On Visibility and Access: The Role of Non-Economic Factors in Inequalities of Medical Resources and Care

Inequalities in health – where certain populations experience greater burdens of disease and worse health outcomes than others – are well established.  It is tempting to explain these as being caused by economic inequalities, and this is not inaccurate; there is a strong correlation between a country’s rates of income inequality and infant mortality (an important barometer of overall health) [figure 1, OECD], and it has been demonstrated for multiple countries that individuals with above average socioeconomic status have lower rates of most disease and live longer than less advantaged peers (Singer and Ryff).  However, explaining health inequality solely with economics ignores other important sociopolitical factors.  I’d like to additionally qualify health inequalities related to public perception and access to care, and argue that similar issues are at work impacting health globally, from rural Botswana to metropolitan Providence.   While economic status of individuals and regions contribute significantly to many of these factors, and the factors themselves are deeply interrelated, considering inequality from a variety of perspectives can offer novel directions for addressing these issues.

GIMP-Ratio-Top-10p-to-Bottom-10p-Income
FINAL-GIMP-Infant-Mortality-Rate Figure 1: Comparison of countries with lowest income inequality and highest income inequality (left to right), and rating infant mortality rate for same countries (bottom image)

Some authors stress the clarification between health inequalities and health inequities.  Kawachi and colleagues define health inequalities as designating “variations … in the health achievements of individuals and groups”, whereas health inequities specify those inequalities “that are deemed to be unfair” or preventable (Kawachi et al).  This distinction suggests that some health inequalities, perhaps due to chance (genetic mutation), biologic definition (cervical cancer affecting women more than men), or choice (injury in extreme sport enthusiasts) may not be inherently unjust or preventable.  I will focus on issues of health inequality that are somewhat preventable (ignoring pessimism regarding unrealistic structural changes).

One contributing factor is the invisibility or misjudgment of the burden of specific diseases on specific groups.  This can manifest in the amount of research, funding, and treatment offered to individuals, and in social stigma attached to their conditions (social perceptions and pressures have huge influences on quality of life and treatment choices).  For decades AIDS was considered to be a primarily male disease, yet by 1991 AIDS was the leading killer of young urban women in the US (Farmer, 61-62).  While this most severely affected women in poverty, the invisibility of all women with AIDS was an issue of public education and attention more than wealth distribution – and structural changes to consider the realities of and offer resources to women with AIDS would have mitigated these problems significantly.  Similarly, the experiences of cancer patients in the oncology ward of Princess Marina Hospital (PMH) in Botswana reflect how cancer in Africa is an “invisible” condition, despite epidemiologists describing it as a “common disease” there (Livingston, 8).  The lack of attention given to cancer in Africa changes the manifestation of the disease and experience of patients; later detection of cancer contributes to a trend of palliative rather than curative responses, and priority is given to funding research and therapies with minimal benefit for these populations (Livingston, 20, 31-34).

Another major consideration is access to care, which seems primarily to be socioeconomic, with poverty preventing people in the US from affording insurance or co-pays for treatment (and uninsured individuals being at least twice as likely to lack necessary care access), and tied to global conditions like Tuberculous, which is both curable and the leading cause of death for young adults in much of the world – its exists because many lack access to affordable treatments (Adrulis; Farmer, 185-186).  Poverty also contributes to health indirectly, including influencing education, proximity to environmental hazards, and availability of healthy foods (Adler and Newman).

However, access can also be politically and culturally driven.  Lovemore Makoni, who desired chemotherapy at PMH, was ineligible for free healthcare offered to Botswanese residents because he was from Zimbabwe, a mere 300 miles away.  Similarly, undocumented immigrants or legal residents of less than 5 years throughout the United States are ineligible from enrolling in state-funded programs like Medicaid.  I witness this need firsthand working at Clinica Esperanza, a free healthcare clinic in Olneyville, which serves a small subset of Rhode Island’s undocumented population (estimated to be at least 30,000), in addition to the many people enrolled in insurance programs who cannot find a PCP (Pew Research Center).  Cultural barriers to access include language barriers, distrust of physicians not representing similar ethnic backgrounds, and lack of sensitivity to unique cultural needs such as diabetic Muslim patients who desire to fast during Ramadan (Armstrong, et al; Singleton & Krause; Aboul-Enein and Aboul-Enein).  While these factors compound with issues of socioeconomic disadvantage, policy and systematic changes could be developed to address specific needs and bring access to populations without redistributing wealth, and these options are important to consider when discussing health inequalities anywhere.

Discussion Questions:

  1. What sorts of interventions might specifically address issues of “invisibility” or cultural and political barriers to access to care?  Do you think that components of these issues could be resolved without redistributing the wealth of a population?
  2. Does considering the causes of inequalities of health to be varied and complicated (rather than ultimately stemming from economic inequalities or some other cause) make the prospect of working to resolve these inequalities seem more or less daunting?  Does it suggest there is far too much contributing in conjunction to worsen certain populations’ health outcomes, or rather that some interventions (which might be more realistic and implementable than ending poverty) could be a valuable change in focus to directly improve the care of disadvantaged groups?

Works Cited:

Aboul-Enein, B.H., and Aboul-Enein, F.H.  2010.  The Cultural Gap Delivering Health Care Services To Arab American Populations In The United States.  Journal of Cultural Diversity, 17: 20-23.

Adler, N.E., and Newman, K.  2002.  Socioeconomic Disparities in Health: Pathways and Policies.  Health Affairs, 21: 60-76.  Web, accessed on PubMed.

