Archive for December, 2008

Death toll in Iraq War: Over a million?

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Just Foreign Policy Iraqi Death Estimator Year end is time for taking stock.  So it seems an appropriate moment to remember what Project Censored has called one of the top 25 stories censored stories of 2008, namely the massive death toll that has come in the wake of the 2003 US-led invasion of Iraq.  Some have estimated this death toll to be well in excess of 1 million (see counter).

It is clearly difficult to make a precise measure of the deaths that can be attributed to the invasion and occupation of Iraq.  In this posting we would like to review some of the attempts to come up with an estimate.

Two peer reviewed papers estimating the mortality impact of the war have been published in the Lancet.  The first,  from October 29, 2004, is entitled Mortality before and after the 2003 invasion of Iraq: cluster sample survey.  The authors conducted in-depth interviews with 998 households during the month of September 2003.  They compared mortality in the 14.6 months before the invasion with that of the 17.8 months afterwards, finding that the risk of dying was 2.5 times higher after the invasion.  Much of this increased risk reflected deaths in Fallujah.  But even if these were excluded, the risk of death was still 1.5 times higher after the invasion.  In terms of absolute numbers this meant “about 100,000 excess deaths.”  This study was updated in an October 11, 2006 paper “Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey” in which 1849 households were interviewed.  This study concluded that “[t]he number of people dying in Iraq has continued to escalate” and calculated the excess mortality as 654 965 (CI: 392 979–942 636).

These studies came under both considerable criticism as well as marked media silence (particularly in the US).  The controversy surrounding the papers is well summarized on Wikipedia.  Concerns about a US media blackout can be found at Project Censored and were the subject of a paper by Lila Gutterman in the Chronicles of Higher Education entitled “Researchers Who Rushed Into Print a Study of Iraqi Civilian Deaths Now Wonder Why It Was Ignored“.  (Gutterman’s article provides a non-technical description of the study).

There are three other relatively official estimates of the Iraqi death toll:

In January of 2008 the New England Journal of Medicine published “Violence-Related Mortality in Iraq from 2002 to 2006.”  This paper was produced  by the Iraq Family Health Survey Study Group, a joint effort of the Iraq Ministry of Health and the WHO.  The study looked at 1086 families and estimated that there had been 151,000 (95% CI 104,000 to 223,000) violence-related deaths from March 2003 through June 2006.  In their conclusions the authors note: “Violence is a leading cause of death for Iraqi adults and was the main cause of death in men between the ages of 15 and 59 years during the first 3 years after the 2003 invasion. Although the estimated range is substantially lower than a recent survey based estimate, it nonetheless points to a massive death toll, only one of the many health and human consequences of an ongoing humanitarian crisis.” Editorial comment and responses to the study were published in the same issue.

Also in January of 2008  ORB (Opinion Research Business), a London-based firm released revised death figures based on polls conducted in Iraq.  They calculated a death rate of 1,033,000 (CI: 946,000 to 1,120,000).  This is the largest estimate so far.

Finally, the Iraqi Body Count Project attempts to follow the civilian death toll through media reports.  When we checked on their website today (12/31) that estimate was 90,147 to 98,413.  Since it is highly likely that the media under-report civilian deaths, it’s hard to know exactly what to make of these numbers.

The number shown in the counter in this posting is derived from the Lancet 2006 study and a rate of increase calculated from the Iraqi Body Count data.  See here for more details.

A recent draft history of the War by the Special Inspector General for Iraqi Reconstruction (SIGIR) concluded the War was (in the words of the New York Times) “a $100 billion dollar failure.”  The SIGIR draft report closes by quoting Charles Dickens:

“We spent as much money as we could and got as little for it as people could make up their minds to give us.”

This, of course, is the monetary cost.  The loss of human life is incalculable.  And whether the death toll is merely 151,000 plus or 1 million plus, it’s a horrendous way to spend $100 billion.  Who has profited from this?  Surely not the people of Iraq or the United States.

Readers interested in anti-war activism and news may want to visit the website of the American Friends Service Committee.

