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Data matches observation in developing countries
- Rajan TD (9 July 2006)
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What does this mean for practice?
- Jean Pigott (10 July 2006)
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Understanding inequalities in injury deaths
- James P. Scanlan (19 July 2006)
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Rajan TD, Consultant Skin & Sex Transm Diseases, Andheri 0091-22-66982747 CMPH Medical College, Mumbai, India
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The study on children from the poorest families in England and Wales facing greater risks of dying from injury matches our observation of the same in underdeveloped countries. Financial considerations affect the treatment of serious cases of trauma among poor children in developing countries. In cases of children with serious and life-threatening injuries the treatment costs are exorbitant. There are public hospitals in countries like India which provide high standards of healthcare to cases of trauma to patients of all sections of society. These services are availed only by the economically poorer sections since the other social classes suspect the efficacy of such publicly funded health systems. Facilities like CT-guided surgery are available only at major private hospitals. Supramajor surgeries are performed only in major public hospitals and tertiary private hospitals. The latter are beyond the reach of the poorer sections of society. Therefore, the poor do not manage to make use of the facilities provided by such private hospitals. Hence the survival of poor children from accidental injuries is much less than the fortunate one's in developing countries. Competing interests: None declared |
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Jean Pigott, Consultant Child and Adolescent Psychiatrist Liaison Team,Whittington Hospital London N19
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This paper, sadly, includes no surprises to anyone working in an inner city area, but could offer a useful additional measure of the effectiveness of community based parenting programmes. The discussions in the paediatric ward based multidisciplinary meetings in this inner city hospital too often highlight the correlation described in this paper. A small increase in our sensitivity to indicators of difficulties in parenting would threaten to deluge local CAMH services, yet a relatively small but ongoing intervention at this stage is likely to be protective in the future. Poverty distorts parenting, including its protective and supervisory functions. It emphasises any inherent weaknesses in parenting in a way that more affluent families with difficulties can guard against in a number of financially based ways. The studies after the Bristol floods showed the correlation of physical injury following emotional trauma. Are some or many of these parents traumatised sufficiently by the difficulties of their day to day lives to pass on the effects down the generations? This would fit with what we see week to week on the ward. It seems quite possible that being able to assess the parents of children on the ward for more subtle signs of mental distress and there being a service that could support them sufficiently intensively as individuals and parents would help. Yet being more sensitive to lower clinical thresholds, and thereby inevitably less specific, is not what is required from CAMHS services at present. We are increasingly pressurised to go down the route of only assessing and treating more extreme pathology, which often means shutting the door after the horse has bolted and disappeared over the horizon. Will the intervention of Sure Start programmes across the country be shown to reduce these statistics? What about the range of other parenting programmes on offer? Is what we are doing across the statutory and voluntary sectors effective or are we just trying to push water uphill in the face of the level of deprivation and lack of opportunity and hope? It would be heartening to see more hopeful statistics than these, but some we could believe in. Competing interests: None declared |
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James P. Scanlan, Attorney James P. Scanlan, Attorney at Law, Washington, DC 20007, USA
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Edwards et al.1 examine the rates of death of children from injuries according to socioeconomic group in England and Wales during the period 2001-2003 and find extremely high ratios of the rates in the lowest socioeconomic group to those in the highest. The authors deem the continued existence of a socioeconomic gradient surprising in light of the recent declines in rates and the low absolute numbers of deaths. Due to problems with comparability of data for different periods, the authors do not assess whether socioeconomic differences are narrowing or widening. But the continued existence of large socioeconomic difference for increasingly rare outcomes ought not to be surprising. Moreover, in all likelihood, during the period of declining injury death rates, the socioeconomic differences were in fact increasing, for that is generally what occurs when an adverse outcome declines. The basis for these observations lies in the statistical tendency whereby, when two groups differ in their susceptibility to an outcome, the rarer the outcome, the greater the relative difference in experiencing it (though the smaller the relative difference in avoiding it).2-6. The tendency is the consequence of the facts that progress in eliminating adverse outcomes is almost invariably a matter of restricting those outcomes to the point where only the most susceptible segments of the overall populations continue to experience them, and that disadvantaged groups make up higher proportions of each increasingly more susceptible segment of the overall population than they do of the preceding one. For the same reason, we can expect that further efforts to reduce injuries, assuming they are successful, may well increase relative socioeconomic differences in injuries even when the efforts seem particularly aimed at the disadvantaged. A study published last year in the American Journal of Public Health is illustrative.7 The authors examined changes in socioeconomic differences in rates of Sudden Infant Death Syndrome (SIDS) in the United States as a result of the Back to Sleep Program. The program, which was aimed at educating the public about the advantages of having infants sleep on their backs, was deemed by the authors as one expected to reduce health inequalities since there would be few barriers to universal implementation of the recommendations. Yet the study found that, while SIDS decreased substantially for all groups, socioeconomic differences in SIDS rates increased. In fact, however, the increase in those differences was just what one should expect as the result of a program like this that serially restricted avoidable SIDS mortality to the very most disadvantaged segments of the population – on the way, one would hope, to the complete elimination of SIDS. This does not mean that by promoting healthy living a society is doomed to increase health inequalities. Rather, it means that some rethinking is warranted concerning the utility of measuring inequalities in terms of ratios of rates of experiencing adverse outcomes. References 1. Edwards P, Green J, Roberts I, Lutchmun S. Deaths from injury in children and employment status in family: analysis of trends in class specific death rates. BMJ, doi:10.1136/bmj.38875.757488.4F (published 7 July 2006). 2. Scanlan JP. Can we actually measure health disparities? Chance 2006;19(2):47-51. In press. 3. Scanlan JP. Measuring health disparities. J Public Health Manag Pract 2006;12(3):294 [Lttr] (http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=641470). 4. Carr-Hill R, Chalmers-Dixon P. The Public Health Observatory Handbook of Health Inequalities Measurement. Oxford: SEPHO; 2005 (http://www.sepho.org.uk/extras/rch_handbook.aspx). 5. Scanlan JP. Race and mortality. Society. 2000;37(2):19-35 (http://www.jpscanlan.com/images/Race_and_Mortality.pdf). 6. Scanlan JP. Divining difference. Chance. 1994;7(4):38-9, 48. 7. Pickett KE, Luo Y, Lauderdale DS. Widening social inequalities in risk for sudden infant death syndrome. Am J Public Health 2005;95:97-81 Competing interests: None declared |
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