Andrulis, D.P.  1998.  Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health.  Annals of Internal Medicine, 129: 412-416.  Web, accessed on PubMed.

Armstrong, K., Ravenell, K.L., McMurphy, S., and Putt, M.  2007.  Racial/Ethnic Differences in Physician Distrust in the United States.  American Journal of Public Health, 97: 1283-1289.

Farmer, P.  1999. Infections and Inequalities: The Modern Plagues.  Print.  Berkeley and Los Angeles: University of California Press.

Kawachi, I., Subramanian, S.V., and Almeido-Filho, N.  2002.  A glossary for health inequalities.  Journal of Epidemiology in Community Health, 56: 647-652.  Web, accessed on PubMed.

Livingston, J.  2012.  Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic.  Print.  Durham: Duke University Press.

Organisation for Economic Cooperation and Development (OECD).  “Ratio of Top 10% Income to Bottom 10% Income (2011)” and “Infant Mortality Rate (2001) per 1,000 live births”.  2012.  Web, Accessed via Inequality.Org, A Project for the Institution of Policy Studies. <http://inequality.org/inequality-health/>

The Pew Research Center.  2011.  Unauthorized immigrant population: National and state trends, 2010.  By the Pew Hispanic Center.  Web.  <http://www.pewhispanic.org/files/reports/133.pdf>.

Singer, B.H., and Ryff, C.D.  2001.  “The Influence of Inequality on Health Outcomes”, chapter in New Horizons on Health: An Integrative Approach, Singer, B.H., and Ryff, C.D., eds., as part of the National Research Council (US) Committee on Future Directions for Behavioral and Social Sciences Research at the National Institute of Health.  Print. Washington (DC): National Academies Press (US).

Singleton, K, and Krause, E.M.S.  2010.  Understanding Cultural and Linguistic Barriers to Health Literacy.  The Kentucky Nurse, 58: 6-9.  Web, accessed on PubMed.

37 thoughts on “On Visibility and Access: The Role of Non-Economic Factors in Inequalities of Medical Resources and Care”

  1. Hi Jacob,
    The discussions we have had in class have emphasized the need to recognize sources other than socioeconomic status as contributors to health inequalities. As you have indicated, acknowledging the many forces that play into global health inequality (corporate power, colonialism and racism, gender inequalities, trauma, etc.) can make the goal of equal global health seem impossible. However, it is certainly necessary for global health workers to be familiar with the several deep layers of the macro structural factors that contribute to and exacerbate global inequalities; this is the only way to combat them properly. In particular, it is extremely important for volunteers/programs to understand that money alone cannot solve health disparities or injustice. While money can assist in providing facilitation and relief, other interventions, such as education/spreading of health literacy and advocating against human right abuses, are just as important outlets to pursue. This is because of the fact that factors, such as the invisibility you mention in your blog post, are deeply ingrained in society. Money alone cannot provide these silenced groups with agency or with the ability to be heard.

    I think that in general, when attempting to intervene and address issues of invisibility/cultural and political barriers to access to care, it is vital to work WITH the populations you are trying to help. While global health workers are able to recognize obvious inequalities, such as the inability to pursue complete treatment or certain medications, they cannot understand the full extent of problems until they step into communities and learn about their stories. This is due to the fact that care, needs, and experiences are subjective.

    1. Nini, I could not agree more that money alone is not enough, and that being inclusive and cooperative with populations being focused on is essential. As you say, “learning their stories” is a prerequisite.

      The question I have is what role does sharing these stories with those not in need of help have? Working with a community and listening to experiences which often go untold is definitely important, but is there a responsibility to make sure other people are aware of the issue as well? Does sharing pictures or stories (with permission, or with names removed) help reduce stigma, or is this exploitive or misleading? What role should healthcare organizations have in the advocacy of invisible burdens?

      1. Hi Jacob,
        Professor Mason talked about the use of imagery (especially in terms of the transformative power of medicine) in global health work; I think sharing the community’s stories is an important way to make people cognizant of inequalities. It can also make people more aware of the social factors that need to be considered when intervening/providing aid.

        But I do think that there is a problem when the sharing of pictures/stories becomes an exploitation of people… Pictures can especially be exploitative and misleading, especially because they are isolated from context. I think that it’s necessary to get consent (as much as possible) from the people who are sharing their stories; I also think it’s important to provide as many direct quotes as possible.

        1. I agree – and it’s also nice to give people a platform to tell their own stories, like when Joseph transitioned from being a before-and-after photo Paul Farmer used to get funds into a collaborator who gave talks about his experiences. Or how Michai Viravaidya (from the video we watched in class) combated stigma surrounding AIDS in Thailand by having infected survivors give presentations, and sharing a glass of water with the speakers.

  2. Thank you, Jacob, for highlighting the “invisibility” of not-so-invisible health inequalities.

    You and Nini wrote about the importance of understanding the multifaceted causes and “causes of causes” of global health inequality. Seemingly, this points to my answer for the first part of your second question – I do think that considering the causes as varied makes the prospect of working to resolve inequalities more daunting. This kind of thinking is the very reason for delayed action, which has its benefits and drawbacks. The benefits may include obtaining a better understanding of the burden of disease and the population’s perception of the disease. Moreover, as a Public Concentrator, I understand that those who are trying to implement an intervention must assess the population’s needs before its execution. Yet, the drawbacks do include time as a constraint. How much time should you spend deliberating the complex causes of equalities (while many are suffering) before deciding to just start somewhere? It is difficult to find that sweet spot, where you have considered alternative action plans in an efficient manner.