Pax tecum.

posted by Matt Anderson

Update from US medical students studying in Havana Cuba

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Over last week’s holiday break, we had a chance to meet with Joanna Mae Souers, an American student at the Escuela Latino America de Medicine (ELAM, Latin American Medical School) in Havana, Cuba.  Ms. Souers, a graduate of Cornell, is currently in her second year of studies.  She is the recipient of one of 500 full scholarships offered by the Cuban government for US students.  For more about this program, please check previous postings on the Portal or an article describing the program written in our online journal.

Ms. Souers shared with us two reports that the US students have prepared about their work.  This is the first:

alumni-conference-02On October 30th ELAM students, alumni, school and government officials were present for the Opening Ceremony for the First International Alumni Conference of Project ELAM here in Havana, Cuba.  Dr. Jose Miguel Barruelos Millar, Fidel Castro’s personal doctor during the Revolution and one of ELAM’s founders, was among the speakers.  Over the course of the conference, students, alumni and professors attended lectures, presentations and roundtable discussion on various themes, including human rights, student movements, indigenous movements, gender issues, alumni relations and healthcare brigades.

Students and alumni, discussing healthcare brigades, debated and defined the future formation, participation and integration of projects such as the Brigada Estudantil de Salud (Student Brigade for Healthcare, BES) and the Federación Internacional de Salud (International Federation of Health, FIS).

Since the First Student Congress of Project ELAM in 2001, students have organized chapters of BES to participate in community service projects during their summer vacations.  Stemming back even further, FIS was defined in 1999 to be the association of Project ELAM graduates working for medical brigades worldwide.  Students and alumni have agreed to strengthen relations between BES and FIS by working together in the collaboration of such projects.

On November 1st, alumni and students of FIS/BES, respectively, presented to the ELAM community on the outcome, social impact and scientific results of their work.  On this day, Joanna Mae Souers, graduate of Cornell University, 2nd year medical student, and BES representative for the U.S. Delegation, presented the U.S. BES proposal for 2009.

The US delegation is currently in the process of organizing and forming brigades to work in communities during the coming months of July and August.  It is our goal to organize students working in brigades to collaborate with doctors, local professionals and community leaders, in order to learn more about their communities, the problems that plague them and the potential solutions that could improve U.S. healthcare and strengthen these students as future healthcare providers.

The overall impact of the conference was quite astounding, as it successfully brought students and alumni together from all over the world to show their support for one another.  It was a true milestone for Project ELAM.  We hope that in the upcoming conferences we get representation from the US physicians that have recently graduated from the Project ELAM.

If you have any questions or are interested in supporting this line of work you are welcome to contact Ramon Alejandro Bernal or Joanna Mae Souers, representatives of the U.S. Delegation.

Contact information:

Escuela Latinoamericana de Medicina
Carretera Panamericana Km 3 ½
Santa Fé, Playa
Ciudad Habana, Cuba
C.P. 19108

Email:  Ramon Alejandro Bernal
Joanna Mae Souers <>

posted by Matt Anderson, MD

Trade & Health at 2008 American Public Health Association Meeting

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Click above to see the video

In November we posted presentations by the Spirit of 1848 caucus at the 2008 American Public Health Association annual meeting.  We also felt it was important to share some of the presentations on trade and health that have been posted by the Center for Policy Analysis on Trade and Health, CPATH.  These represent cutting edge work on how trade agreements are impacting upon health.

Here is a listing of presentations, most with links to the actual slides or posters. You can also download them from the CPATH website.

Health & Trade Policy for Specific Industries. Moderator: Garrett Brown

Public Health Strategies to Address Trade Policy. Moderator: Kristen D. Smith

Trade Policy, Health, Economics & Justice Moderator: Susanna Rankin Bohme

Influence of Trade Policy on Health: Poster Session

To obtain copies of the following presentations, you should contact the authors:

  • Cross-border hazard and cross-border justice: The Case of DBCP. Susanna Rankin Bohme
  • FTAs and public health in Chile: The need for a policy research agenda. Leonel Valdivia
  • Trade and nutrition: Consequences of free trade agreements in Peru, Chile, and Mexico. Sural Kiran Shah
  • Corporate social responsibility: What is it good for? Beth Rosenberg
  • Economic Liberalization and the Postcommunist Mortality Crisis. David Stuckler
  • CAFTA and the Global Campaign for High Drug Prices. Ellen R. Shaffer

posted by Matt Anderson

Primary Health Care in Times of Globalization

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logo-itg-defAs one of many activities marking the 30th anniversary of the 1978 Alma Ata Conference, the Institute of Tropical Medicine in Antwerp Belgium sponsored a conference on “Primary Health Care in Times of Globalization: Alma Ata, Back to the Future ” [11/26 – 11/27/2008].  The presentations and background material for this conference have now been posted on the web.  The different presentations – available as powerpoints – provide a quick snapshot of current international thinking regarding Primary Health Care (PHC).

