Social Injustice and Public Health

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Social Injustice and Public Health (Part
II) Victor W. Sidel, MD Distinguished University
Professor of Social Medicine Montefiore Medical
Center and Albert Einstein College of
Medicine Adjunct Professor of Public Health Weill
Medical College of Cornell University
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Massachusetts Health Disparities 1989-1991
Percent of Population Mortality Rate
With Incomes Below per 100,000
Poverty Level Population 0.0-4.9
168.9 5.0-9.9 216.5
10.0-19.9 271.2 20.0-100.0
365.5
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I become sick because of my poverty. I
became poor because of my sickness.
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Social Injustice and Public Health Part II

• Social Injustice in Medical Care
• Role of medical care in assuring the
  conditions in which people can be healthy
• Barriers to access to medical care
• Inadequate quality of medical care
• Addressing Social Injustice in Medical Care

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Social Injustice in Medical Care

• Role of Medical Care in the Promotion and
  Protection of Health
• Barriers to Access to Care
• Lack of medical care insurance
• Documentation status
• Access to facilities
• Inadequate Quality of Care
• Uneven quality by location , specialty, and
  sponsorship
• Absence of language skills
• Lack of cultural sensitivity

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Role of Medical Care in the Promotion and
Protection of Health
Medical care provides diagnosis and treatment of
people who are ill and reassurance of people who
are concerned they may be ill. Preventive
medicine, a part of medical care, is important in
prevention of illness among patients and their
families. Since medical care is important to
health, a right to health requires a right to
medical care.
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Role of Medical Care in the Promotion and
Protection of Health
The right to health requires assurance of the
conditions necessary for health, including
peace, shelter, education, food, income, a stable
eco-system, sustainable resources, social
justice, and equity. The right to medical care
requires a medical care system that provides
equitable care to all who seek it.
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U.S. Health Problems

• Each year in the United States there are
• 60,000 chemical spills, leaks, explosions, 8000
  serious, with over 300 deaths
• 76 million episodes of food-borne illness,
  325,000 hospitalizations and 5000 deaths
• 110,000 hospitalizations and 20,000 deaths from
  influenza
• 40,000 new cases and 10,000 deaths from HIV/AIDS

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U.S. Cancer Statistics Compared to Statistics in
Other Industrialized Nations
Breast Cancer Mortality 13th Cervical Cancer
Mortality 14th Lung Cancer Mortality 25th Colon
Cancer Mortality 10th Overall Cancer
Mortality 13th Overall Cancer Incidence
9th Source OECD, 2000
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Medicine cannot deal with the many factors that
cause ill-health
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Social Injustice in Medical Care

• Role of Medical Care in the Promotion and
  Protection of Health
• Barriers to Access to Care
• Lack of medical care insurance
• Documentation status
• Access to facilities
• Inadequate Quality of Care
• Uneven quality by location , specialty, and
  sponsorship
• Absence of language skills
• Lack of cultural sensitivity

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Number of Uninsured Children and Adults, 2000-2004
In millions
45.5 M
44.7 M
43.3 M
40.9 M
39.6 M
Note Sums may not equal totals due to rounding.

SOURCE KCMU and
Urban Institute estimates based on March Current
Population Surveys, 2001-2005.
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Barriers to Health Care by Insurance Status, 2003
Percent experiencing in past 12 months
Notes Experienced by the respondent or a member
of their family. Insured includes those covered
by public or private health insurance. SOURCE
Kaiser 2003 Health Insurance Survey.
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Nonelderly Uninsured by Race, 2004
Risk of Being Uninsured
Asian group includes Pacific Islanders American
Indian group includes Aleutian Eskimos.
SOURCE KCMU and Urban Institute analysis of the
March 2005 Current Population Survey.
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Health Insurance Coverageby Poverty Level, 2004
Employer/ Other Private
Notes The federal poverty level was 19,307 for
a family of four in 2004. SOURCE KCMU and
Urban Institute analysis of the March 2005
Current Population Survey.
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Consequences of Being Uninsured

• People who are uninsured
• use fewer preventive and screening services
• are sicker when diagnosed
• receive fewer therapeutic services
• have poorer health outcomes (higher mortality and
  disability rates) and
• have lower annual earnings because of poorer
  health.