    To address your first question, although I do not have an exact answer, I believe that any intervention that aims to address cultural and political barriers to accessing care must work with those in power in a country to plan, implement, and disseminate the intervention. These “power parties” may include the government, the Ministry of Health, and local governing bodies within villages. As Nini emphasized, it is absolutely imperative to work with the population you seek to help because this will yield far better results than doing as you please. This echoes our general discussions about the role of imperialism and colonialism within the realm of global aid. In reference to the second part of that question, it would be very difficult to redistribute the wealth of a population to increase everyone’s access to care because those in power, generally, do not want to lose that power. And those without power do not have the means to demand it.

    1. Thanks Natalie – you make a good point, that getting overwhelmed and delaying your response comes with its own host of problems. I had intended the post’s discussion on varied sources of inequality to hopefully suggest that if there are multiple sources of a problem there can also be multiple directions for solution. It seems to be a hard balance to find – between being careful to address everything sufficiently and include all the necessary players and consider possible consequences, while also not getting bogged down or delaying helping as soon as possible.

      You say these organizations should work with groups in power (as well as those in need of help) to address cultural and political access issues. I wonder if there are ever situations where it is acceptable for an NGO to work without permission or collaboration from the national government?

      For example, China forbid the existence of any fully autonomous NGOs, and places some pretty strict restrictions on NGO action. Registration can take years and a lot of money, and the relationship between the government and NGOs is ever-changing and often tense (an article from earlier this year talking about these struggles: https://www.opendemocracy.net/joy-y-zhang/contested-symbiosis-statengo-relations-in-china). Many NGOs in China prefer to be unregistered, and therefore, illegal. Especially in rural areas, these NGOs feel like they are capable of offering some people valuable access to resources and care, and they wouldn’t be otherwise. There is also a problem in Kenya where the government recently deregistered a bunch of NGOs. I know this is likely a different situation than what you meant (I agree, by the way, that working with the government and the people in need is a great idea), but I wonder what you think about the existence of an NGO which provides services people desire, but works illegal, or in some amount of opposition to the national government where it works.

  3. Hello Jacob,

    Your thoughts seem to parallel much of what the Reimagining Global Health textbook espouses in the chapter about social theories of public interventions. Specifically, your discussion of health inequalities as being caused by more than just economic factors seems like the perfect extension of the biosocial analysis of the sociology of knowledge. I agree that a deeper understanding of the sociopolitical factors that contribute to health inequity is needed by all public health professionals attempting to assist a population, and this understanding should include a deep reflection of the historical, cultural, and societal determinants that lead to differences in health outcomes and clinical processes.

    It is rather difficult to say what specific interventions can directly address the issues of the “invisibility” of certain barriers to accessibility but the simplest answer I can conjure is that public health professionals should undergo adequate cultural sensitivity training and must demonstrate an understanding of the historical context of the areas which they serve. Furthermore, these workers should have the willingness to cooperate with local representatives and to perform an adequate needs assessment by engaging the population directly. Naturally, this is easier said than done; as we read in the What Really Matters reading by Kleinman, our best intentions to help can be thwarted by factors beyond our control (i.e. bureaucratic red tape and top-down governmental corruption).

    In response to your second question, the truth of health inequality being the result of varied causes certainly does make the possibility of remedying this issue more daunting (and seemingly less attainable). Nonetheless, this fact shouldn’t be cause for a defeatist attitude among health care professionals. On the contrary, this knowledge should serve as impetus for designing and executing interventions that do more than just give funds to those who need them. In other words, this opens the possibility of seemingly unique interventions (i.e. the promotion of female education and equal opportunities in the work force in some countries) as feasible ways to improve the health outcomes of a population and to better its prospects for the future. Additionally, public health workers can now feel more empowered to address factors such as social suffering and structural violence as a way to achieve its goals.

    1. Hey Jacob,

      I really like how you pointed out the invisibility of health disparities among certain populations. Like Sachit and Natalie wrote in their responses, I think a good way to approach the issue of invisibility of burden of disease on certain groups is to conduct a careful assessment of the population to figure out what exactly needs more attention and how the specific population perceives certain diseases. As Natalie mentioned, this assessment does take time and one must find the right balance between assessment and implementation of interventions to increase awareness, but this approach is necessary to organize a culturally sensitive and effective intervention.

      You mentioned the invisibility of women with HIV living with poverty, but I’d also like to extend the invisibility to sex workers (male and female) living with HIV/AIDS, especially in America. There is a dearth of research and information about treatment and interventions for HIV/AIDS specifically for this population, which negatively affects the development of a national HIV response for sex workers. The lack of information and recommendations for intervention specific to this population only furthers the marginalization and “invisibility” of this population in national policies and interventions.

      To address issues of invisibility of certain populations, there needs to be disaggregation of data in research studies. Research needs to be focused on marginalized populations like sex workers, especially since sex workers face unique challenges (e.g., criminalization for their sex work, pressure for unprotected sex) and suffer a disproportionate HIV disease burden. With data collection focused specifically on marginalized populations, programs can then move forward to start thinking about increasing public awareness, implementing policy changes, developing prevention strategies, and providing treatment for those affected.

      Again, as Natalie and Sachit have mentioned above, it definitely is intimidating to think about the complications and complexity of health disparities and social determinants of health. But of course, we cannot just stop there and give up. I think you bring up a good point here that focusing on specific marginalized populations (i.e., a targeted intervention approach as described above in my comment) seems more feasible, less daunting, and possibly more effective. Even so, we must keep in mind that too narrow of an approach will not do much good in the long run, as we discussed in class with humanitarian approaches of Doctors without Borders. Yes, the organization does great work in many countries in crisis situations, but their focus is very narrow – their aim is to “bandage” the problem during the short-term emergency. While there are drawbacks to a narrow, more focused approach, such interventions can have good health outcomes in the short run, so they can be used to supplement more horizontal approaches with long-term effects.

