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EDITORIALS: David Atkins and Ernest M Moy Left behind: the legacy of hurricane Katrina BMJ 2005; 331: 916-918 [Full text]

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Expanding publically funded healthcare is not the answer

Mira de Vries   (24 October 2005)

Rich is Better

Graeme M Mackenzie   (25 October 2005)

Thinking More Deeply About Health Disparities

Linda S. Gottfredson   (31 October 2005)

Expanding publically funded healthcare is not the answer 24 October 2005
Mira de Vries, Chairman Assoc. for Medical and Therapeutic Self-Determination P.O. Box 761 1180AT Amstelveen NL Send response to journal: Re: Expanding publically funded healthcare is not the answer	David Atkins is almost right. “The healthcare sector alone” cannot eradicate poverty. It cannot even contribute to this noble cause. “What it would take to create more equitable and healthier communities in New Orleans” and elsewhere is not “infrastructure for public health” or “health insurance”. It is universally true that wealth promotes healthcare. Conversely, healthcare does not promote wealth, except among healthcare workers. The United Kingdom is a case in point. In spite of free access to healthcare for over half a century, an estimated 17% of the population remains below the poverty line. What public health schemes promote is burgeoning healthcare budgets of sometimes dubious benefit, and the medicalisation of social problems. The poor need money, not medicine. Competing interests: None declared
Rich is Better 25 October 2005
Graeme M Mackenzie, gp Whitehaven CA28 7RG Send response to journal: Re: Rich is Better	Did someone once say, "I have been poor and I have been rich and rich is better". While wanting to live and contribute to a utopia (as we all must do (apart from Aldous Huxley, I suppose)), is the constant highlighting of the adavantages of being wealthier not a bit of a no brainer. Is that not why we all get up in the morning to make money: to make sure we have a better life? How do health policies aimed at more equality in health outcomes deal with the fact that since sophisticated economies began, the dominating factor has been to make money to make one's life better (or at least believe it will make one's life better)? Can you address health inequalities without questioning the very basis of all societies? Competing interests: None declared
Thinking More Deeply About Health Disparities 31 October 2005
Linda S. Gottfredson, Professor, School of Education University of Delaware, Newark, DE, USA 19716 Send response to journal: Re: Thinking More Deeply About Health Disparities	In their editorial, “Left Behind: The US Hurricane Puts the Health Effects of Poverty and Race in Plain View” (BMJ 2005; 5: 440), Atkins and Moy ask Americans to think more deeply about how to create more equitable and healthier communities. Their six strategies for better health care might indeed improve overall health in communities of all sorts, but they would do little to narrow race and class disparities in health. Although health disparities within nations are still routinely attributed to differences in wealth and social status, health scientists have noted for decades that differences in material resources and access to health care cannot explain three remarkable facts about group disparities in health: (a) disparities are ubiquitous, regardless of country, health system, decade, disease, organ system involved, and treatability of disease, (b) health is better at successively higher levels of socioeconomic status, even beyond the level of resources required for good health and health care, and (c) health disparities increase when health information and medical care become more widely available (as happened, for instance, when the media alerted the public to the dangers of smoking and when Great Britain instituted free national health care in the 1950s).1 Investment in better health care matters, of course, and it raises average levels of health in all groups. But it simultaneously creates greater variation (disparities) in health, because some individuals are better able to capitalize on the new resources. Health literacy research and related studies have shown that an individual’s mental resources are critical for effectively exploiting available care. Persons who learn and reason poorly practice healthy behaviors less often, seek less preventive care (even when free), know fewer signs and symptoms of disease, and adhere less effectively to treatment regimens. Good health also depends in large part on apt self-care: preventing illness and injury, and exercising independent judgment in the daily self-management of chronic diseases such as diabetes and hypertension. A seminal study of health literacy in two urban hospital outpatient populations (N=2659) found, for example, that 26% of patients did not understand information about when a next appointment was scheduled and 42% did not understand the directions for taking medicine on an empty stomach.2 Another found that half of insulin-dependent clinic patients with “inadequate” health literacy did not know the signs of high blood sugar, low blood sugar, or what to do about them.3 The US Department of Education’s 1993 National Adult Literacy Survey (NALS) documented very large race and class differences in success at performing comparably elementary reading and reasoning tasks in daily life.4 Epidemiologists point to variation in both exposure and susceptibility in explaining patterns of disease. So, too, do health disparities depend on differences in both access to care and relative ability to exploit it. Reducing health disparities therefore requires not just making health care more equally available, but also reducing the cognitive hurdles which, for many individuals, stymie its effective use. 1.Gottfredson LS. Intelligence: is it the epidemiologists’ elusive “fundamental cause” of social class inequalities in health? J.Pers.Soc.Psych 2004; 86: 174-199. 2.Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, Nurss JR. Inadequate health literacy among patients at two public hospitals. JAMA 1995; 274: 1677-1682. 3.Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patiernts’ knowledge of their chronic disease. Arch.Int.Med. 1998; 158: 166-172. 4.Kirsch IS, Jungblut A, Jenkins L, Kolstad A. Literacy in America: a first look at the results of the National Adult Literacy Survey, 1993. Princeton, NJ: Educational Testing Service. Competing interests: None declared