Monique Van Dormael of the ITM began with a presentation suggesting that the publication in 2008 of three reports – the Report of the WHO Commission on the Social Determinants of Health, the WHO World Health Report and the second Global Health Watch – were all hopeful signs for PHC.  Her presentation explored some of the ways in which PHC (and the language of Alma Ata) might and might not be relevant in the world today.  She made the distinction that health problems were not complicated – meaning “systems that experts can fix if they get the right technology” – but rather were complex – meaning “systems driven by social actors who cannot be controlled like robots.”  This was, she felt, a key insight of the Alma Ata conference that had been lost in the last 30 years.

A number of experiences with constructing primary care systems – in the Democratic Republic of the Congo, in Eduador,  in Mexico City and in Belgium were presented. There was a discussion of new modalities of “aid” and human resources development.  Each of the three reports mentioned in the introduction – the WHO World Health Report, the Report of the Commission on the Social Determinants of Health, and the second Global Health Watch – was also the subject of a presentation.

Community Participation was highlighted in presentations from Cuba, Venezuela, and Belgium.  In Ghent, Belgium a Community Oriented Primary  Care (COPC) model has been adopted to involve the community in the solution of health problems. A presentation by Wim De Ceukelaire examined some of the political questions concerning community participation. Quoting Wallerstein, he emphasized that true community participation must involve “capacity to challenge non-responsive or oppressive institutions and to redress power imbalances.”  This might be done, he suggested through People’s Organizations, Health committees and Community health workers.  On the second day of the conference an international panel offered suggestions on how to go about promoting community participation.

The conclusions and preliminary recommendations of the conference are summarized in the final powerpoint, available at this link.

Reflecting on these presentations from New York City, one wonders if the US really sits on the same planet everyone else lives on.  We struggle here just to get everyone covered by the health care system.  But this is only one (necessary) step towards  building a real system of care and of building a real system of primary care.  The very idea of community participation in the development and management of a health care system seems entirely foreign to our corporate model.  In a health care market “consumers” are limited to the “choice” of which plan (i.e. which commodity) is most economically rational for them.

But the US does sit on planet Earth.  Seeing what is happening in other countries reminds us another world is possible.  And even what it might look like and how to go about building it.

Posted by Matt Anderson

Vicente Navarro on Democracy & Corporate Control in Health

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Dr. Vicente Navarro

Dr. Vicente Navarro

In the midst of 2008 Presidential primary, Vicente Navarro published an article in the Harvard Health Policy Review discussing the “relationship between national health care systems and the policy process.”  His paper has now been republished in the International Journal of Health Services and is now available on-line.  In this article Dr. Navarro analyzes why, unlike most countries in the world, the United States has not adopted a system of universal health care coverage.  What is particularly valuable about Dr. Navarro’s analysis is that  he steps out of the US context and contrasts our system to that of Europe in Canada.  Doing so offers an illuminating perspective on what is different about the US system.

The context for his discussion is the stunning failure of the current US system to provide any insurance to 47 million Americans and adequate insurance to an estimated 108 million Americans. This failure is costly in medical and financial terms.   Medical bills are among the most common reasons for personal bankruptcy.  As he notes: “None of the E.U. countries face this dramatic situation.  It’s abundantly clear that this situation is not due to lack of resources. What then sets the US apart?

Navarro argues that our problems begin with the very nature of our private health care industry,  financed – ironically enough – in the majority with public money.  This creates powerful vested interests, among whom the most important are the insurance companies, who have an economic stake in perpetuating the status quo.

