Immorality of inaction on inequality
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j556 (Published 08 February 2017) Cite this as: BMJ 2017;356:j556
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Dear Editor,
The recent editorial in your journal titled “Immorality of inaction on inequality” is interesting and an eye opener of sorts. While the authors have covered most of the stretch, I will like to add that it’s time that the plight and predicaments of the elderly population also needs to be taken into account as well, and on an urgent and doable basis. Kindly don’t forget the gaps and inequities in the timely care and appropriate management of the morbidities that the frail aged already have, and whose numbers are increasing worldwide. Some of the aged may be turning despondent and losing hopes due to multi-morbidities, poly-pharmacies, inequities in appropriate and readily available geriatric care, which as such is getting more fragmented with either actual or perceived limitations of geriatricians, and the effect of super-specializations. If one cares to search the current literature on elderly care, the gaps, inequities, increasing waiting times, failing expectations, shortfalls in insurance for various reasons, shortcomings in state’s health policies and budgetary allocations, poor infrastructure and insufficient resources to deal with the medical issues of the aged, etc, I am positive about the results being readily available.
It is no secret that at many places around the globe, the available resources and medical facilities for the elderly population are getting overwhelmed. There are such long waiting periods for even helping those elderly who are in need of such simple things like hearing aids. Isn’t t that we all certainly do have choices, and in that either we can keep toeing the line of whatever the current practice, conventional wisdom, and the conventional text tells us, or we once in a while look beyond as well, and try to see things for ourselves with our own current perspectives and experiences. Here I would like to take the example of relying on hearing aids around the world for patients suffering from age-related hearing loss (Presbycusis) that comes with aging.
Quite frankly, although I may be wrong about the usage of hearing aids, but I have always thought differently. When it already is a common knowledge that regular exposure to loud sound is one of the prime factors that destroys ‘hair cells’ within the inner ear, and the hearing loss is consequent to this destruction of hair cells, and that these hair cells are considered most essential for the conduction of sound, then why must we subject the remaining hair cells now to augmented sounds through hearing aids? Wouldn’t this management be putting at risk the remnant population of ‘hair cells’ through a louder and augmented sound from hearing aids? To my mind, this seems like a matter of pure convenience, expediency, and following the established course, which is being followed in the absence of any other genuine and scientifically appropriate modality of remediation for those becoming hard of hearing due to aging. Dr. Arul Rhaj Technique was a consequential development that had been submitted to your journal some years ago as a rapid response.
The question remains, are we interested to improve the present situation? If yes, then perhaps there first of all there is a need for a re-look at all established modalities of managing common morbidities that affect the elderly. It will be appreciated that many elderly may keep wandering in the elusive search of cure for their morbidities as they start weighing down on them, and when adequate respite is not achieved from the current established modalities of management. Many may turn now towards alternative medicine. Therefore, shouldn’t the society, the administrators, law and policy makers, NGOs, philanthropists, researchers and scientists around the world sit down together and decide the way forward, and if the present methods, treatment modalities, etc, is enough and sufficient.
As a way forward, would it be totally unreasonable to think of amalgamating various modalities after thorough understanding, careful planning, and research, and be brought under one umbrella for the sake of patients? Maybe it is also a time to look into some newer possibilities as well, that might have come by accidentally, and as nascent or incomplete any innovative technique may be, the world’s scientists and medical fraternity should be happy taking them on from here, discarding whatever is unsuitable, and improving whatever can be improved and accepted.
Another area for a bit of concern is about the health care getting fragmented due to super specializations, and this possibly becomes a bit difficult for some of the aged population who may have to visit different specialists for their morbidities. At times the consultations are spread out in both time and space, which may put a patient with multi-morbidity or the caregiver into a sort of spin and inconvenience and at times burdened with repetitions and poly-pharmacy, and the results thereof. Simply put, there is a need for the medical fraternity to decide and prepare an exhaustive, practical, and a reasonable curriculum for the geriatricians that can enable and ensure adequate training and matching knowledge and skills to all medical students who undertake the studies of primary care and of geriatrics, so that they are able and also prepared to resolve more by themselves, and refer less. Patients might love this change, with full backup support from specialists whenever needed.
