By Professor Jane Huntington, Family Medicine, University of Washington
What can you learn from exploring this topic?
- The relationship between being poor and being sick is complicated. How can the study of “health inequalities” or “health disparities” help explain the relationship between poverty and health?
- Paul Farmer travels widely (Haiti, Russia, Peru) in his quest to bring health care to people who need it. What disparities in health and health care exist here in our own community?
- Paul Farmer has developed a way to act in the world on multiple levels. Does his example and what you can learn from him about health problems help you explore your own response to the “health care crisis?”
Poverty and Health
The map of the United States, by contrast, would depict a healthy nation speckled with disease. In Boston’s Mission Hill neighborhood, right next to the Brigham, for instance, infant mortality is higher than in Cuba. In New York City’s Harlem, a famous study from 1990 showed, death rates for males between the ages of five and sixty-five were higher than in Bangladesh.
Meager incomes don’t guarantee abysmal health statistics, but the two usually go together. Many of the groups of people living on the wrong side of the great epi divide have brown or black skin. Many are female. What they all have in common is poverty. Absolute poverty, the lack of almost every necessity – clean water and shoes, medicine and food – in a place like Haiti. Relative poverty in a place like New York (Kidder, Mountains Beyond Mountains, p. 125-26).
Being poor is bad for your health. On almost every measure of health – infant mortality, life expectancy, rates of heart attack, diabetes, stroke – the average person who lives in a very poor country is worse off than the average person in a rich country, and within countries, poorer people are worse off than richer people. This is called “health inequality” in Europe and the U.K. and “health disparity” in the U.S., and it has been a subject of study and theorizing for the past 30 years.
Imagine a graph showing the income per capita of the world’s countries on the x-axis and life expectancy (a general measure of how healthy a population is) on the y-axis. Each country gets a point on the graph and the points will make a diagonal line angled upward. In other words, the richer the country, the longer the life expectancy. People who live in very poor countries have shorter life expectancies for a variety of reasons.
Now, click on this link for an animated version of the graph you just imagined: http://tools.google.com/gapminder/. Countries are shown in different colors and the graph shows the change in the relationship between income and health through time from 1975 to 2004.
But once spending on health care has provided the basics, such as clean water, adequate food, and sanitation – basics that are not available in much of the developing world – it’s not a simple case of more spending on health care leading to better health. The U.S., with 4.6 percent of the world’s population, spends 40 to 50 percent of the total world spending on health, and yet, on most measures of health, we rank lower than 20 or 30 other countries. The University of Washington’s Population Health Forum calls this the Health Olympics; rankings of the U.S. on several health measures are on their website.
In the U.S., we spend a lot on health, but on average, we aren’t as healthy as many other countries who spend less. How can we explain this? Something else must be going on to explain why disparities in health within a rich country such as the U.S. are so great. Perhaps inequality within a society, the concept of “relative poverty,” or the gap between the richest and the poorest contributes to poor health. Perhaps levels of stress and social hierarchy, of unemployment and poor social support, of environmental safety and neighborhood security, perhaps these “social determinants of health” are as important as direct spending on health care once a society has met basic needs. Paul Farmer’s concept of structural violence, the institutionalized ways that certain individuals are made unhealthy, offers an analysis of this much-debated inquiry.
Health Disparities in King County
Lest anyone come away from a reading of Mountains Beyond Mountains believing that the arguments and descriptions in the book apply only to the developing world, it is useful to take a look at health disparity in our own King County. Communities Count, a project of Public Health – Seattle & King County and other public and private agencies, reported on social and health indicators across King County in December 2005. This very readable report is available at: www.communitiescount.org. Public Health – Seattle & King County published a report on the health status of King County residents in 1996, available here.
Some highlights from these reports:
- Residents of King County are healthier than residents of the state and the nation on average, though death rates, life expectancy, infant mortality, and years of potential life lost by death before age 65 are not evenly distributed across regions of King County, or by race and ethnicity. When the statistics are broken down by poverty level, poorer King County residents have higher death rates among newborns in the first year of life, higher rates of death even after accounting for different distributions of age, lower life expectancy, and different causes of death.