      1. Yuki, thanks for your thoughtful and concrete suggestions. Careful assessment surveys are definitely very important. Do you think door-to-door surveys are an appropriate means of conducting surveys like this? Or having community health workers and other local representatives develop this information somehow? And publishing the data in research is a great way to get that information to other providers, but should other mediums be considered to address general stigma from people not reading publications like this.

        And thank you for drawing attention to the needs of sex workers. As a population with both high burdens of disease (and often one with poor socioeconomic status, drawing them into the profession in the first place) but also facing a lot of prejudice and stigma as it is, this individuals deserve extra attention, and any work done to improve the lives of invisible groups should certainly focus here.

        I also agree that there is a balancing act needed – MSF is just a band-aid, but it can be a very effective one. And PIH, which does a lot more structural and horizontal work, ran into trouble in Sierra Leone when several workers got infected at an acute ebola virus treatment center. I think it might be okay to have a narrow focus, as long as other groups are working on different and more distributed goals. I feel like a lot of times we criticize humanitarian organizations for not doing enough, but thats an easy criticism to make that isn’t all that constructive – these organizations have limited resources, and it might be better to do something small well than to do a whole lot poorly. Just a thought.

        1. Hey Jacob,

          Yes, I do think door-to-door surveys conducted by community health workers would be a good way to go about collecting the data for needs assessment. I think it’s best to involve community health workers who have been educated on the major health disparities in the community they are working in and are familiar with the cultures and values of that community in the needs assessment, rather than using NGO volunteers or health professionals from developed nations.

          And yes, that’s exactly what I was thinking – a narrow approach would work as long as it’s well-supplemented by more broad, wraparound services that would be characteristic of a horizontal approach. It would basically be a diagonal approach where one issue is used as a primary focus to bring patients to the clinic, and this is also used as an opportunity to diagnose and treat those patients for other illnesses and to provide food supplementation, transportation, financial assistance, or any other structural barriers to health care.

          1. Also, to answer your question about whether it’s best to publish the data collected in research papers, I think it would also be a good idea to make easily-understandable visuals (with short captions) about the barriers to access to care. The organization running the needs assessment should also work with the community health workers to set up workshops to raise awareness within the community about those barriers. I think the information should also be made available to local governments or the Ministry of Health in that region (if such infrastructure exists) to try to involve more community leaders who can affect substantial change.

          2. I definitely agree – involving community health workers is a bit of a win-win: it allows you, as an organization, to utilize local resources with expertise in the specific needs of the community, and it also provides jobs and longer-lasting job experience and information to the community you are hoping to engage in.

            I also think your suggestion about workshops and presentations to the local health department are both great ideas! I think a big challenge of some organizations is the inability to change their content to suit a wide variety of populations, but working on spreading this information to all levels of society could really bring about substantial lasting change.

    2. Sachit, I think these are great suggestions. On the topic of cultural sensitivity training (something that should definitely be a requirement and constant area of improvement for healthcare systems), I wonder when this should start, and how it should be done. Should it be a requirement for med or pre-med students? A module required for service like HIPPA training programs?

      I also like your suggestion for needs assessments – I think this is an often overlooked part of health care interventions. One of the best ways to figure out how to help people is always to ask.

      It seems that if public health ills are affected by a variety of sociocultural factors, that public health workers are entitled/expected to work in a variety of ways. Where do you think the line should be drawn, if ever, on the scope of the field? Is there a point where health workers might be trying to much or focused on too many different things (education, transportation, political restrictions and cultural interventions), and should get back to “the basics” (medicine, nutrition, access)?

      1. Hi Jacob,

        I’d argue that cultural sensitivity training should start during one’s undergraduate education (at the level of pre-med students). Personally, I think that cultural sensitivity training should begin earlier rather than later so that individuals have times to process and internalize the importance of open-mindedness and empathy in this line of work.

        Among other things, this class has taught us that population level wellness certainly isn’t an easy objective to accomplish—in order to bring significant changes to the health outcomes of a population, community health workers need to be equipped to address the social, cultural, and economic determinants of the wellness of the recipients of their care in addition to their basic biological and medical needs. I think that while addressing “the basics” is important there should always remain the continued focus on interventions that address other facets of a person’s life situation.

        1. I think that’s wise Sachit – where can I sign up (but actually)? Exposure to people with a variety of backgrounds and unique needs and desires is one of the reasons for my interest in healthcare in the first place; something about health seems like it should be a universal equalizer. Though as we see again and again, the inequalities in health are some of the most pervasive. It is interesting how relevant empathy seems to be – despite well rooted and varied causes of health inequalities, invoking a plea to health seems to be a quick way to stir people’s emotions when other injustices won’t, and there is a well-established trend in research and grants to mention potential treatment applications (of almost any project which might tangentially include such benefits far down the line) to increase the amount of money given.

          I also agree with you about the role of healthcare workers. To treat the basics as if they were unaffected by everything else – as if health existed in a vacuum, seems foolish and short-sighted. However, this does increase the “scope” of the field considerably.

  4. Hi Jacob,

    I found your blog post to be very insightful and informative as it highlights that invisibility and causes of health inequalities around the world.