Finally, the world would do well perhaps by not restraining and limiting the roles and scope of primary care physicians, general practice, experts in family medicine, and geriatricians. Remove them from virtual straightjacket that they are presently in, that is limiting their roles and scope. Don’t let their talents be wasted or left unused. They should be able to resolve more and refer less. The subtle interplay and the impact of the corporate, the industry, the insurance sectors, etc, will also have to managed and looked into, if one were to think about bringing about some welcome, effective, and meaningful changes for improving healthcare, while keeping only the best interests of the patients in mind.
Best regards.
Dr (Lieutenant Colonel) Rajesh Chauhan
Honorary National Professor IMA CGP, INDIA.
Competing interests: 1. These are my personal views and have no bearing to any and all the professional affiliations that I have. 2. I have written about many of my innovative medical techniques to your journal as rapid responses as I feel that these should not go with me to my grave. For the same reason I have also penned down two medical books on some of these innovative medical techniques, before my memory faded, and I was still around.
Dear Editors
I suggest that there are better terms to describe what different rapid respondents (to this article) meant in spite of obvious cross talk using the same phrase "health inequality" when "health inequity" may be more apt.
This extract from "Global Health Europe" explains the situation well:
"Inequity and inequality: these terms are sometimes confused, but are not interchangeable, inequity refers to unfair, avoidable differences arising from poor governance, corruption or cultural exclusion while inequality simply refers to the uneven distribution of health or health resources as a result of genetic or other factors or the lack of resources. "
http://www.globalhealtheurope.org/index.php/resources/glossary/values/17...
A good illustration of such differences in definition is found here:
http://www.sollis.co.uk/wp-content/uploads/2016/10/equity-vs-equality.jpg
Those covered by national health insurance schemes in various countries (NHS in UK, Medicare in Australia, etc) have access to health services more or less equally once they are in the system, regardless of gender, ethnicity, creed or religion. However the ability to benefit from these services is subject to individual autonomous decision making, socio-economic circumstances, social network; to ensure health equity, extra resources (including affirmative action) are needed to assist those perceived to be disadvantaged to make use of the same service provided by the health scheme. This may include travel assistance rebate or subsidy, income protection/supplementation and any other means-tested assistance schemes.
Obviously there will be health inequity, when those in higher income group can access private health services in addition to the national health scheme.
Obviously there is health inequality as well as inequity when comparing health services and outcome across the world. Much of the difference is due to uneven distribution of disposable wealth within the country as well as between nations. However, some of the apparent inequalities are also religious or societal.
Thus not all health inequalities can be solved by simply throwing large amounts of money at it, although money used at the right level can help a lot.
Competing interests: No competing interests
Yes, inequality is a social, health and environmental problem. But, the authors of this Editorial should have expressed a more coherent discourse about how we should solve this problem.
For instance, they state that "economists have also identified the negative effect of inequality on economic stability and growth". Here, the authors are assuming that economic growth is positive in terms of health outcomes and happiness for the whole planet. The crude reality, neglected in this Editorial, is that humans live in a planet with limited resources (energetic, mineral, fresh water). Therefore, in a fair world all rich nations should stop their economic growth NOW and initiate an ordered economic degrowth NOW. In this way, developing nations could raise their health standards (and happiness) closer to developed countries.
Sadly, we will not advance in the right direction if experts in inequality and health (i.e. in this Editorial) do not publicly recognize that economic growth (mostly confined to rich countries) is the main driver of planetary health inequalities. So, if you want to reduce the immorality of INEQUALITY, do not forget to vote for a degrowth party in your country. Difficult task, isn't it?