Navarro goes on to argue that not only has health care been privatized, but so has the electoral process in the United States.  Paraphrasing Mark Twain he notes that “The U.S. Congress is indeed the best Congress money can buy…” and refers to an article he wrote in Counter Punch: “A Guide for Europeans: How to Read the US Primaries.” As a point of contrast he notes that “[m}any ministers of European governments have had to resign when it came to light that they had received private funds for the electoral process.”

The privatization of the electoral process explains why political candidates consistently raise lack of health coverage as an issue in campaigns, but then fail to address them once in office.  And why increasing popular (and physician) support for a  national system is ignored.

Navarro’s article is subtitled: “The Deficits in U.S. Democracy and the Implications for Health and Social Policy”.  There is much evidence that democracy is ailing in the US.  The 2000 Presidential campaign revealed serious problems with the voting process. The fact that the President is not elected by popular vote has not been addressed by the U.S. political class.  The corporate domination of media has become ever stronger over the past decades restricting the bounds of acceptable political debate.  Clearly, the fight for universal health care needs to re-invigorate the institutions of popular control over government.

Dr. Navarro is a Professor at the Bloomberg School of Public Health at Johns Hopkins University.  He is also editor of the International Journal of Health Sciences.   In the HHPR article he discusses a bit of his educational and academic background.

posted by Matt Anderson

Human Trafficking

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Girls are not for sale

Girls are not for sale

On Tuesday, December 9th, 2008 Ms. Lori Cohen, a lawyer from Sanctuary for Families spoke at Social Medicine Rounds on “Understanding Human Trafficking.”

Sanctuary for Families is the largest New York State non-profit “dedicated exclusively to serving domestic violence victims and their children.”  However, over the past 20 years Sanctuary’s work in domestic violence has led the organization to become  increasingly involved in issues of trafficking.  DV victims are not uncommonly also victims of trafficking.

And, as Ms. Cohen pointed out, they often first come to the notice of health professionals who see them for the sequelae of their abuse.  Clinicians, therefore, can play an important role in identifying and referring victims.  A website ( has been set up to alert Emergency physicians to the problems of trafficking.  This very simple, but quite useful site, is a joint effort by the (NY) Mount Sinai Department of Emergency Medicine, the American Osler Society, AMSA and Brown Medical School.

Much Ms. Cohen’s talk was devoted to sex trafficking, and particularly sex trafficking among minors.  About 450,000 children run away from home each year.  One out of three are estimated to be lured into prostitution within 48 hours.  This may explain why the average age at which prostitution begins is 13.  Ms. Cohen showed the beginning of a film (which is currently being aired on Showtime) entitled “Very Young Girls” about tween and teenage prostitutes.  This was not a very easy film to watch.   However – in a section of the movie we did not see – it traced how Rachel Lloyd, “a survivor of commercial sexual exploitation and trafficking” established GEMS – Girls Education & Mentoring Services – to help young women who are victims of trafficking and to end commercial sexual exploitation of children.  The bracelet pictured in this post is sold by GEMS to raise money.

Whereas most human trafficking is within the United States (state to state and within states) New York City has a large population of immigrant victims of trafficking.  Trafficking into the United States comes from Southeast Asia (China, Thailand, Vietnam), followed by Eastern  Europe (Russia, Ukraine, Czech Republic), and finally Latin America.  As Ms. Cohen noted, whenever there is an important military conflict affecting civilian populations, trafficking from that area increases.   She discussed clients of hers from Russia, Venezuela, the Ukraine, Korea and Sri Lanka, as well as locally trafficked victims of abuse.  Sometimes women are brought in by organized crime rings, other times by “Mom and Pop” or family operations, such as the infamous Carreto family in New York.

Ms. Cohen emphasized that recognizing that a woman was a victim of trafficking is often difficult.  Women are distrustful of government agencies. They often times do not have identification papers and believe that they have committed crimes.  Their stories are programmed by the trafficker.  Denial or minimization is common, as is shame.  Language poses a barrier with abusers often serving as “interpreters.”  The Human Trafficking ED site offers recommendations for providers seeing patients who they suspect are victims of trafficking.

The take home message is that clinicians should be aware of this problem, maintain an index of suspicion for abuse and trafficking, know how to sensitively interview a patient and have access to referral sources, such as Sanctuary for Families.

