Inequality isn't just unfair — it's making people sick

Inequality has become a popular topic over the past decade. In books like Capital in the Twenty-First Century and Inequality and Instability, economists have warned that the growing income gap is spinning us back to strict 19th-century-style social hierarchies, where elites dominate everybody else, usually on the basis of inherited wealth.

What's usually overlooked in the conversation is how rising inequality can erode our health. This is a subject that Michael Marmot, a British physician and epidemiologist, knows a lot about. He's spent the past 40 years amassing a body of research that shows how inequality can be intrinsically bad for health outcomes — work he's collected in his new book, The Health Gap.
His findings are stunning. Marmot discovered that health and social status are often inextricably linked — even when you control for income, education, and other risk factors. This is true if you look at countries or at cities, or even drill down to the level smaller communities. And the implication of this research is that high levels of inequality can, on their own, make people sick.

15 years ago, Kansas City realized life expectancy for black residents was 6.5 shorter than for white ones. Here’s what the city is doing to change that.

Most famously, his Whitehall studies established a link between the relative rank of officers in the British civil service and their risk of disease and death. The higher an officer was ranked, the better his or her health. This was despite the fact that all civil servants were relatively well-off, with similar levels of education. Again, the stratification itself seemed to be the important factor.

Marmot calls the link between health and status "the social gradient in health." One possibility is that it's all related to a sense of control in one's life. People lower down in the social order feel like they have less control, which can lead to stress that then negatively impacts health.

Marmot has documented this social gradient in many other settings around the world. In London, life expectancy drops by one year for every stop heading east on the Jubilee metro line. In Baltimore's inner-city Upton neighborhood, men can expect to live until 63. In nearby Roland Park, an affluent social enclave with safer streets and better job prospects, that life expectancy rises to 83 — an incredible 20-year difference in a tiny geographic area.

Again and again, Marmot finds, health isn't just determined by how much you exercise or what your genes dictate; it's influenced by your social environment. I spoke with him recently by phone to find out more about whether there was anything we could do to address these imbalances.

Julia Belluz: One thing that comes up again and again in your book is that the US, despite having "the best health care system in the world," has terrible health and life expectancy outcomes compared with other wealthy countries. Why? 

 

Life expectancy mapped by London metro stops. (spatial.ly)

Michael Marmot: In many people's minds, inequality means poor health for the poor. That’s true — the poor do have poor health. But what the Whitehall study of British civil servants showed is that among people who aren’t poor and aren't rich either — among a population of employed people that excludes the poorest and richest — the higher the position in the hierarchy, the better the health, and it runs all the way from top to bottom. I called that the "social gradient in health."

The implications of that are rather profound. If you think about your readers, they probably think, "We’re not poor. We may not be well-off, but we’re not poorest or the richest, so this doesn't affect us." But the implication of the gradient is that they’re not free of this either. We’re all involved. All of us below the top have worse health than we would if we were at the top. The figures in Britain — which are not different from the US — say that someone with middle income has eight fewer years of healthy life than if he were at the top. Eight fewer years of healthy life means a decline in grip strength, mental function, and, eventually, a shorter life. The gradient is very profound and important.

JB: How do we know that social rank affects health outcomes and not the other way around? 

MM: In this cause, correlation is causation. We’ve got good evidence, and it goes through the life course. It starts with early childhood development, continues with education, the likelihood of getting a job at all, the quality of work, and elsewhere, and the conditions for older people beyond working age. All of those impact health and the gradient in health. We’ve got strong evidence for that. It’s not just that you’ve got a correlation. Not only do we have evidence for the causal role, but we also have good evidence of what you can do to address it — which is why I wrote the book.

JB: Your work seems very pertinent given a new paper this week that showed that middle-aged white people are seeing increases in their death rate, while other age, racial, and ethnic groups in the US have seen only declines. The trend is clearly driven not only by health care but by social circumstances. 

MM: If you look at the probability that a 15-year-old will not survive to 60 in the US, it's 13 percent. The US ranks 50th out of the 194 member countries of the World Health Organization on this measure, which means there are 49 other countries where a 15-year-old has a better survival chance than in the US. This is a country that spends far, far more on health care than any other country.

