Tag: social determinants of health

Reading Notes #1: Health care inequities. Overdiagnosis. The Doctor/Patient Relationship

Posted by Jan on January 17, 2015 @ 4:49 pm

What follows are items I found interesting in magazines I’ve recently read. Normally I would have tweeted these links, but since I was on vacation from Twitter (see My Twitter vacation), I decided to create a type of blog post called Reading Notes (see Blogging and my Twitter vacation).

The bulleted titles below link to the specific item. There’s more detail on the articles I mention under References. OA indicates open access. $ indicates a pay wall. Note that emphasis in quotations has been added by me. Read more

How we came not to care: Rosanvallon

Posted by Jan on October 2, 2014 @ 2:04 pm

How did we become a society that passively accepts the injustice and discrimination inherent in inequality? How did we come not to care? It would undoubtedly take me a very long time to adequately address that question, but in this and the next two posts I offer a few small clues.

We are each the stars of our own lives

First up is Pierre Rosanvallon’s recent book The Society of Equals. In a review of the book, Paul Starr mentions what may be an impediment to a society of equals: We see ourselves not simply as individuals, but as unique singularities. (emphasis added in this and the following quotations)

The story that Rosanvallon tells here is that as new forms of knowledge and economic relations have emerged, people have come to think of their situation in less collective ways. Since the 1980s, he writes, capitalism has put “a new emphasis on the creative abilities of individuals,” and jobs increasingly demand that workers invest their personalities in their work. No longer assured of being able to stay at one company, employees have to develop their distinctive qualities—their “brand”—so as to be able to move nimbly from one position to another.

As a result of both cognitive and social change, “everyone implicitly claims the right to be considered a star, an expert, or an artist, that is, to see his or her ideas and judgments taken into account and recognized as valuable.” The demand to be treated as singular does not come just from celebrities. On Facebook and many other online sites millions are saying: here are my opinions, my music, my photos. The yearning for distinction has become democratized.

Rosanvallon does not criticize the society of singularities, with its “right to be considered a star.” Since it’s now a fact of life, we need to figure out how to deal with it. Read more

Interrogating inequality: An annoying article

Posted by Jan on September 29, 2014 @ 11:50 am

I recently read an article that really annoyed me. It was called “Rebooting Social Science: The interdisciplinary Tobin Project addresses real-world problems.” I began to realize that I wouldn’t see eye to eye with this article when I got to the section that discussed the “real-world problem” of inequality. The section was titled “Interrogating Inequality.” Not “addressing” inequality. Interrogating. Shades of “doubt is our product,” as I’ll explain.

One of the scholars interviewed for this article characterized inequality as “the most contested of contemporary issues.” The evidence cited for said contestation was the lack of agreement on whether inequality contributed to the recent financial crisis. Some claim that it did. Others, however,

dismiss this argument, viewing rising inequality “as little more than a hiccup” or even celebrating it as “a favorable development … in the progress of American capitalism.”

As it turns out, the real issue being “contested” by these “social scientists” (economists, not sociologists) is not whether inequality exists or whether it’s just a hiccup or an inevitability of capitalism. No. (emphasis in the original)

The problem is, there is no consensus in the research on the consequences of inequality.

No consequences? What about childhood trauma, increased rates of disease, shorter lifespans, human dignity? Well, it turns out those things may affect individuals, but what these researchers are looking for are societal consequences. For example, is there a relationship between inequality and economic growth? Evidently, if we cannot detect a decrease in economic growth, there’s no reason to alleviate inequality. And it seems social scientists disagree among themselves about the quality of the evidence on that issue. Read more

For U.S. health care, some are more equal than others

Posted by Jan on February 2, 2014 @ 2:39 pm

The Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”

The general health checkup: Its origins, its future

Posted by Jan on July 16, 2013 @ 10:33 am

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling. Read more

Healthy lifestyles: Social class. A precarious optimism

Posted by Jan on October 8, 2012 @ 2:22 pm

Continued from the previous post, where I noted that the Lalonde report — despite its good intentions — was followed by an emphasis on healthy lifestyles and personal responsibility for health, as well as increased health care costs.

Personal responsibility and social class

In Why Are Some People Healthy and Others Not?, Marmor et al, writing in 1994, were disappointed that the Lalonde report had not effectively prompted governments to address the underlying causes of health and disease. One reason for this, they believed, was that health policy reflects public opinion. If the public holds traditional views on what makes us sick (pathogens), what prevents disease (medical care), and what we can do to be healthy (take personal responsibility), new policies that include social determinants are unlikely. Those who are on the forefront of professional, scientific opinion may very well understand the importance of social determinants, but public opinion changes slowly. Without an education program, such as the relatively successful anti-smoking campaign, the public is unlikely to endorse change.

