Variations in health care (by place, race, class, gender)

Table of Contents

Variations in health care (by place, race, class, gender)
Initial notes
Annotations on common readings
Annotated additions by students
Idea: Inequalities in people's health and how they are treated are associated with place, race, class, gender, even after conditioning on other relevant variables

Initial notes

The issues here are not only variations or disparities, but also how to measure, track, and talk about those variations.
Alter et al. conclude that despite Canada’s Universal Health Care System a individual’s socioeconomic status affected access to cardiac services and increased the prevalence of mortality.
Krieger (2010) reviews "how racism harms health," holding that, to do so, "it is necessary to employ the socially created categories of race/ethnicity.."
Krieger (2010a) provides a teacher's overview of the subject of inequalities and health.
Krieger et al. (2005) started the Public Health Disparities Geocoding Project because socioeconomic data is often lacking in US public health surveillance systems. Socioeconomic deprivation contributes to racial/ethnic health disparities in more than half of the cases studied.
Krieger, et al. (2014). Whereas Lynch suggests we should not worry too much if health inequities (in Krieger's words) "rise as population health improves, due to health improving more quickly among the better off," this article analyzes 50 years of data in USA that indicates that that is not necessarily the case.
Krieger, N. (2014a). More studies pay studies attention to experience of discrimination as a risk factor, but they "remain focused primarily on interpersonal discrimination, and scant research investigates the health impacts of structural discrimination."
Bailey et al. makes us think about racism as a structural matter, not simply something that affects risk factors for individuals.
Calzoa et al. provide some perspectives on teaching about gendered inequalities and thus provide entry-points into the relevant literature.
Davey Smith advises against using ethnicity as a proxy for socioeconomic position and advocates for incorporating both in quantitative models.
Gawande describes how medical costs can be high even in poor areas; this results from the overuse of medicine from over-treating patients and over-prescribing tests and procedures.
Marmot and Wilkinson argue that researchers should look beyond material privation to examine psychosocial effects on variation in health outcomes, particularly relative deprivation concerning individual agency and control.
Wright et al.'s study of asthma among children in low-income urban settings found a correlation between asthma, stress, and exposure to violence that suggests the need for addressing these intervening variables. However, smoking was not found to be associated with asthma attack incidence.
Sparke does not apply epidemiological methods, but provides a critical review of literature that links health to place and, in doing so, highlights inequalities in health.
Finally, Franks et al. from the last session is relevant given that SES is associated with CHD even after controlling for the major risk factors included in the Framingham risk score.
Notes and annotations from 2007 course, 2009
Common readings and cases: Alter 1999 (Access to cardiac procedures), Krieger (2010)
Supplementary Reading: Bassuk 2002, Davey-Smith 2000, Dunn 2007, Egede 2003, Gawande 2009, Krieger (2005, 2010, 2010a, 2014, 2014a), Lynch (2007), Marmot 2001, Roger 2000, Wright 2004

Annotations on common readings

Annotated additions by students

(In alphabetical order by author's name with contributor's initials and date at the end.)

Psychosocial and material pathways in the relation between income and health: a response to Lynch et al
Michael Marmot, Richard G Wilkinson
BMJ 2001; 322: 1233-6 (Published 19 May 2001)

Historically the gradient in health, correlating socioeconomic position to morbidity and mortality levels, has been observed in all societies and continuously exhibits shifts in magnitude. The discourse about health disparity has generally focused on the effects mediated by poverty. However, numerous studies have suggested that inequalities’ psychosocial impact is directly implicated in poor health outcomes. It is said that Lynch et al. cosigns the link between income inequality and life expectancy at the population level. However, according to Marmot et al., they convincingly refute the ability of individual income to explain the health gradient. Instead, Lynch et al. espouses the “neo­material” pathway “a combination of negative exposures and lack of resources held by individuals, along with systematic under investment across a wide range of human, cultural, and political­ economic processes(Lynch et al.)” as being the underpinnings of health inequalities. Marmot et al. argues that the deliberate exclusion of psychosocial factors as being components of the “neo-material” pathway thwarts any meaningful distinction between neo­material factors and material factors. The impetus of this article is to counter Lynch et al. dismissal of psychosocial pathways as being significant contributors to the socioeconomic gradient in health.

Marmot et al. posits that material conditions do not adequately explain health inequalities particularly in rich countries. The negligible relation between average income and life expectancy is purported to indicate that “absolute material standards are not, in themselves, the key (Marmot et al.)”. The authors contend that the psychosocial effects of relative deprivation acts in tandem with the direct effects of absolute material living standards to influence health outcome. Moreover, Marmot et al. postulates that the relation between smaller inequalities in income and better population health reflects augments in psychosocial wellbeing. It is their conjecture that wellbeing is associated with relative income rather than absolute income in rich countries. Marmot et al. ranks psychosocial wellbeing factors, such as social dominance, inequality, autonomy, and the quality of social relations as being among the most powerful explanations for the health gradient pattern observed in rich countries. (SY)