 

All-cause mortality, ages 45 to 54 for US White non-Hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE). (PNAS)

But this is not a health care issue. If you look at the causes of that premature mortality in the new study — it’s alcohol- and drug-related poisonings, suicide, other alcohol-related deaths, and external causes of death, and by that we mean homicide, violence, traffic pressures, and the like. So people don’t die of drug-related poisonings because of a lack of medical care; they die because they are taking drugs and/or committing suicide.

JB: Why do you think that's now happening in this group in particular? 

MM: Well, I think you have to go back to early childhood. Countries that have bigger income inequalities, like the United States, in general have a steeper gradient in the quality of early childhood development. If you look at school performance, the US doesn't do as well as other countries. So the lower people's socioeconomic position, the worse their children do in standardized school tests. Going on from schools — in the US, the average earnings have not increased for over three decades.

So you start from worse early childhood development, worse performance in education, and then you come into adult life and think, "I'm going to be worse off than my parents. What I hoped to be able to give my children, I'm not sure I'm going to be able to." And then you think of the disinvestment from the public realm because of the relatively low tax rate in the US, the low degree of public spending — lower than any of the other rich countries. If you don't spend much money on improving communities and services, people's own income is not growing, the public sphere is under attack, people are under stress, and they turn to drugs and alcohol and suicide.

JB: What's the mechanism by which social rank and environment impact health?

  

Years of life lost (YLL) due to premature mortality by cause and country-income group. (WHO 2010)

MM: I'll contrast two pathways.

One is behavior. If you think about what most people think about when they think about public health, it's, "Don't smoke, eat sensibly, don't become overweight, be physically active, drink in moderation," and the like. That's all very important. But those behaviors tend to follow the social gradient: The lower people are in the social hierarchy, the more likely they are to be obese, to be less physically active, to smoke, to suffer the consequences of alcohol. The social environment impacts on health by conditioning people's behaviors. People under stress turn to alcohol, drugs, and violence because of that stress. It's not very mysterious that people do that.

The other way it affects health is through stress pathways. I talk about disempowerment: If you have little control of your life, you might smoke, drink, and so on, and you can’t do anything about the future anyway — so you might as well get drunk. There's evidence that these stress pathways related to disempowerment impact negatively on cardiovascular diseases, diabetes, and mental illness. That starts from the beginning of life.

JB: You've been called a "health Nazi" for advocating using the tax system and strengthening social programs to make fairer and healthier societies. While the evidence of health harm from inequality is clear, politically this is a tough message to get across — especially in the US, where individual rights and freedoms tend to trump social values. 

MM: There has to be more of a focus on the social. We want to create the conditions for people to be empowered to take control of their lives. It’s not about trying to deprive individuals of control of their lives; it's trying to create conditions where they have it. I think the fact that the US ranks 50th on the chance of a young man surviving to 60 is reflecting disempowerment. It’s all very well to say it’s up to the individual. But to not get shot? To not feel 

suicidal? We’ve got an epidemic, and it's not due to a pill deficiency.

So it’s not just about improving health — it’s about improving society. Building a more cohesive society means equalizing life chances. This requires action at the community level, the national level, and the global level. That action needs to be through the life course. We have to create a more cohesive society where people can flourish.

What are Non-Technical Documents and Are They Important? Examples from a Lead Soil Assignment in Environmental Health

What is a Non-Technical Document?
Have you ever opened up a package of medicine and found that paper inside?  You know, the one you usually toss away as you dig for your medicine?  Well, I am sure some of you have opened that piece of paper before and read it.  Remember how it was really confusing and really really technical?  

Some of you may have worried.  Some of you may have shrugged it off.  Some of you may not have taken the medication.  Some of you may have called up a medical professional in a frenzy.  Some of you may have consulted the Internet in a hope to decipher what was on that piece of paper.

Or some of you may have looked at the print out that your medical professional gave to you with the medicine.  Or you made a bullet list of points.  You know, the one where it says that you just pop 1 pill in your mouth every 6 hours and in about 2 days you will begin feeling better?  She/he may have told you some side effects, like you may sleepy, cranky, hungry, thirsty or achey.  But they told you in words that you understand and don't need the Internet or a dictionary to comprehend.

That is what a non-technical document is.  A simplified version of all that jargon (or fancy mumbo-jumbo words) in a way that a reader who may or may not be familiar with the topic at hand can comprehend and read easily.