    In response to your first question, I think there are many interventions that could address the “invisibility” mentioned in your post, as well as cultural and political barriers to access to care. Interventions regarding socioeconomic status, racial boundaries, health as a human right, etc. can all impact this issue and redistribute health equality globally. For the second part of this question, I think that the most effective way to resolve these issues is to redistribute the wealth of a population. I understand how difficult and unrealistic this is, but I feel as if this would be the most effective way to produce equality for all.

    In regards to your second question, I believe that considering the causes of inequalities mentioned above does make the work to resolve these issues more daunting. As Natalie mentioned, people are less inclined to act on these issues if the many consequences, problems, and obstacles are foreseen. However, contrasting that answer, I believe that the knowledge around such health issues can motivate certain people to create a new focus and interventions that could improve the overall quality of care.

    1. Julianne, I like your suggestions and appreciate your response. Certainly, the numbers do not lie, redistributing the wealth of a population would effectively end a lot of these issues. But who’s job is it to do this, the government? Wealth has many forms (such as property) which are harder to distribute, and this is why so much inequality becomes structurally ingrained in a society.

      Paul Farmer, with PIH, used some economic tactics to improve “compliance” when it came to taking TB medication in Haiti, such as paying for transportation and giving financial incentives for participation in programs. We also learned about BRAC, an NGO in Bangladesh (actually the largest NGO in the world), which besides trying to reduce childhood mortality by teaching women about oral rehydration therapies, put a lot of effort into giving loans and providing jobs – tying together healthcare with economic aid. Do you think this is a model other NGOs focused on health should follow? The clinic I work at has some health programs (such a nutrition & healthy lifestyle class), where we give gift cards to participants for starting and completing the program. We did this to try and improve retention, because a lot of our participants have a hard time getting there or have completing interests, and we wanted to make sure we were able to deliver the information the program aimed to deliver. Offering the incentive really boosts the number of people who complete the class, and I think there are good outcomes that come of that. But I wonder if it is also problematic – people might be doing the program for the giftcard, and not for health-related reasons. I wonder about incentives in other health-related situations, if they are ever inappropriate and when they are best used. What do you think?

      1. Hi Jacob,

        Thanks for your response. The examples of effective implementations such as BRAC and the clinic you work with at home can be used when addressing this situation. As you mention, redistributing wealth is a very complex task, with many potential unintended consequences. To start, I think one of the most effective ways to address this situation is offering jobs to those that are on the unfortunate side of this. With more jobs and money in resource-poor settings, these populations may start to turn around.

        You also mentioned the importance of incentives. While the main incentive for people of these populations will be to improve health and equality, they may not be properly trained or educated to work in certain settings. How do you think this situation could be addressed?

        1. Offering jobs, even jobs specifically designed to address the unique health needs of resource-poor communities (two birds with one stone) seems like a good idea. Your question about how to properly train people in these settings is a good one – this brings us back to discussions on the barefoot doctors in China. It seems that within the realm of cultural sensitivity training, people need to be prepared to deal with the specific needs of the community they are working in. Some of this might be closer to case management than health literacy. However, the worry behind barefoot doctors and other variations on the community health worker model is what the lacks in their training might leave them unprepared to deal with – some more complicated problems might be missed in the process.

  5. Hi Jacob,

    Thanks for your post. You made several great points in your post and it was neat to hear you personally relate to some of the topics from your experiences at Clinica Esperanza.

    I think something that could help improve issues of “invisibility” would be to have coordinated responses to epidemiological surveillance data. Instead of donors pouring money into “sexy” interventions, it would be great if donors actually aligned their interests with the needs of the population receiving care. In Professor Benton’s book on HIV Exceptionalism, we can see how in Sierra Leone most of the health budget goes to HIV/AIDS interventions even though only 1% of the Sierra Leonian population is infected with HIV/AIDS. Despite having epidemiological surveillance data about the greatest health problems in that country, there is a misconnect between that data and the interventions that are funded. I think we could really do a better job in matching up these two things.

    To me, the idea that inequalities of health are more varied and complicated can be pretty daunting. The reality is that there is no one-fix-all solution to global health. Even if there was more socio-economic equality, that wouldn’t necessarily translate to better health because there are so many other factors that contribute to health besides economic inequalities. I do agree with you, however, that this can be twisted into a positive. It is unlikely that we will ever solve the world-wide problem of economic-inequalities, and so the fact that health is not solely dependent on that factor can be a good thing. Perhaps there are other ways to improve global health that are more practical and feasible than total wealth equality.

    Thanks again for your post–it was super interesting!

    -Rebecca

    1. Thanks Rebecca! We definitely need more coordination between epidemiological surveillance information and resources directed at interventions. Surveillance of this type is often linked to infectious disease – determining how much risk a new outbreak poses populations, etc. It seems like the surveillance you are discussing is more general than this – examining existing health problems in equal lighting to “emerging” ills, and essentially determining which conditions actually pose the greatest burdens on quality of life. Is this a fair reading?

      I imagine the difficulty here is that it is hard to get funding for the “needs assessment” stage of a public health interventions, and the findings of that assessment should dictate where future funding goes. Perhaps it is an issue of a lack of trust between donors and those conducting interventions, because it is so hard to imagine someone writing a blank check without interest in seeing specific outcomes of his/her donation. Sometimes the most helpful thing is incredibly unsexy, like building a road.

