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

Health Disparities

Etiologic Agent	# deaths per year
Tobacco use	400,000
Diet/activity	300,000
Alcohol	100,000
Microbial agents	90,000
Toxic Agents	60,000
Firearms	35,000
Sexual behaviors	30,000
Motor vehicles	25,000
Illicit use of drugs*	20,000

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.

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[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)

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[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