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Social Injustice and Public Health Victor W. Sidel, MD

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

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Social Injustice and Public Health Victor W. Sidel, MD

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  1. 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

  2. Injustice anywhere is a threat to justice everywhere. The Reverend Dr. Martin Luther King, Jr. Letter from Birmingham Jail April 16, 1963

  3. 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.

  4. Populations or Groups That Suffer Social Injustice May be defined by: • Race • Socioeconomic position (class) • Age • Gender • Sexual orientation • Other perceived characteristics

  5. Social Injustice Definition #2 Based on the Institute of Medicine’s definition of public health: “What we, as a society, do collectively to ensure the conditions in which people can be healthy.”

  6. 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]

  7. 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.

  8. 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.

  9. 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

  10. High-Quality Community Medicine • Emphasis on prevention • Provision of primary care • Cultural sensitivity • Effective communication • Respect for patient autonomy

  11. 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

  12. 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 (60:2), June 2003.

  13. 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.

  14. 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.

  15. National Average 18% 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.

  16. Medicaid/ Other Public Uninsured 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.

  17. Inadequate Quality of Medical Care • Lack of language and cultural skills • Lack of good clinical practice • Barriers to specialty referrals • Lack of preventive medicine

  18. 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.

  19. 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

  20. 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

  21. 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

  22. 100% 100% 100% 100% 100% 100% 92% 80% 60% 45% 40% 20% 0% U.S. Germany France Canada Australia Japan U.K. 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

  23. 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

  24. Medicine cannot deal with the many factors that cause ill-health

  25. 100% 72% 75% 53% 50% % of Pharmacies with • Adequate Opioid Supply 25% 25% 0% <21% 21-60% >60% % Minority Residents in Neighborhood Pharmacies in Minority NeighborhoodsFail to Stock Opioids Source: N Engl J Med 2000; 242:1023

  26. Incarceration Rates, 2000

  27. 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

  28. 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

  29. 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.

  30. Military Spending in 2008 Source: U.S. Military Spending vs. the World, Center for Arms Control and Non-Proliferation, February 22, 2008

  31. 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

  32. Trade-Offs • Employment • Education • Housing • Public Health • Medical Care

  33. 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

  34. Overall Employment Effects of Spending $1 billion for Alternative Spending Targets in U.S. Economy, 2005

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