The morbidity of rich and poor

BMJ 1998; 316 doi: (Published 18 April 1998) Cite this as: BMJ 1998;316:0

Which of the following populations would you expect to have the highest self reported morbidity? The people of rural Bihar, the poorest of Indian states; the people of rural Kerala, the Indian state which by a long margin has the highest life expectancy; or the Americans? You will by now have smelt a rat, reflected on the question, and will answer, “the Americans.” You are right, but you may be surprised by the margin: Americans report about 150 active conditions a year for every 100 people, the people of Kerala about 100, and the people of Bihar around 10.

These figures come from a lecture delivered in Florence by Amartya Sen, philosopher and economist and now master of Trinity College, Cambridge. The main point of Sen's lecture was to argue that mortality should be used as an indicator of economic success or failure, and he produced the morbidity data to show that they could not be used because they suffer from major biases. The main problem, says Sen, is that “a population that has little experience of medical care and widespread health problems as a standard condition of existence can have a very low perception of being medically ill.” Another problem may be that the person in Bihar sick with diabetes or a similar condition may die, whereas the American will survive and need long term care. But, whatever explains the phenomenon, it is the undoing of those—like Aneurin Bevan, the founder of the NHS—who invest in health services in the hope of mopping up all illness and so reducing expenditure on health care.

These thoughts might usefully underpin your reading of this week's BMJ. Despite its low self reported morbidity Bihar “carries the burden of about half of the world's annual cases of visceral leishmaniasis” (p 1200). Worse, the disease is becoming unresponsive to treatment with antimony compounds. But a team from Bihar report the results of a randomised controlled trial that shows that the aminoglycoside aminosidine is a highly effective treatment. Unfortunately, explains Diana Lockwood (p 1205), the drug is expensive and has not been marketed since the manufacturers were taken over.

Back in the rich world, people are still fretting about cholesterol. A group from Canada finds that questionnaires designed to encourage people to have cholesterol tests are not very successful (p 1208), while a systematic review discovers that dietary advice has only a small effect in reducing people's cholesterol concentration (p 1213). George Davey Smith and Shah Ebrahim observe that while people “locked in a room and fed lettuce” will experience a fall in serum cholesterol, those out in the real world tend to eat fatty foods because they are cheap and available and they like them (p 1220). They advocate health protection through legislative and fiscal means.

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