Posted by Matt Anderson, MD

Free & Low Cost Medicines

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Herceptin costs $3,000 a month

Herceptin costs $3,000 a month

As part of our series on free and low cost health care in New York I wanted to share a few resources on free and low cost medicines.

Dr.  Brian Alper (a family physician who founded DYNAMED) has put together a very useful set of clinical links for physicians at: Among the many categories in this list are six links to “indigent drug programs.”   To test these sites out, I decided to look up Herceptin, an anti-cancer agent made by Genentech.  [I was recently asked to find this drug for a medically indigent patient.]

Needy Meds: is a not-for profit “with the mission of helping people who cannot afford medicine or health care costs.” The information at NeedyMeds is available anonymously and free of charge.  The most useful part of this website is the listing of drugs – both generics and brand – that are available from patient assistance programs (PAP’s).   If you find a drug and a PAP, many of the applications can be downloaded from the website.  Most of the links seem to be from 2008.  The site also has a link to free clinics.   I easily found Herceptin on the Needy Meds site with links to application form in English and Spanish as well as the Genentech website.

Rx Assist is managed by Astra Zeneca and claims to be the “Web’s most current and comprehensive directory of Patient Assistance Programs.”   The Rx Assist site has a searchable database so you don’t have to scroll down lists.  Herceptin was also easy to find on RxAssist, but the site linked only to the English application and the Genentech site.

Benefits CheckUp is run by the National Council on Aging and is a very different type of site.  It provides information on a wide variety of benefits – housing,  food, medication, medical care, utilities, “and more.”   It works a little bit like an online social worker.  To find information on Herceptin (for a fictious patient), I needed to input zip code, age, information about work, income, and assets; this process generally takes 10-15 minutes according to the website.  I could easily imagine that it would take much longer if you had to find all the documentation.  When this was through, Benefits CheckUp suggested I apply for New York State’s EPIC program (which helps elderly people with prescription costs), New York State Medicaid and also offered the Genentech program.  There were links to the Genentech site, application forms, and even a list of documents I would need.  Very complete, but a bit daunting in terms of the information I needed to supply.

All three of the above sites linked to a variety of health care resources, not just medications.

Partnership for Prescription Assistance also links to PAP programs.  This site required me to enter information (age, location, income, insurance coverage, etc) before leading me to the Genentech site.  It did not link directly to the Herceptin application. Unlike the sites listed above PPARx did not provide links to other types of social programs (such as free clinics).

Finally, Dr. Alper’s site links to an August 2004 article in the American Family Physician “Curbside Consultation:  When Patients Cannot Afford Their Medications” This is a very thorough review of the topic with – in typical AFP style – lots of useful information. According to the AFP article 5.5 million people were enrolled in PAP programs in 2002.

I would note that – based on my personal experience – the typical patient who needs the PAP’s often times does not have access to the internet nor facility with completing forms.  So having someone to be their advocate is crucial.  This is a weakness of these websites.

A couple of additional suggestions:

Patients should always check to see if they are overpaying.  Do this by looking up the prices of medicines on  Oftentimes pharmacies charge unreasonable prices (people go, after all, to the local store) and lots of money can be saved by shopping around.

A recent blog from Suite entitled “How to Find Free, Cheap Drugs” offered (among other information) a list of retailers offering low cost or free medications.   These include WalMart, Target, K-Mart, and various food chains.  For example, “Publix supermarkets offer free antibiotics if you have a valid prescription, regardless of whether you have health insurance.  A 14-day supply is offered.”

Some sites I have seen offer to help patients find low-cost drugs from a small fee.  Clearly this is not reasonable since this information is available for free.

As I have noted in previous blogs these various efforts do not solve the root cause of the problem: lack of universal access to healthcare (including medications) in the United States.  But for patients in need these resources can be helpful.

Posted by Matt Anderson, MD

Havana Medical Education Conference & the US students studying medicine in Cuba

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Students represent their country at ELAM

Students represent their country at ELAM

Last week, Havana’s Hotel Nacional was the setting for the Medical Education for the 21st Century conference (see our posting of May 11, 2008).  Among the groups participating in this conference were PAHO, ALAMES, the Global Health Education Consortium (GHEC), MEDICC and the Cuban Ministry of Public Health.