Why Are They Important?
So imagine that one day, someone who seems really important (like a doctor or scientist) comes into your home and begins showing you charts and figures about something.  They use a lot of words that you've never heard of before and when you ask them to stop and explain, they just continue going and going, like the Energizer bunny.  Next thing you know, they ask you if it is ok if they can do something-but that something is something you don't understand.  You think they're really important, so you trust them.  And since you trust them, you say yes.  Only to find out later that it is not what you wanted-you did not want a double lumpectomy! All you wanted was to get your sore tooth pulled!  Ok sure, that is an extreme and ridiculous example, but one that illustrates my point:

We are responsible for our health and have the ultimate say in what healthcare services we want performed on us.

So, in order to do this, we need to be able to understand what is being done, right?

But It's Impossible to Condense All of That Information Into a Non-Technical Document!
I know it can seem daunting, but I promise it is possible because so many people have done it time and time again (like with every medicine!).  So, what you can do is to try to take the parts that would be the most important to the reader.  Not to you, who cares that there was 95% power and a delta of 10 but significance was not found through an ANOVA but rather via a Chi-Square test (shame on you for utilizing the inappropriate statistics just to make your results seem significant), but rather the reader who needs to know why she/he should not play with mercury with their hands and what will happen.

Ok, I Wrote It!  I Think It Sounds Way Too Basic but Am Worried It May Be Too Technical!
Chances are, you're correct.  Often times, when we spend a lot of time researching a topic we become 'mini experts' or actual experts.  So when we do try to 'dumb it down', we often fail to do so.  It's ok, don't fear that you will never be able to communicate to anyone outside of your research again!  I promise, it takes time, effort and practice to communicate to others effectively.  Not only within your research, but in every aspect of life.  This just seems even more challenging because you've not had too much practice at it or are learning it so late in life.  Think of it this way:  Remember when you first had to ask if you could be excused to go to the bathroom in kindergarten and you were probably nervous about it?  But overtime, you got better at it and within no time, you could do it with ease.  Well, same concept:  practicing will help you to become an effective communicator.

Time for Review...
One way of doing this is to have someone quickly look over your non-technical document.  Try to grab someone who doesn't work in your field.  Your parents, roommates or friends may be a good option.  This should not be too bad since they're typically about 1 page with lots of white space.  Don't use a small font and tiny margins.  Because if you're asking a friend for a favor, you do not want to waste their time and you want to make it easy for them to read and give feedback, right?  Besides, you'll probably have to ask them for a second opinion.

Do You Have An Example?
I sure do!  I have an example of the non-technical document right here that was written for one of my classes in my MPH program.  

I have also included my technical document right here.  

You can see the differences between the 2 documents as a side by side comparison if you wish.  


Please do not ask what my scores on these assignments were.  I do not remember if I got a perfect score on it or not, but I do remember doing very well on it.  These assignments are posted only to serve as examples of a technical and non-technical documents.

Medical Tourism and Antiretrovirals for HIV/AIDS: Assessing the Market Demands in Jamaica

What is Medical Tourism?

Medical tourism is the practice of travelling outside of one's home country to receive quality healthcare at affordable prices.  

Why Should I Care About Medical Tourism? 

As healthcare costs continue to increase, more Americans are being priced out of the market for treatment.  As a result, it is an emerging phenomenon in the healthcare industry although it is currently a niche market.  This is especially valid for individuals who suffer from chronic diseases. 

Is Medical Tourism Safe?

The safety and quality of care available in many offshore settings is no longer an issue: Organizations including the Joint Commission International and others are accrediting these facilities.

But I Saw So Many Botched Surgeries and Things! Will Medical Tourism Decrease?

Studies have shown that outbound medical tourism is expected to experience explosive growth over the next five years.

So You Did a Project - For What and Why?

This project was completed as my practicum for completion of my Masters of Public Health (MPH) degree from an accredited institution in the United States.  The practicum is one of the requirements for the completion of the MPH degree.

Normally, I Hear About Medical Tourism for Plastic Surgery in Thailand - Not HIV/AIDS in Jamaica.  Why Did You Choose This Specific Topic?

I chose to focus on this aspect because my practicum consisted of gathering proprietary data.  My specific interest was to collect data that would influence and impact policies that promote medical tourism in selected countries.  During my research, I often spoke with administrators, providers and other healthcare workers.  Many of them briefly mentioned the issue of HIV/AIDS which sparked my curiosity.