SOURCE Hadley, Jack. Sicker and Poorer The
Consequences of Being Uninsured A Review of the
Research on the Relationship between Health
Insurance, Medical Care Use, Health, Work, and
Income, Medical Care Research and Review (602),
June 2003.
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Social Injustice in Medical Care

• Role of Medical Care in the Promotion and
  Protection of Health
• Barriers to Access to Care
• Lack of medical care insurance
• Documentation status
• Access to facilities
• Inadequate Quality of Care
• Uneven quality by location , specialty, and
  sponsorship
• Absence of language skills
• Lack of cultural sensitivity

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• How Good Is the Quality of Health Care in the
  United States?
• Studies over the past decade show that some
  people are receiving more care than they need,
  and some are receiving less.
• 50 received recommended preventive care
• 70 received recommended acute care and
• 60 received recommended chronic care but
• 30 received contraindicated acute care and
• 20 received contraindicated chronic care.
• These studies suggest that the care delivered in
  the United States often does not meet
  professional standards.
• Schuster MA, McGlynn EA, Brook RH. Milbank
  Quarterly 1998

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Disparities in treatment of cardiovascular disease

• Cooperative Cardiovascular Project observational
  study of 169,079 Medicare beneficiaries
  hospitalized for acute MI
• Medical therapies underused in the treatment of
  black, female and poor patients with acute MI
• Rathore SS. Berger AK. Weinfurt KP. Feinleib M.
  Oetgen WJ. Gersh BJ. Schulman KA.
• Race, sex, poverty and the medical treatment of
  acute MI in the elderly. Circulation. 2000
• 102 642-648.

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Disparities in treatment of cancer

• Members of minority populations tend to have
  lower rates of cancer screening and present later
  in the course of illness
• Members of minority populations often receive
  less effective treatment for cancer
• Members of minority populations often receive
  less effective care for symptoms, such as pain
  control

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Disparities in treatment of people with HIV/AIDS

• Prevention efforts often culturally incompetent
• Needle exchange not instituted
• HIV infection often diagnosed late
• Drug treatment options often inadequate
• Members of minority groups rarely included in
  clinical trials of experimental drugs

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Social Injustice and Public Health Part II

• Social Injustice in Medical Care
• Role of medical care in assuring the
  conditions in which people can be healthy
• Barriers to access to medical care
• Inadequate quality of medical care
• Addressing Social Injustice in Medical Care

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Addressing Social Injustice in Medical Care

• Practice of high-quality community medicine
• Support for the equitable organization and
  financing of medical care
• Alleviation of related forms of social injustice

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High-Quality Community Medicine

• Emphasis on prevention
• Provision of primary care
• Cultural sensitivity
• Effective communication
• Respect for patient autonomy

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Addressing Social Injustice in Medical Care

• Practice of high-quality community medicine
• Support for the equitable organization and
  financing of medical care
• Alleviation of related forms of social injustice

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Evaluating Proposals for Expansion of Medical
Care Coverage

• Who will be assisted?
• Targeting expansion to currently uninsured
• Take-up rates based upon income
• What is the scope of benefits?
• Importance of comprehensive benefit packages
• Catastrophic coverage
• Will coverage be affordable?
• Level of subsidy
• Method of subsidy

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Evaluating Proposals for Expansion of Medical
Care Coverage(continued)

• How much will it cost?
• Public or private financing
• Efficient targeting of expansion financing
• Impact on existing system?
• Adverse risk selection
• Incentives for quality/efficiency

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Percent of Population withGovernment-Assured
Insurance
Note Germany does not require coverage for
high-income persons, but virtually all buy
coverageSource OECD, 2002 - Data are for 2000
or most recent year available
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Addressing Social Injustice in Medical Care

• Practice of high-quality community medicine
• Support for the equitable organization and
  financing of medical care
• Alleviation of related forms of social injustice

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Pharmacies in Minority NeighborhoodsFail to
Stock Opioids
Source N Engl J Med 2000 2421023
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Incarceration Rates, 2000
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Challenges for the Future

• Problem growing
• Employer coverage erosion
• Incomes shifting downward
• Medicaid cutbacks
• Costs rising
• Increasing health costs
• Rising premiums
• Public resources limited
• Federal deficits
• State budget crunch
• No consensus on reform strategy or willingness to
  pay

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Conclusion What You Can Do
Learn the facts about social injustice in the
United States and other nations Educate others
about social injustice and ways to confront
it Agitate for justice and relief of disparities
in health Join or Organize groups opposing
injustice with friends and co-workers
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Who Votes? Voter Turnout by Income, 2000
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Doc Lowell 4-5-06