Social Injustice and Public Health

Victor W. Sidel, MDDistinguished University Professor of Social Medicine

Montefiore Medical Center and Albert Einstein College of MedicineAdjunct Professor of Public Health

Weill Medical College of Cornell University

University of Kansas Medical CenterKansas City -- October 19, 2009

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Injustice anywhere is a threat to justice everywhere.

The Reverend Dr. Martin Luther King, Jr.Letter from Birmingham Jail

April 16, 1963

Social InjusticeDefinition #1

The denial or violation of rights of

specific populations or groups in

society, based on perception of their

inferiority by those with more power

or influence.

Populations or Groups That Suffer Social Injustice

May be defined by:

• Race

• Socioeconomic position (class)

• Age

• Gender

• Sexual orientation

• Other perceived characteristics

Social Injustice Definition #2

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

Health and Medical Care Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services” [Article 25, Part 1 of the Universal Declaration of Human Rights, 1948]

“The attainment of the highest possible level of health is a fundamental human right.” [Preamble to the WHO Constitution, 1946]

Role of Medical Care in the Promotion and Protection of Health

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

Role of Medical Care in the Promotion and Protection of Health

Medical care provides diagnosis and treatment of people who are ill and reassurance of people who are concerned they may be ill. Preventive medicine, a part of medical care, is important in prevention of illness among patients and their families.

Addressing Social Injustice in Medical Care

• Assurance of access to high-quality medical care

• Support for the equitable organization and financing of medical care

• Alleviation of related forms of social injustice

High-Quality Community Medicine

• Emphasis on prevention

• Provision of primary care

• Cultural sensitivity

• Effective communication

• Respect for patient autonomy

Barriers to Access to Medical Care

• Insurance status• Immigration status

-- Lack of needed documentation-- Fear of detection of status

• Access to facilities-- Distance or lack of transportation-- Conflicting obligations

Effects of Un- or Under-insurance

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

SOURCE: Hadley, Jack. “Sicker and Poorer – The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income,” Medical Care Research and Review (60:2), June 2003.

Number of Uninsured Children and Adults, 2000-2004

30.2 31.7 34.0 35.5 36.5

9.4 9.2 9.3 9.1 9.0

0

10

20

30

40

50

2000 2001 2002 2003 2004

Children

Adults

Note: Sums may not equal totals due to rounding. SOURCE: KCMU and Urban Institute estimates based on March Current Population Surveys, 2001-2005.

39.6 M 40.9 M43.3 M 44.7 M

In millions45.5 M

Barriers to Health Care by Insurance Status, 2003

8%

16%

13%

9%

15%

23%

36%

37%

35%

47%

Contacted by collectionagency about medical bills

Had problems payingmedical bills

Did not fill a prescriptionbecause of cost

Needed care but did notget it

Postponed seeking carebecause of cost

Uninsured

Insured

Notes: *Experienced by the respondent or a member of their family. Insured includes those covered by public or private health insurance. SOURCE: Kaiser 2003 Health Insurance Survey.

Percent experiencing in past 12 months:*

Nonelderly Uninsured by Race, 2004Risk of Being Uninsured

13%

16%

29%

18%

34%

21%

0% 20% 40%

Two or More

Am. Indian

Asian

Hispanic

Black

White

National Average18%

Asian group includes Pacific Islanders; American Indian group includes Aleutian Eskimos. SOURCE: KCMU and Urban Institute analysis of the March 2005 Current Population Survey.

Health Insurance Coverageby Poverty Level, 2004

37% 29%

42%

27%

66%

21%

45%

71%89%

18%18% 7%

10%16%

4%

0%

25%

50%

75%

100%

U.S. Total <100% FPL 100-199%FPL

200-299%FPL

300%+ FPL

Employer/ Other Private

Medicaid/ Other Public

Uninsured

Notes: The federal poverty level was $19,307 for a family of four in 2004. SOURCE: KCMU and Urban Institute analysis of the March 2005 Current Population Survey.

Inadequate Quality of Medical Care

• Lack of language and cultural skills

• Lack of good clinical practice

• Barriers to specialty referrals

• Lack of preventive medicine

Disparities in treatment of cardiovascular disease

• Cooperative Cardiovascular Project: observational study of 169,079 Medicare beneficiaries hospitalized for acute MI

• Medical therapies underused in the treatment of black, female and poor patients with acute MI

Rathore SS. Berger AK. Weinfurt KP. Feinleib M. Oetgen WJ. Gersh BJ. Schulman KA.Race, sex, poverty and the medical treatment of acute MI in the elderly. Circulation. 2000:102; 642-648.

