Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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"health is not a tradable commodity,"
- Steven Ford (8 September 2008)
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The market will always fail to ensure health equity
- Dirk Van Duppen (9 September 2008)
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Closing the gap between generations
- Sebastien TASSY, Frederique RETORNAZ (9 September 2008)
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Health Inequities
- Evan L Lloyd (14 September 2008)
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Equity is an emergent phenomena from complex dynamic systems?
- Carmel M Martin (16 September 2008)
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What is the function of health?
- Hugh Mann (17 September 2008)
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Steven Ford, Retired GP lolling 'neath the swaying palms...
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Editor You really did not need any picture on the front cover of this week's BMJ. The simple WHO derived phrase - "health is not a tradable commodity," - in big bold black on white would have sufficed. Steven Ford Competing interests: None declared |
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Dirk Van Duppen, GP Doctors for the People, Grouppractice, Antwerp
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Three inequalities which are inherent in health care are three basic reasons why ‘health shouldn’t and can’t be a tradable commodity’. First there is the unequal risk in healthcare. 10% of patients, the elderly and chronically ill people need 75% of care. Then there is the fact that social inequality translates into unequal health outcomes. In other words, there is a strong social gradient of health. If healthcare would be a basic human right, then we have to ensure health equity. If people who have the least resources have also the most need of care, then solidarity and not commercial gain should be the basis of health care. Solidarity means a transfer of resources from rich to poor, from healthy to sick and from young to old. Solidarity clashes with the market. Finally there is the information inequality, a disparity of information or information asymmetry between doctor and patient. Health is not an ordinary consumption product in which the customer (the patient) itself simply can choose for example which drug against hypertension he would take. It is the doctor who will choose and prescribe. Be fully informed is a condition for a optimal working of the market. Therefore patients can never be customers. The market will always fail to ensure health equity. Competing interests: None declared |
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Sebastien TASSY, Geriatrician Departement Of Psychiatry, Pr Azorin, Ste Marguerite University Hospital, 270 Bd Ste Marguerite, 130, Frederique RETORNAZ
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Dear editor, Everyone should agree with recommendation made in the WHO’s report to reduce health inequities related to social injustice (1). However, we feel a key determinant of social and healthcare inequities is missing and must be highlighted, interest in patients decreases as they are becoming “Geriatric” patients. After the Heat Wave of summer 2003 and thousands of elders’ death, France and other European countries discovered that many elderly people were totally isolated and socially excluded (2). It perfectly illustrates a natural tendency to focus less on Elders, unless special events. General medical journals, including the BMJ, have such a tendency and underestimate importance of geriatric cares. Using the Age-specific search strategies recommended by Kastner (3), we found that between 1980 and 2005 publications indexed as geriatric in the five international general medical journals with the highest impact factor were more or less around 11% and were decreasing (4). In the same time, population of 65 and over constantly increased and Total Health Expenditures spent for population of 65 and over in USA and Canada was above 35% and were rising. Thus there is a clear gap between level of geriatric publications in journals that are a major source of medical information and the demographic reality of healthcares provided. Such an attitude maybe quoted as Ageism(5)or blindness. 1 WHO Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: WHO, 2008. 2 Grynszpan D. Lessons from the French heatwave. Lancet. 2003 11;36:1169-70 3 Kastner M, Wilczynski NL, Walker-Dilks C, McKibbon KA, Haynes B: Age-specific search strategies for Medline. J Med Internet Res. 2006;8:e25 4 Tassy S, Vignally P, Retornaz F, Gorincour G, Soubeyrand J. Geriatric Publications and the Actual Burden of Geriatrics: Mind the Gap!. Submitted 5 Butler RN: Age-ism: another form of bigotry. Gerontologist. 1969;9:243-6 Competing interests: None declared |
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Evan L Lloyd, retired 72 Belgrave Road, Edinburgh EH12 6NQ
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Dear Sir There has been a great furore arising from this W HO report. The main items taken up by the media, particularly in Scotland, are that people in a poor (Carlton) area of Glasgow have a very low life expectancy, 30 years less than in a nearby prosperous (Lenzie) area, and even less than in "poverty" areas in India. However several important factors, which can explain some of the differences, have been overlooked. Cardiovascular diseases, mainly heart disease and stroke, are major causes of mortality in the West of Scotland. Research (1) has shown that the incidence of these deaths is related to climate, and this is true worldwide. The experience of cold is not just related to temperature. Wind and wet are at least equally important. In the UK the incidence of heart disease rises going west and going north. The further north the colder it gets and the further west the wetter it gets, and there is more wind. The further north and west the more frequently the weather changes. (It is often said that Glasgow can have four seasons in one day.) The climate is so important that people of social class I & II (like Lenzie) in North and Northwest England have a higher incidence of heart disease than social classes IV & V (like Carlton) in East Anglia. Another major factor is housing quality. Recently published research (2) done in Easthall in Glasgow investigated the effect of improving the quality of housing, from housing which was cold, damp, mouldy and draughty, with great temperature variations within the house, to housing which was dry, draught free and comfortably warm throughout the house i.e. similar to Lenzie housing. There was a general reduction in many items of ill-health and the blood pressures showed a large fall which should be accompanied by a major reduction in the incidence of heart attacks and strokes. It also had other effects including reducing the costs of heating and reducing the time off work or school. While the poor in India have a much lower absolute income than the people in Carlton, this will probably buy more than the greater absolute income in Carlton. Also the housing, while more basic, is dry and uniformly comfortable throughout, and the climate is in general much warmer with much less frequent variations in temperature wind and rain. This does not mean that other factors are not important but substandard housing is one factor which can be tackled. Yours faithfully Dr Evan L Lloyd 1. Lloyd, E L The role of cold in ischaemic heart disease. Public health, (1991), 105, pp 205-215. 2. Lloyd, E L, McCormack, C, McKeever, M, Syme, M The effect of improving the thermal quality of cold housing on blood pressure and general health: a research note. Journal of Epidemiology & Community Health, (2008), 62, pp 793-797. Competing interests: None declared |
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Carmel M Martin, Associate Professor of Family Medicine Northern ontario School of Medicine, Canadawhat
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Equity - which aims to reduce unfair disadvantage - is in fact an elusive concept that continually changes in response to dynamic environments. This is despite great efforts in measurement by epidemiology and the social sciences. Equity is an emergent phenomenon from collective activities in multiple and complex dynamic human systems judged from diverse social perspectives. The recommendations by the WHO are noble and idealistic.(1) Take the vision - "Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and die." This is a wonderful aspiration, but it involves an enormity of complex systems, dynamics and interdependencies in numerous domains; including economics, politics, culture, religion etc across the globe. Clearly, the mechanisms proposed to achieve equity - "Measure the problem, evaluate action, expand the knowledge base, develop a workforce etc" cannot hope to address these complexities without a more appropriate theoretical base. Rather than the measurement of variations being central to the strategy, there needs to be a radical shift to the understanding and adapting of complex system dynamics to enhance the emergence of equity. (1)George Davey Smith and Nancy Krieger Tackling health inequities BMJ 2008; 337: a1526 Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Health is the shield between life and death. Competing interests: None declared |
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