What Are the Gaps in Knowledge That Justify Your Study?

Recent studies have revealed that pre-exposure prophylaxis (PrEP) with antiretrovirals (ART) can reduce HIV acquisition.

While these results are promising, many questions remain regarding their use in clinical practice such as the cost, development of HIV drug resistance, and provider willingness to prescribe.  Currently, there are limited data on healthcare providers’ willingness prescribing antiretrovirals for prevention in Jamaica.

What Were Your Objectives?

• To assess the current knowledge and awareness of PrEP and PEP.
• To assess Jamaican internal medicine residents’ willingness to prescribe PrEP as a method of HIV prevention in high-risk populations.
• To determine specific concerns or barriers that would prevent internal medicine residents from discussing or prescribing PrEP to high-risk populations.

Ok, Hurry Up and Just Tell Me the Conclusions (and Policy Implications)!

•Many of the respondents have heard of PEP but not PrEP.  

•Knowledge of both PEP and PrEP are low, especially for PrEP.

•Those who have heard about PrEP have heard it through talking with their colleagues or a medical lecture.

•The willingness to prescribe is highly contingent upon the scenario.

•The biggest concern for prescribing ART, PEP, and or PrEP were the issues of affordability and feasibility.

•For medical tourism to flourish within Jamaica, the providers must be able to meet the demands of its clients.

•Jamaica must denote additional funding resources for HIV education and resources.

•Practitioners should be encouraged to rely on scientific findings rather than medical gossip or other popular trends.    
This can be accomplished in that continuing education and or lectures be incentivized.

Can I See The Poster?
Of course!  I have it here as a Google Doc.  Enjoy!

Why Are Complicated Soft Skin and Tissue Infections a Problem?

Why Should You Be Interested in Complicated Soft Skin and Tissue Infections (cSSTI)?

Complicated skin and soft-tissue infections (cSSTIs) occur frequently and comprise a broad range of clinical presentations. Postoperative surgical site infections (SSI) represent up to 25% of all nosocomial infections and about 15% of diabetic patients will develop foot infections.  cSSTIs are common in persons with diabetes and are typically more difficult to treat than those without diabetes.  Despite the frequent occurrence of these infections, there is a lack of consensus on how to best treat these infections.  

Why Do Public Health Workers Care? 

Despite the frequent occurrence of these infections, there is a limited understanding of several aspects of cSSTIs as well as a general lack of consensus on how to best treat these infections.  Very few studies have explored the current clinical practices of cSSTIs and their related outcomes.  This is of particular concern with the expansion of Medicaid and it is necessary to study the factors that influence the clinical and patient-perceived outcomes of cSSTIs.

If They’re So Common, Why Is This An Issue?

Some think that the lack of validated standardized tools that guide the clinical management and treatment of cSSTIs results in compromised patient and clinical outcomes and increased cSSTI prevalence rates.

Can You Explain This Issue?  Where Did You Get That Idea From?

This is based on 4 observations. 

1. First, there are different classification measures for cSSTIs, none of which are validated.  cSSTIs can be classified according to the anatomical site of infection, microbial etiology, or severity.  Classifications are designed to alert the provider to the level and type of care needed for treatment.
2. Second, the knowledge of the epidemiology and susceptibility of pathogens (which are needed to guide the selection of antibiotics) are often unknown.  Coupled with the increased prevalence of multidrug resistant pathogens (e.g.: methicillin-resistant Staphylococcus aureus (MRSA), etc.), has further complicated the development of guidelines for treatment. 
3. Third, the fundamental source of these issues may lie in the US Food and Drug Administration’s (FDA) definition of cSSTIs. Coined in 1998, it is to serve as a guide for industry in designing clinical trials that would include similar groups of infections.  It was not to provide a clinical framework for the treatment of cSSTIs. 
4. Fourth, cSSTIs are common in persons with diabetes and are typically more difficult to treat than those without diabetes.

Ok, I am Scared/Worried/Concerned.  What Can I do?

Well, there is not much you can really do except adhere to the prescribed treatment that your provider gives you. 

You can also try to prevent such infections, especially diabetic foot infections.  Here is a site to offer some help with prevention (by the American Family Physician and another easy to read one here).

You can also help write to our legislators (find yours here) to help create standardized lists, kind of like surgical checklists.

WE ARE PUBLIC HEALTH

What are your thoughts?