Disparities in treatment of cancer

• Members of minority populations tend to have lower rates of cancer screening and present later in the course of illness

• Members of minority populations often receive less effective treatment for cancer

• Members of minority populations often receive less effective care for symptoms, such as pain control

Disparities in treatment of people with HIV/AIDS

• Prevention efforts often culturally incompetent

• Needle exchange not instituted

• HIV infection often diagnosed late

• Drug treatment options often inadequate

• Members of minority groups rarely included in clinical trials of experimental drugs

Addressing Social Injustice in Medical Care

• Assurance of access to high-quality medical care

• Support for the equitable organization and financing of medical care

• Alleviation of related forms of social injustice

Percent of Population withGovernment-Assured Insurance

Note: Germany does not require coverage for high-income persons, but virtually all buy coverageSource: OECD, 2002 - Data are for 2000 or most recent year available

92%100% 100% 100% 100% 100%

45%

0%

20%

40%

60%

80%

100%

U.S. Germany France Canada Australia Japan U.K.

Addressing Social Injustice in Medical Care

• Assurance of access to high-quality medical care

• Support for the equitable organization and financing of medical care

• Alleviation of related forms of social injustice

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

Pharmacies in Minority Neighborhoods

Fail to Stock Opioids

Source: N Engl J Med 2000; 242:1023

0%

25%

50%

75%

100%

<21% 21-60% >60%

% Minority Residents in Neighborhood

% o

f P

harm

acie

s w

ith

» Ade

quat

e O

pioi

d S

uppl

y

Incarceration Rates, 2000

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A nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual death.

The Reverend Dr. Martin Luther King, Jr.Beyond Vietnam: A Time to Break Silence

Riverside Church, NYCApril 4, 1967

Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and not clothed.

President Dwight D. EisenhowerAmerican Society of Newspaper Editors

April 16, 1953

World Military Expenditures

After a period of declining military expenditures after the end of the cold war worldwide spending grew to $1.5 trillion in 2008, a 45% increase from 1999.

The United States spent $711 billion in 2008, 48% of world spending, distantly followed by the United Kingdom, China, France, Japan, Germany and Russia.

Military Spending in 2008 Country Dollars (billions) % of total Rank

United States 711 48.3 1

China 121.9 8.3 2

Russia 70 4.8 3

United Kingdom 55.4 3.8 4

France 54 3.7 5

Japan 41.1 2.8 6

Germany 37.8 2.6 7Source: U.S. Military Spending vs. the World, Center for Arms Control and Non-Proliferation, February 22, 2008

Wars in Iraq and Afghanistan

In FY 2010 cost of military operations in Iraq & Afghanistan will be $130 billion

By March 2010, total spending in Iraq & Afghanistan will hit $1 trillion

Monthly cost during 2009 averaged 5 billion, up from 3.5 billion in 2008

The $800 billion spent on the Iraq war alone exceeds the $700 billion spent in Vietnam

Trade-Offs

Employment EducationHousingPublic HealthMedical Care

Job Creation

The 915 billion spent in the wars in Iraq and Afghanistan could have provided:

Salaries for 4 million public safety officers for 5 years

Salaries for 3 million elementary school teachers for 5 years

Construction of 7 million affordable housing units

• National Priorities Project www.nationalpriorities.org

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

Spending Targets # of Jobs

Created

# of Jobs Relative to Military Spending

Average Wages and Benefits per

Worker

1. Military 11,977 --- $65,986

2. Tax cuts for personal consumption

15,090 +26.2% $46,819

3. Health care 18,036 +50.2% $56,668

4. Education 24,758 +106.7% $74,024

5. Mass transit 27, 713 +131.4% $44,462

6. Construction for home weatherization/ infrastructure

17,927 +49.7% $51,812

Medical Care

Nearly 45,000 annual deaths are associated with lack of health insurance

Uninsured have higher death rates form hypertension, and heart disease

62 percent of bankruptcies in 2007 were caused by a medical condition

American Journal of Public HealthSeptember 17, 2009

Trade-Offs

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

• National Priorities Project www.nationalpriorities.org

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