There were a fair number of US citizens at the conference and we are fortunate that US Pediatrician David Keller (of UMass Medical School) has posted a day-by-day description of the conference (along with a few pictures) on his blog Rosie D and Me.  He notes: “The conference is fabulous and oversubscribed (> 700 attendees), but the facility is not perfectly designed for such a number. So it is sometimes a little crowded; they didn’t make arrangements for such a number to tour hospitals and the medical school, and I was unable to get my name on the proper list to have that opportunity. Still, the atmosphere is electric. People from all over the world (I heard 22 countries, but I have no official word on who is here) are gathered to discuss the complexity of integrating social medicine (for want of a better word) into the lexicon of medical education. Each country faces challenges consistent with the way in which their health care system is designed.”

Another participant in the conference, my colleague Sherenne Simon, has posted photos of Cuba and the conference on Picasa.

One of the benefits of having  US attendees in Havana was that they go to meet with the US students studying at the Latin American School of Medicine (see our posting Studying Medicine in Cuba: The Experience of Two US Students).  Figuring out how to support these students in their transition back to the United States is a challenge.  Medical education in Cuba is quite different from the US.  However, as a group, the ELAM (Escuela Latinoamericana de Medicina) students seem highly motivated (who else would spend six years living as scholarship student in Cuba?), speak Spanish, and have a commitment to work in under-served areas on their return to the US.  In some ways, they are ideal residency candidates for a US health care system that struggles to provide clinicians to many underserved communities.

One of the ELAM students provided us with a link to letters that student Ramon Alejandro Bernal has been sending back to his hometown Seattle. These are available at the website of Western Washington PNHP. ELAM has its own publication, Panorama: Cuba y Salud available at  Articles have abstracts in English.

Any readers that might be interested in helping the US ELAM students out, can contact me.  Their main interest is in finding clinical placements in the US during their summer breaks.

Finally, the keynote address was given by Dr. Charles Boelen, of the WHO’s Human Resources for Health Department:  Entitled “Social Accountability: Medical Education’s Boldest Challenge” Dr. Boelen notes: “Until recently, the prevailing assumption was that community orientation and posting, along with problem-based learning, were adequate for medical schools to serve social needs. But now, this notion of social accountability has emerged, meriting attention worldwide, even within traditional medical circles. This concept urges medical schools to go beyond pedagogical innovations and search for optimal integration of their graduates into health systems.” This paper was published in the most recent edition of MEDICC Review which has several excellent articles on international experience in Teaching for Health Equity.

posted by: Matt Anderson, MD

Lincoln Hospital: The Decline of Health Care, A 1971 Radio Documentary

The old Lincoln Hospital

The old Lincoln Hospital

In April of 2007, our journal Social Medicine, published the audio tapes of a 1971 Pacifica Radio documentary about the conditions at Lincoln Hospital, one of the largest public hospitals in the Bronx.  Lincoln had been briefly occupied by the community in 1970 and this takeover was the subject of several articles in the journal.

Unfortunately, technical problems broke the link to this audio. Thanks to help from Sebastian Pais Iriart this has now been corrected and the audio file is available at this link in mp3 format.

The audio tape was accompanied by an article.  Here are the first few paragraphs:

“Lincoln Hospital: the decline of health care” was broadcast on WBAI radio in New York City on April 22, 1971, roughly a year after the community takeover of Lincoln Hospital (see Fitzhugh Mullan’s article “Seize the Hospital to Serve the People” on page 98 of this journal).  The documentary provides an opportunity to
hear the voices of some of the people at the center of the struggle to reform – or revolutionize – one of New York City’s most dysfunctional hospitals.

These voices include physicians (Drs. Martin Stein, Helen Rodriguez-Trias, Lewis Fraad, Arnold Einhorn, and Fitzhugh Mullan), a community activist (Cleo Silvers), administrators (Antero Lacot, Edmund Rothschild, Stanley Bergin) and several patients.

Much of the documentary focuses on the health issues of the Bronx and the inadequacies of the hospital. Dr. Lewis Fraad notes, for example: “Lincoln Hospital is full of lead poisoning. And until recently, we have seen children get lead poisoning while hospitalized at Lincoln Hospital.” Patients recount long waits in the Emergency Room. […to read the rest of the article, click here]

What makes this documentary particularly interesting is the extensive discussion/debate regarding woker and community control of the hospital. This topic is essentially absent from the current corporate-dominated discussion of hospital management.