      Maybe one thing we could try and do is promote new methods of surveillance data gathering. One study I read talked about implementing a massive email campaign throughout Colombia to generate new data on the health needs of the community (http://www.ncbi.nlm.nih.gov/pubmed/16149893). I imagine even though we already know issues that communities face, new ways of penetrating into communities and asking people what they need directly could be involved in generating interest in needed projects. New models for funding, like using kickstarter campaigns, is also on the rise. Do you think any of this might be a step in the right direction?

      1. Thanks Jacob! You definitely had a fair reading on how I was thinking of surveillance. I think your idea about generating new methods for surveillance data is great! I think using these types of methods (like the Colombian study you provided the link for) can help engage the population that is actually experiencing the health problems and make them feel more involved in building solutions. I think by really considering the target population as a key stakeholder, health interventions would be more successful because people would feel that there was good reason for health programs and would be encouraged to participate in these programs.

        Thanks!

        -Rebecca

        1. This idea, that the community is itself a stakeholder, is a think a great ultimate take-away for a lot of the themes and examples we’ve learned in class. The community, as a unit, might not be as integral in regenerating funds, but interventions which ignore thinking of the community in this matter often fail in important respects, and lose credence in the global health sphere. Gaining trust, encouraging participation, and integrating new methodology to approach these problems all seem essential.

  6. Hi Jacob,

    I really enjoyed your blog post and found it really interesting as well as very helpful to understand how non-economic factors influence inequalities of medical care. I entirely agree with you when you say that economic factors ignore other sociopolitical factors when it comes to explaining health inequalities. Using a comparison between rural Botswana and Providence and your own personal experience made it a lot easier to understand your point of view and illustrates how inequalities are due to the misjudgment of the burden of diseases on different group as well as the access to care.

    Regarding you first question, I think that one way to approach the problem of invisibility or cultural and political barriers to care could be for public health professional to understand the social and cultural context of the country where the intervention is being implemented. It is important for health officials to collaborate, not only with the local population, but also with the local government in order for their intervention to be efficient. As Yuki, Sachit and many others previously said in their comments, it is by increasing awareness and education that inequalities can be reduced, if not eradicated. For the second part of your question, I do think that some components of these issues could be resolved without redistributing the wealth of the population. As you said in your post, economic factors only reflect one side of the problem and redistributing wealth would only solve one part of the problem. I think that by resolving the problems of access to health care or by increasing awareness and education about the interventions implemented and by breaking preconceived thoughts on the burden of certain diseases, we would definitely be able to resolve some components of these issues.

    Concerning your second question, I think that having many varying and complicated causes to health inequalities can be very overwhelming and daunting. As Natalie, Julianne and many others mentioned in their comments, having many causes and consequences can make people less inclined to act on the problem. However, I think that it also has a somewhat “positive” spin to it since there is not only one huge impossible problem to fix, which gives and infinite possibility of interventions that can be set up to tackle each problem. By having many causes for one issue, you are able to fix the more obvious and simple problems first in order to improve the situation and then attack the most difficult causes of the problem to finally try to eradicate that issue.

    1. Thanks for your response Claire. It seems like your suggestions focusing on increasing cultural awareness through local collaboration and integration, and through increasing access separate from radical wealth distribution. I think these are both excellent suggestions and directions most respectable public health programs are moving towards.

      On the issue of access, I wonder your thoughts on a topic raised earlier in the comments. One strategy often imposed in resource-poor settings to improve access to programs and treatment is to offer incentives – often these sorts of programs might have a research component attached to them, and use incentives to improve participant retention, like offering a gift card for people who attend certain sessions, or providing food, transportation, etc for visiting a healthcare setting. These strategies might be helpful for convincing people to attend, and ultimately contribute to a more successful program with (presumably) better health outcomes. However, is it problematic if people participate in a program or treatment plan partially due to the incentives, rather than the goal of improved health? Is it an issue if research is often tied into ventures to improve community health, because publications are important ways to leverage funds?

  7. Hi Jacob,

    I enjoyed reading your thoughtful post on the varied determinants of health, and especially liked that you took the time to differentiate between health inequalities and health inequities.

    I think you’re absolutely right that lack of access to care is one of the biggest deterrents to receiving adequate healthcare. While you mention the ties to socioeconomic status and contributing sociopolitical factors that prevent one from receiving care, I would like to add the difference between living in an urban or rural area. Often times public health interventions only take place in densely populated areas, since it’s the most cost effective method to reach a large number of people, and ignore people who live in more isolated areas of a nation. Additionally, other barriers increase as you move away from densely populated suburban areas, such as transportation, outreach, and knowledge of what health options exist.

    To address your second question, while I understand what Natalie and many others have commented about how having so many social determinants of health can be extremely daunting and cause delayed action, I am actually more optimistic that there are more factors at play in determining health access than just a person’s socioeconomic status. This means that are a large number of ways that we can try to improve health, including ways that require limited budgets. For example, campaigns relating to education, and smaller solutions like the introduction of oral rehydration therapy, can have dramatic effects on things like infant mortality, which you brought up, without needing massive social infrastructure overhauls. However, it is definitely true that the notion of erasing all health disparities, with so many contributing factors, seems so difficult to ever obtain.

    1. Interesting point about the barrier involved in nonurban settings, thanks for bringing that up! That raises new forms of questions too – do the professional responsibilities of doctors change when access is sparse in regions like this? Would the only (insert some medical specialty profession here) have a duty to care for a larger subset of people in a rural area? Would a doctor’s position on procedures he/she might not be comfortable with personally performing (such as an abortion) need to be questioned in areas where it is simply impossible to refer someone to someone else qualified to perform them?