Competing interests: No competing interests
Is it not time that we acknowledged that health inequality is the inevitable and inescapable consequence of socio-economic inequality? And that there is no hope of remedying the former while the latter persists. The history of our NHS, whose main purpose was to reduce health inequality, surely demonstrates this beyond all doubt. As such it might help to abandon the phrase “health inequality” altogether as it implies that its cure lies in new health policies, re-organisation, more expenditure on health etc. whereas the evidence flatly contradicts this approach.
justin.robbins3@btinternet.com
Competing interests: No competing interests
Inequality is one of the overwhelming questions for now and any other time. Identifying the small number of billionaires who own such a large proportion of the world's resources should not distract us from the more relevant issue of inequalities in income and consumption where it is the top 10% (which includes most doctors) who use such a large share. If we believe that this is an important public health issue for which we have some responsibility then we should be campaigning for more even distribution of income which would almost certainly lead to us paying more tax and having to forgo some of the luxuries to which we have become accustomed.
In the meantime, Giving What We Can (www.givingwhatwecan.org) provides a practical suggestion at a personal level to help us even things up.
Competing interests: No competing interests
While I fully agree that inequality matters, is related to poorer health outcomes and ought to be tackled not just for economic and public health reasons but primarily for moral ones I disagree with the claim that global inequality is rising.
The Oxfam report cited measures wealth with data for the bottom 50% of the world's population coming from Credit Suisse's Global Wealth databook. The trouble with measuring wealth is that many people who are in debt are not who we'd think of as poor - a British medical student who owns a laptop and a bicycle but has £40,000 student debt is considered to have less wealth than a street child living in the slums of India with 10 rupees in their pocket.
According to Credit Suisse's data, the bottom 10% of global population wealth are of people with net debt ($1.1trillion) - primarily from North America ($371bn) and Europe ($612bn). 19.6% of German, 14.6% of Canadian and 9% of UK adults are in the bottom 50% of the world's wealth rankings.
Meanwhile the number of people living in absolute poverty, global income inequality (between countries), and global consumption inequality are falling. All of these should be celebrated while acknowledging that more needs to be done because the gap is still too large. Income inequality within countries is rising - and needs to be addressed, but misleading claims arising by measuring wealth inequality only questions the legitimacy of those calling for meaningful change.
References:
Oxfam Report:
http://policy-practice.oxfam.org.uk/publications/an-economy-for-the-99-i...
Credit Suisse Report:
http://publications.credit-suisse.com/tasks/render/file/index.cfm?fileid...
BBC More or less podcast:
http://www.bbc.co.uk/programmes/p04q68z3#play
Competing interests: No competing interests
Every year, hundreds of billions of dollars are spent in useless, counterproductive, or even harmful ventures.
Extreme World poverty could be quickly and easily eliminated, Millenium Goals achieved, if only corruption was fought against, and logical consensus was achieved in order to channel part of these funds to charitable deeds.
References
http://daily.financialexecutives.org/nearly-400-billion-lost-annually-du...
http://www.independent.co.uk/news/world/europe/corrupt-european-countrie...
http://www.politico.eu/article/corruption-costs-eu-990-billion-year-rand...
http://www.rand.org/blog/2016/03/the-true-economic-cost-of-corruption-in...
http://time.com/3908457/red-cross-six-homes-haiti/
http://www.huffingtonpost.com/2015/06/04/red-cross-haiti-report_n_751108...
http://www.theguardian.com/world/2015/jun/05/red-cross-haiti-black-hole-...
http://borgenproject.org/how-much-does-it-really-cost-to-eliminate-globa...
https://www.oxfam.org/en/pressroom/pressreleases/2013-01-19/annual-incom...
http://www.fao.org/3/a-i4959e.pdf
http://www.oecd-ilibrary.org/docserver/download/4313111ec005.pdf
http://www.theguardian.com/global-development/2015/jul/06/united-nations...
Competing interests: No competing interests
What absolute nonsense? If you care to search your consciences, redistribution is good as long as its someone else's money that is being redistributed. It would be another matter if it was your personal wealth.