This is certainly true, although I believe there’s also something more fundamental at work here, namely, how a society accounts for the different life outcomes of its citizens. In Unequal Childhoods: Class, Race, and Family Life, Annette Lareau describes the assumptions people make when they hold others personally responsible for their life circumstances. Read more

Healthy lifestyles: The unfortunate consequences

Posted by Jan on October 8, 2012 @ 1:48 pm

Continued from the previous post, where I discussed the expansion of universal health care prior to the 1970s, how this created a growing demand for health care, and the problem health care costs posed for governments, especially when the economy suffered a downturn in the seventies. One response to the situation was to consider new ideas. Rather than limit strategies to what could be done by the health care industry, why not directly address the underlying causes of disease by considering social determinants of health.

Canada’s Lalonde report

In 1974, Canada produced the Lalonde report. It has been described as

[the] first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.

The US Congress emulated this thinking in 1976 by creating the Office of Prevention and Health Promotion. The US Department of Health, Education, and Welfare began publishing the document Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The response in European countries — caught in the same bind of greater demand, increasing costs, and the financial consequences of a deteriorating economic landscape – was similar.

The common thread in these new perspectives on health was the assertion that health could be improved — without increasing health care costs — if we concentrated on such things as the work environment (occupational health), the physical environment (air and water pollution, pesticides and other carcinogens in food), genetics, and healthy lifestyles. The approach was broad: the environment was considered at least as important as the promotion of healthy lifestyles. Read more

Healthy lifestyles: The antecedents

Posted by Jan on October 7, 2012 @ 6:02 pm

In the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.

Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.

A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified. Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part

Posted by Jan on July 20, 2012 @ 2:34 pm

Continued from parts one, two, and three.

A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.

Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water. Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections

Posted by Jan on July 18, 2012 @ 11:14 pm

Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.

If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.

Healthism

~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.

“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable. Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political

Posted by Jan on July 17, 2012 @ 11:02 pm

Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.

The social determinants of health

Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.

The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment. Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine

Posted by Jan on July 16, 2012 @ 8:58 pm

It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.

Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.

Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)

Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are. Read more

What is healthism? (part two)

Posted by Jan on February 20, 2012 @ 3:20 pm

In part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health. Read more

What is healthism? (part one)

Posted by Jan on February 20, 2012 @ 2:20 pm

Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”

In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.

Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.

One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.

This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself. Read more

Paging Dr. Frankenstein

Posted by Jan on December 28, 2008 @ 4:12 pm

A scant few hundred years ago we began to believe we could understand the world through reason and science. Not only that, we believed we could bring it under our control. These new beliefs brought many wonderful things: Electricity, modern medicine, iPods.

Risks have always been with us: natural disasters, wild animals, accidents, epidemics, and other ‘acts of god’. But over the last century, especially since World War II, new categories of risk emerged. These modern risks follow from the negative byproducts and side effects of the very same science, technology, industrialization, and global economy that we otherwise benefit from and enjoy.

Global warming, environmental carcinogens, toxic waste disposal – all these effects of technology reach forward in time to touch future generations. Such trans-generational risk is uniquely post-industrial. Some of these, like species extinction – which can now result from human activity – are irreversible.

But modern risk has not only expanded through time. Tainted products from anywhere in the world – food, toys, or jewelry for children – can end up on any local store or pantry shelf. These modern risks are not merely medical and ecological, but psychological as well: Is this can of tuna safe to eat?

As our dependence on technology and a global economy increases, the negative consequences are more difficult to predict, or to control when prediction fails. What are the implications of mapping and sequencing the human genome? Perhaps we’ll recreate a long-extinct species. Will these make nice pets or nice nightmares?

Before and after science

In the heady days of the Enlightenment we looked towards a Utopian future, the promise of science, technology, rationalism. Yet only in Frankensteinian fiction did we ever consider the down sides of this brave new world. It’s a bit like how the Bush administration failed to plan the post-invasion phase of the Iraq war. Compared to the impacts of industrialization, globalization, and mass media, that one should have been a no-brainer.

Today’s risks get defined by scientists, lawyers, and politicians, whose differing interests are often reflected in those definitions. “Yes, there’s mercury in your salmon and melamine in little Jenny’s formula, but not enough to do any real damage.”

Risks are communicated, breathlessly and repeatedly, by a media whose interests may not be identical with those of “viewers like you.” Perhaps a lack of confidence in our information sources is an even greater risk than lack of confidence in our food supply.

Humans could never control natural disasters. Now we are losing control of the man-made ones. But we try to control what we think we can. So we regularly lift weights and practice yoga, or at least try to. We buy organic food and avoid trans fats. We practice a ‘healthy lifestyle’ (or at least try to), even though behavior has less influence on overall health than genetics, social status, economic inequality, and environmental degradation. Those are all beyond the direct control of individuals. So we drink pomegranate juice instead, distracting ourselves from the complex and real issues at the root of our suspicions, outrage, and despair.

Reources:

Ulrich Beck, Risk Society: Towards a New Modernity

Deborah Lupton, Risk

Tag Archives: social determinants of health

The role of elite institutions of higher education

We have neglected to cultivate a culture that cares