      I’m glad you feel optimistic about the situation as a whole – I too, while uncertain about the prospect of actually ending health inequity, feel encouraged by the fact that many different people with many different backgrounds and ranges of experience can offer valuable contributions in the battle to increase access, sensitivity, and appropriateness of improved health to everyone.

  8. Hi Jacob!
    I thought you wrote a really good post. I did an audio blog on this topic, and I thought we discussed some similar issues.
    To answer your first question, I think that in order to address the issue of “invisibility” of access to healthcare requires a more horizontal approach to the situation. What comes to my mind is the term “pragmatic solidarity,” which can be found in Farmer’s readings about going to countries and listening to the needs of the people and then making efforts to solve these issues to the best of our abilities. I think this can also be related to the McKeown hypothesis, where he deems that a rising standard of living, improvements in hygiene, and better health will reduce the mortality rates in developing countries rather than medications. That being said, I think redistributing wealth of a population is a great idea, however, I think this would be a difficult task. How do you think this could be done?

    1. Thanks Samantha. Pragmatic solidarity, paired with McKeown’s research on how little direct medical interventions do to actually address systemic health inequality, definitely paints a progressive picture on work in this field. We need to build more collaborations and strive to include those who suffer from inequalities of health, not only in our interventions, but in the process of understanding how health inequalities affect communities and in the process of determining a proper solution.

      I can’t really speak to how to redistribute wealth – I think based on the history of our economic system we are moving in the wrong direction to accomplish this, and the ability to manipulate these trends is increasingly only rooted in the hands who stand to lost the most from economic equality. I do think the recent “popularity” of philanthropism and social justice ventures is going to be a helpful trend, although this will do more to address the symptoms of inequality rather than the causes. I do think that when considering inequality of this nature, considering financial incentives as being integrally related to health interventions, whether by providing transportation, loans, subsidizing medications, or giving some other form of monetary assistance to patients with little to no access could be considered a more “necessary” component of public health work.

  9. Hi Jacob, thanks for your post! This was very interesting to me, as I often do end up thinking about inequality in terms of economic class and forgetting to address to “socio” part of socioeconomics. Yet while I agree that we may often put so much weight on the economic side that we forget there are other factors as well, I still feel the reason we have a concept that combines the social and the economic is that they cannot be so easily separated and are often very interwoven. For example, when you talk about disease invisibility and lack of research, do you really feel these concepts can be separated from money? To me it seems that the diseases that we study and publicize are those that affect certain populations – namely, populations that can pay for the interventions developed, and sometimes even single-handedly support research themselves.

    You address this a bit more clearly with access to care, a factor that is very tied up in economic as well as social factors. Again, though, while the social factors you bring up are very interesting and relevant, I feel that it is possible that if they were the only problem these people would have gotten care long ago. What I mean is that if they had money and resources their immigrant status for example wouldn’t be a significant or as significant of a barrier to lack of care. Just like in the AIDS example, rich white men were able to overcome stigma surrounding homosexuality and the bureaucratic authority of the FDA (social factors) with their economic power. While social factors should be recognized, I think that in the U.S. at least, economics unfortunately remain the deciding factor in health (which should guide our interventions, if not be the explicit purpose of all of them).

    1. Allison, these are good points. It is definitely true that some of these “socio” causes of health inequity are themselves caused by economics. My goal in discussing them as separate entities was not to paint them as independent of these economic underpinnings, but to suggest that some solutions can be tailored to addressing these “symptoms” of the greater disease of inequality. Efforts to increase access (whether by making treatments more affordable, helping people get to clinics, helping providers get to previously unreached populations, and offering other benefits and services to make populations have an easier time addressing health issues, etc), increase education and decrease stigma, and consider cultural sensitivity as integral to health care, can all work on reducing secondary causes of health inequality, without what might be considered more radical and harder to accomplish smoothing out of structural inequality which created those problems in the first place.

      One valid criticism of this approach is that putting on a lot of bandaids might make people less inclined to treat the actual wound, and this is one I hadn’t really considered. If we make a lot of successful efforts to minimize the problematic outcomes of wealth inequality, do you think there will be less effort applied to redistributing wealth? If safety net facilities do “too good” of a job caring for the uninsured, will there be less incentive to get insurance?

      Beyond that, you raise a good point that awareness of economics should therefore become a part of our health interventions. Do you mean something like offering financial incentives to patients to improve outcomes of treatments, or something of a different nature? How might you suggest we improve public health interventions within the context of economic inequalities?

  10. Hi Jacob,

    Upon reading your blog post at the conclusion of our class, I appreciate you bringing to light some very interesting things to consider–especially invisibility. Health has so much to do with access, poverty, and of course politics and culture through the examples you brought up, and it is far too easy for a group of peoples’ suffering to go unnoticed because of stigma or just lack of awareness.

    Invisibility can happen both intentionally and unintentionally, but both are equally dangerous for those being overlooked. You asked the question of how we can address this issue without redistributing wealth, and I feel like education can play a big role in the solution. Education means having people be much more aware of who diseases affect and how, as well as education those affected to seek help so that their presence is known. It takes some work on both ends to make people visible.

    Your second question is really interesting, and I agree that a problem coming from all sides is much harder to handle than a problem with a specific root cause. However, just because an issue is more complicated does not mean it shouldn’t be addressed, and I wanted to make a connection with the “nail soup” analogy from Benton’s lecture. Perhaps by targeting one certain aspect of an issue, for example access to medical care, can lead to other aspects of health improving as well.

