All posts by Jacob S Buckley

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.