Left behind: the legacy of hurricane Katrina

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