Social Injustice and Public Health

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Social Injustice and Public Health 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 University of Kansas
Medical Center Kansas City -- October 19, 2009
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• Injustice anywhere is a threat to justice
  everywhere.
• The Reverend Dr. Martin Luther King, Jr.
• Letter from Birmingham Jail
• April 16, 1963

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Social InjusticeDefinition 1

• The denial or violation of rights of
• specific populations or groups in
• society, based on perception of their
• inferiority by those with more power
• or influence.

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Populations or Groups That Suffer Social
Injustice

• May be defined by
• Race
• Socioeconomic position (class)
• Age
• Gender
• Sexual orientation
• Other perceived characteristics

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Social Injustice Definition 2

• Based on the Institute of Medicines
  definition of public health What we, as a
  society, do collectively to ensure the conditions
  in which people can be healthy.

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Health and Medical Care Rights

• Everyone has the right to a standard of living
  adequate for the health and well-being of himself
  and his family, including food, clothing, housing
  and medical care and necessary social services
  Article 25, Part 1 of the Universal Declaration
  of Human Rights, 1948
• The attainment of the highest possible level of
  health is a fundamental human right. Preamble
  to the WHO Constitution, 1946

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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
  adequate levels of housing, nutrition, education,
  income, public health services and medical care.
• The right to medical care requires a medical
  care system that equitably provides adequate
  medical care to all who seek it.

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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.

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Addressing Social Injustice in Medical Care

• Assurance of access to high-quality medical
  care
• 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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Barriers to Access to Medical Care

• Insurance status
• Immigration status
• -- Lack of needed documentation
• -- Fear of detection of status
• Access to facilities
• -- Distance or lack of transportation
• -- Conflicting obligations

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Effects of Un- or Under-insurance

• People who are uninsured or underinsured
• use fewer preventive and screening services
• are sicker when diagnosed
• receive fewer therapeutic services
• have poorer health outcomes and
• have lower earnings.

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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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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Inadequate Quality of Medical Care

• Lack of language and cultural skills
• Lack of good clinical practice
• Barriers to specialty referrals
• Lack of preventive medicine

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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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Addressing Social Injustice in Medical Care

• Assurance of access to high-quality medical
  care
• Support for the equitable organization and
  financing of medical care
• Alleviation of related forms of social injustice

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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

• Assurance of access to high-quality medical
  care
• Support for the equitable organization and
  financing of medical care
• Alleviation of related forms of social injustice

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Medicine cannot deal with the many factors that
cause ill-health
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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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• A nation that continues year after year to spend
  more money on military defense than on programs
  of social uplift is approaching spiritual death.
• The Reverend Dr. Martin Luther King, Jr.
• Beyond Vietnam A Time to Break Silence
• Riverside Church, NYC
• April 4, 1967

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• Every gun that is made, every warship launched,
  every rocket fired signifies, in the final sense,
  a theft from those who hunger and are not fed,
  those who are cold and not clothed.
• President Dwight D. Eisenhower
• American Society of Newspaper Editors
• April 16, 1953

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World Military Expenditures

• After a period of declining military expenditures
  after the end of the cold war worldwide spending
  grew to 1.5 trillion in 2008, a 45 increase
  from 1999.
• The United States spent 711 billion in 2008, 48
  of world spending, distantly followed by the
  United Kingdom, China, France, Japan, Germany and
  Russia.

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Military Spending in 2008
Country Dollars (billions) of total Rank
United States 711 48.3 1
China 121.9 8.3 2
Russia 70 4.8 3
United Kingdom 55.4 3.8 4
France 54 3.7 5
Japan 41.1 2.8 6
Germany 37.8 2.6 7
Source U.S. Military Spending vs. the World,
Center for Arms Control and Non-Proliferation,
February 22, 2008
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Wars in Iraq and Afghanistan

• In FY 2010 cost of military operations in Iraq
  Afghanistan will be 130 billion
• By March 2010, total spending in Iraq
  Afghanistan will hit 1 trillion
• Monthly cost during 2009 averaged 5 billion, up
  from 3.5 billion in 2008
• The 800 billion spent on the Iraq war alone
  exceeds the 700 billion spent in Vietnam

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Trade-Offs

• Employment
• Education
• Housing
• Public Health
• Medical Care

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Job Creation

• The 915 billion spent in the wars in Iraq and
  Afghanistan could have provided
• Salaries for 4 million public safety officers
  for 5 years
• Salaries for 3 million elementary school teachers
  for 5 years
• Construction of 7 million affordable housing
  units
• National Priorities Project
• www.nationalpriorities.org

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Overall Employment Effects of Spending 1 billion
for Alternative Spending Targets in U.S. Economy,
2005
Spending Targets of Jobs Created of Jobs Relative to Military Spending Average Wages and Benefits per Worker
1. Military 11,977 --- 65,986
2. Tax cuts for personal consumption 15,090 26.2 46,819
3. Health care 18,036 50.2 56,668
4. Education 24,758 106.7 74,024
5. Mass transit 27, 713 131.4 44,462
6. Construction for home weatherization/ infrastructure 17,927 49.7 51,812
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Medical Care

• Nearly 45,000 annual deaths are associated with
  lack of health insurance
• Uninsured have higher death rates form
  hypertension, and heart disease
• 62 percent of bankruptcies in 2007 were caused by
  a medical condition
• American Journal of Public Health
• September 17, 2009

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Trade-Offs

• With the more than 2.5 billion spent by Missouri
  taxpayers and more than 1.3 billion spent by
  Kansas taxpayers on the war in Afghanistan,
  medical care insurance could have been provided
  for almost a million Missourians and 400,000
  Kansans.
• National Priorities Project
• www.nationalpriorities.org

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Doc Kansas City-SocInj-10-19-09-Final