We hope in January 2009 to publish a video interview with Cleo Silvers, one of the key activists at Lincoln.

posted by Matt Anderson

Dollars & Sense and Dr. Ichiro Kawachi on Inequalities of Health & Wealth

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Dollars & Sense is a bimonthly magazine “of economic justice” produced by the Economics Affairs Bureau, Inc, a not-for-profit publisher in Boston.  EAI also publishes a series of “Real World” books which cover a variety of topics such as macroeconmics and political economy.  All the issues of Dollars & Sense are available on the web and – together with their blog – provide some welcome critical orientation on the current economic crisis.  Interested readers may want to look at Larry Peterson’s series: The Subprime/Securitization Market Panic: A Guide for the Perplexed.

Earlier this year D&S interviewed Ichiro Kawachi, of Harvard’s School of Public Health reagarding the effects of income inequality on health.  In this interview Dr. Kawachi discusses his views on how both absolute income levels and relative inequality affect health:

“Most obviously, income enables people to purchase the goods and services that promote health: purchasing good, healthy food, being able to use the income to live in a safe and healthy neighborhood, being able to purchase sports equipment. Income enables people to carry out the advice of public health experts about how to behave in ways that promote longevity.

But in addition to that, having a secure income has an important psychosocial effect. It provides people with a sense of control and mastery over their lives. And lots of psychologists now say that sense of control, along with the ability to plan for the future, is in itself a very important source of psychological health. Knowing that your future is secure, that you’re not going to be too financially stressed, also provides incentives for people to invest in their health Put another way, if my mind is taken up with having to try to make ends meet, I don’t have sufficient time to listen to my doctor’s advice and invest in my health in various ways.

So there are some obvious ways in which having adequate income is important for health. This is what we call the absolute income effect—that is, the effect of your own income on your own health. If only absolute income matters, then your health is determined by your income alone, and it doesn’t matter what anybody else makes. But our hypothesis has been that relative income might also matter: namely, where your income stands in relation to others’. That’s where the distribution of income comes in. We have looked at the idea that when the distance between your income and the incomes of the rest of society grows very large, this may pose an additional health hazard.”

Dr. Kawachi’s interview updates the concept that relative income inequality, in addition to absolute levels of wealth, is an important determinant of health. This idea has been debated for several decades in Britain. It had been hoped that the introduction of the National Health Service would eliminate health disparities by providing universal and equal access to care.  However the publication of the Black Report in 1980 revealed that health inequalities persisted in the “socialist” NHS.  In response Ruskin College Oxford and the Socialist Health Association prepared a series of reports.  The fourth, Income and Health,  was published in 1991. It was written by Allison Quick and Richard Wilkinson and began:

“The key argument of this report can be stated in three sentences.  Overall health standards in developed countries are highly dependent on how equal or unequal people’s incomes are.  The most effective way of improving health is to make incomes more equal.  This is more important than providing better public services or making everyone better off while ignoring the inequalities between them.’

From this argument derives a socialist commitment to income equality.  Interested readers may want to look at the Socialist Health Association’s Health Inequalities Policy Statement for the practical implications of this viewpoint. Of course, “socialism” was recently used during the US Presidential campaign in an attempt to “smear” President-Elect Obama.  So the concept of increasing income equality is, frankly, off the table.  And one does not think to ask if income and social inequality are both not intrinsic and necessary in a capitalist economy.

Dr. Kawachi’s interview updates the thesis of Quick and Wilkinson with modern evidence.  He cites the 2006 JAMA study showing that Americans – with higher levels of income – are less healthy than our British counterparts and he suggests some more technical solutions designed to bring economics to the service of health, such as Health Impact Assessments (HAI).

I have been disturbed by the emphasis on the psychological impact of health inequality. This was a prominent part of the recent PBS series Unnatural Causes.  One cannot help escape the feeling that the practical implications of this theory are not the promotion of income equality, but rather the teaching of the exploited to relax and accept their fate.

posted by Matt Anderson