    1. Absolutely Thu. As we’ve progressed through this course, I’ve found myself more and more viewing education as a component of the best global health interventions. It seems like education is ultimately an incredibly “horizontal” approach – it builds the base, where everyone from laypeople to providers have a new set of skills and understanding necessary to help themselves, helps build the next generation of providers, and helps bring trust and participation back into a system. Interventions which don’t focus on some aspect of education – or include incredibly limited education, like teaching people in West Africa to use a cloth screen which filters out Guinea Worm but not other water-borne bacteria (when a different filter works for this purpose) – are more short-term, and have more problematic colonial aspects. Even in local interventions, this short-sighted and paternalistic approach is really common. There is a big discussion in American public health about how much we should promote self-management of chronic diseases like diabetes. These programs are currently on the rise because they are low-cost and long-term interventions. They initially suffered resistance because a lot of providers were worried that people would not be able to manage their own care, they would not take their medicine correctly, and that big behavior changes need closer monitoring to happen successfully. This reminds me of Paul Farmer’s reaction to concept of compliance in Rwanda Tuberculosis treatment – he suggests the term is a misnomer, and says that if people are given the means and education, they will be compliant – it is other factors which stand in the way.

      The other point you touched on that I think is really important is this idea that invisibility is a two-way street. When having these conversations we usually think about the provider/system end of it, where it is important to make sure the healthcare system is aware of a population that has a high burden of some disease, and the needs of that population. However, often that population itself is unaware of its risks and health needs, and making sure people are proactive in caring for themselves is also incredibly important. We might consider the case of getting young people – especially young women – to consider getting an HPV vaccine, which can help reduce rates of cervical cancer later in life, to be a decent example of this. The population we are targeting is often not yet sexually active, so the future burden of HPV and cervical cancer could be considered to be invisible here. But since the intervention is most effective in this age range, this group has a huge need to be aware of this risk and this intervention.

  11. Hi Jacob!

    I really liked your point in distinguishing between health inequalities and health inequities. I have never heard the term “health inequities” be used, so I thought it was an interesting point. I think that realizing that some health inequalities could happen no matter what a person’s lifestyle is is important. Distinguishing this could definitely help steer interventions to either looking at the more genetic component of a disease vs. looking at the social/cultural factors of something. That being said, if one is trying to create an intervention that addresses “invisibility” or cultural/political barriers to access of care it’s important for that person/organization to truly understand the barriers and what will help these people. I think that more thought and effort has to be put into the creation of a service that affects health inequities. If you’re trying to create a clinic in an area of many immigrants, one must be conscious of what language they speak, how their culture might influence their views on health and medicine, and how to best serve someone who might be afraid of say, stigma. It requires more planning, but it will better serve the community it’s geared at. I think that redistributing the wealth could help in a country like the US where healthcare is rationed based on ability to pay. I do think though that because of political or cultural barriers, not all of the health inequalities in the US could be solved.

    I think looking past economics doesn’t make the task of resolving the causes of inequalities more daunting. I think, in fact, looking at factors such as politics and culture can give answers to certain problems that money and economics can’t necessarily give. Just looking at economics won’t help in the situation of solving the large amount of late stage cancer in Botswanna. One must look at the culture, the stigma against cancer existing in developing places, and the access to actual equipment and knowledge collectively in order to start to try to bring better health care to these people. Economics doesn’t give all the answers, but neither does culture or politics. One must take a biosocial approach in every intervention because each person’s life is affected by many different things.

    1. Thanks Katherine! I agree with you – creating targeting interventions and facilities which consider the needs of the community they serve is really important. A clinic which serves a large amount of immigrants needs to be aware of the specific needs of that community, which might mean spanish-fluency, cultural awareness (Guatemalan immigrants are a very distinct population from Dominican immigrants, and this can actualize itself in different forms in the healthcare sphere). One question the clinic I work at is dealing with is trying to respond to changes in these communities – recently there has been a larger influx of African and Middle Eastern immigrants to Rhode Island, which is a change from the previous trend of mostly Central American and Caribbean. Does it make sense for a separate clinic to exist to address the needs of this new population, or as a clinic devoted to cultural sensitivity and bringing access to the uninsured, should we be adapting ourselves to meet this new demand?

      I’m glad you see the spread of relevant factors as encouraging rather than daunting. It does take a very different approach to combat stigma than economic disadvantage, and both are incredibly necessary.

  12. Hey everyone,

    To wrap up my blog post I’ve been thinking about other populations who suffer from invisibility of some kind in the healthcare sphere, and some types of interventions which address access, education, and stigma through non-economic approaches. Beyond women with AIDS, African cancer, and as one commenter mentioned, sex workers, and immigrants there are other populations who do not get a lot of attention in the healthcare sphere. One group which still has a huge burden of care is individuals with intellectual disabilities – especially in the context of managing chronic disease. Other groups which suffer enormously in the healthcare sphere are people with drug addictions, those in prisons, and the homeless.

    Some interventions which improve access at low cost are things which work to coordinate care better from distributed healthcare modules – working on EMR systems and getting people enrolled in care programs which address their particular status – whether they are illegal or legal residents still ineligible for Medicaid, etc. A new model of program which is incredible popular is called Pay for Success – which attempts to give delivery systems payment for costs that they will save down the line. So if our clinic takes care of X number of people who in the next 2 years will be eligible for Medicaid, and in that time we help them with preventative and chronic care, we might have saved the Office of Health & Human Services a lot of money down the line. This is looking at care from an economic perspective, but just increasing incentives for non-economic and low-cost interventions. Finally, a lot of models that work with stigma approach early-education and addressing attitudes in schoolchildren, as a way of distributing these ideas into families and into the next generation.

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