- In neighborhoods where 5 percent of the population lives below the poverty level, about 3 out of every 1000 live-born newborns die in the first year of life. In poorer neighborhoods where more than 20 percent of the population lives below the poverty level, the infant mortality rate is more than twice as high, approximately 7 out of every 1000 newborns die in the first year of life.
- The gap between the rich and the poor, which many believe is crucial in determining the health of the population, is widening in King County as it is in most places in the United States. In 2004, the poorest 20 percent of residents earned 3.6 percent of the total earnings in the county. The richest 20 percent earned 47.4 percent of the total earnings.
- In 1994-1996, the life expectancy of a person born on Mercer Island was 81.8 years of age compared to a person born in Central Seattle whose life expectancy was 69.3 years of age–12.5 years fewer than the child born across the lake.
What factors cause these health disparities? What can we do to improve the health of the public? On what levels do we need to work? For example, if the goal is to prevent obesity, there are multiple approaches, some probably more effective than others. There is the individual level (encouraging a person to lose weight), the family level (teaching parents about healthy diets), the community (funding for bicycle paths), the state (taxing soft drinks), and our national culture (addressing the economics of food production, urban planning, stress and depression, and fundamental causes of overeating).
What PIH-ers should take from Paul wasn’t a manual for their own lives but the proofs he’d created that seemingly intractable problems could be solved.…I was with him one time when he was stewing over an e-mail from a student who had written that he believed in Paul’s cause but didn’t think he could do what Paul did. Farmer said aloud to his computer screen, “I didn’t say you should do what I do. I just said these things should be done!” Then he framed a mild reply. (Kidder, Mountains Beyond Mountains, p. 244)
There is widespread agreement that the U.S. health care system is in crisis, although there is very little agreement about how to solve the problems of access, cost of care, use of technology, and disparities in health outcomes and health care delivery. If you decide that the inequalities in health are inequities – in other words, if the inequalities are unfair and unjust, what is your responsibility? What action do you take?
Paul Farmer addresses seemingly impossible problems throughout the world: treatment for prisoners who have multidrug resistant TB which requires not only expensive second-line medications but also a change in policy, and care for patients who have HIV/AIDS and live far from medical centers but need a complicated regimen of expensive medications. In what way is his action a model and in what ways would you decide to act differently? What are your priorities?
Banks, J., Marmot, M., Oldfield, Z., Smith, J.P. (2006). Disease and disadvantage in the United States and in England. JAMA; 295: 2037-45.
Carter-Pokras, O., & Baquet, C. (2002). What is a “health disparity”? Public Health Reports; 117: 426-33.
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.
Kawachi, I., & Kennedy, B. (2005). The Health of Nations: Why Inequality is Harmful to Your Health. New York: The New York Press.
Kidder, T. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. New York: Random House.
Marmot, M. (2002). The influence of income on health: views of an epidemiologist. Health Affairs; 21(2): 31-46.
Sered, S.S., & Fernandopulle, R. (2005). Uninsured in America: Life and Death in the Land of Opportunity. Berkeley: University of California Press.
Wilkinson, R.G. (1996). Unhealthy Societies: the Afflictions of Inequality. London and New York: Routledge.
Websites on Health Disparity and Health Inequality
Communities Count, a project of Public Health–Seattle & King County: www.communitiescount.org
Department of Health (United Kingdom):
Gapminder: Visualizing World Development: http://tools.google.com/gapminder/#
Public Health Agency of Canada: http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php
Public Health-Seattle & King County. General Health Status: www.kingcounty.gov/healthservices/health
The CDC (Center for Disease Control) Office of Minority Health: http://www.cdc.gov/omh/AboutUs/disparities.htm
The World Health Organization Commission on Social Determinants of Health:
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