 4, 2008) and expressed my concerns about this movement from the point of view of the patient. The advantage for hospitals and health systems that employ physicians is obvious – they can have some doctors that work in the ambulatory setting, and some that work in the hospital, and each can be most “productive” in that setting and not have to leave to go to the other, decreasing efficiency.  In theory, at least, the hospitalists are very good at managing the problems of people in the hospital, so quality may improve. And, to be sure, doctors often like it also – it makes their lives easier, or more controllable – they are only responsible for outpatient medicine, and don’t have to travel to the hospital to see their patients, or if they are hospitalists, don’t have to go to the office. While not one of those listed by Nelson et al. as a benefit of having hospitalists, this advantage for doctors is real.They can work set shifts, like many of the most popular specialties such as emergency medicine and anesthesiology and intensive care – and then be off.  

This, of course, leaves the patients. While hospitalized patients certainly want to be cared for by a physician or physicians who are skilled in addressing the problems that they have, it is also often a very scary time, and a good time to have the involvement of someone who knows you, who knew what you were like before you got so ill that you had to be hospitalized. Your primary care doctor, if you are lucky enough to have one. The technical skills of the hospitalist may be fine, but they do not know what you were like before, and will not be involved in your care after, your hospitalization. Plus the same attractions that lead to hospitalists in the first place now have led to a sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily even have the same hospitalist making decisions about your care, even during the day, for the duration of your stay.

In addition, the skill sets of hospitalists vary. Dr. Wachter is one of the founders of the hospitalist movement and heads a long-standing hospitalist service at the University of California San Francisco (UCSF). His 1996 article, The emerging role of "hospitalists" in the American health care system,[2]written with Lee Goldman, is one of the seminal articles in the field. But the results that are achieved by teams of experienced career hospitalist groups such as his, in terms of both quality and cost, may well not be replicated by hospitalists who are just out of their residency training and spending a year working in this role prior to subspecialty fellowships in cardiology or gastroenterology. Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction with hospitalist care is equal to that provided by primary care doctors,[3]but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now not seeing them from those who do not.

That said, I do not have a problem with most specialty hospitalists. Specialists are not generalists, unlike primary care providers, we don’t think that every person should have one of each. The person who comes in to the Emergency Department with an acute stroke and benefits from having a stroke neurologist right there is not likely to have a general neurologist. The same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery, among others, or for people who need emergency intervention for an acute heart attack. The case of “laborists” is somewhat different; the women having a baby (arguably the most common reason for people being glad to be in the hospital) who has been followed by an obstetrician or family doctor might well want and expect to be delivered by that doctor (a point acknowledged by Nelson). While many primary care doctors would like to provide this continuity to their patients, they may be unable to in the system they work in. And if it is not their “fault”, it is a pretty guilt-free way to enjoy the benefit.

If the hospitals and health systems make more money and operate more “efficiently” with separate hospitalist and “ambulists” (yes, this term is being used by some!), and if the doctors are happy with the arrangement because it makes their lives more controllable, the boat on generalist hospitalists and “laborists” has probably already sailed, at least in communities large enough for this to be feasible.

Anyone who has flown in and out of the Kansas City International Airport (KCI) knows what a pleasure it is compared to other airports in even relatively big cities. Built on only one level in 3 almost-circular terminals, there are only a few gates for each security checkpoint so the lines are relatively short (compared to, say, the nightmare at Denver International). Once you come in you get off your plane, walk right out into the hall where your baggage carousel is nearby, and then you walk right out to the street (even sooner if you have no checked bag), where you can be picked up or go to your car in the garage right there. It is a true pleasure for the traveler.

But it is not so desirable for the airport and airlines. I have heard that this setup requires more security people than any airport except Heathrow. There are rumblings about redesigning, maybe rebuilding, the airport to make it more “efficient”. Sure, it will be worse for the traveler, but that’s the way it goes.

So maybe you want to ask your doctor if s/he will see you in the hospital. And let the hospital and health system know that you think it is important, too. It is unreasonable to ask your primary care doctor to work a full day in the office and also care for patients in the hospital; that time needs to be built into their schedules by their employers. It could work; you never know. What’s good for people sometimes actually happens.

And if you haven’t flown in and out of KCI, you should do it soon before it becomes Denver. 

[1] Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700.
[2] Wachter RM, Goldman L., The emerging role of "hospitalists" in the American health care system, N Engl J Med. 1996 Aug 15;335(7):514-7.
[3] Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.

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