The reason much of the world is impoverished is because of ideological support, for example, from ignorant British academics and Universities as they championed such foolish pursuits as decolonisation and independence for many countries who would never be able to support themselves without the skills of their so-called white masters. How foolish you all were to think that the process of colonialism could be placed in reverse and we would all live happily ever after.
Let us take Robert Mugabe in Zimbabwe, for example. We all know he inherited a country with money in the Bank, a large formal economy with a banking system, industry and agriculture etc. It didn't take long for his thugs to resort to genocide, murder and mayhem, all the while cheered on by the idiots in places like University of Edinburgh, bestowing honorary degrees upon him. Now he rules over a population reduced to self-imposed penury.
That is why there are huge disparities. Half the world is not capable of doing anything for itself, except destroying what has been built or has been created. And here you have people in places like the UK, the do-gooders, cheering on this destruction because it is righting the wrongs of the past. Not the wrongs in far off places, but the anger in people's hearts in Western capitals realising how they have failed in life to achieve anything of significance. Their self-imposed misery pleads for retribution, just as ISIS does when it destroys ancient monuments. It wants everyone to suffer their suffering.
It is time everyone took responsibility for their lives?
Competing interests: No competing interests
Forever, some in every society produced more than they needed to live, while others like the young and very old, or less able, produced less than they needed. Someone has always had to decide how the surplus of production was used. Those people used to be the slave owners (the slaves had no say), then the feudal lords (their tenants had no say), but are now the owners of capital (their workers have no say as they have entered into an agreement to take a wage and hand over their surplus to the boss).
When you have a surplus to use you can make donations to influence policy makers and regulators; or control the public discourse by mass media ownership; or fund think-tanks. All of these can be used to bring about changes which improve your ability to accumulate more of the surplus. And so it goes on, feeding on its own success, and leading to greater inequality of wealth.
We can recognise the problem, or tinker, often one progressive step forward and two regressive steps backward.
It's largely about who decides what to do with the surplus of production.
Competing interests: No competing interests
Essential reading : The Spirit Level.
The role of inequality in determining the incidence of debility, disease, and premature death, was eloquently described by Pickett and Wilkinson in 2009.(1) The multitude of ways in which that tendency finds expression were clearly described and referenced.
‘The Spirit Level’ may have as strong a claim to be, and remain, a text for our times, as did ‘Effectiveness and efficiency’, (2) more than four decades ago.
Only political initiatives will reduce inequality, so the choice of title for their editorial is a justified comment on the attention, or lack of it, that politicians have paid to their work. Such inattention is no surprise.
The muscle and power to initiate political change comes from outside any party which claims a parliamentary mandate in western democracies. Multinational, corporate elites decide parties’ and countries’ agendas, and fund changes, and enable corrupt practices, that will benefit themselves. (3,4,5) They habitually use language, often unremarked, that would now be labelled ‘alternative facts‘ by the USA administration.
The global investment strategist for the wealth management division of Rothschild recently explained that the world “has never been in a better place in terms of the average wealth of its population.” (6) Whether such use of the concept of ‘average wealth’ is misleading or worse, it illustrates the impossible gulf that a self interested elite places in the path of those who wish to explore the role of inequality in the maintenance of human suffering.
Earlier responses to this editorial suggest that the writers have never read The Spirit Level, which deals in detail with most of the issues they raise.
No doctor can afford to neglect the important causes of disease and debility in those who seek their help and advice, and a doctor’s reading should take account of this.
1 Richard Wilkinson and Kate Pickett, The Spirit Level, Allen Lane. 2009
2 Cochrane AL , Effectiveness and efficiency: Random reflections on health services. Nuffield Trust. 1972
3 David Cromwell, Why are we the good guys ? Zero Books 2012
4 John Cafferky, Lord MIlner’s Second War, Cafferky, 2013
5 Joseph Plummer, Tragedy and Hope 101, Bushfire Publishing 2014
6 Kevin Gardiner, quoted in Western Mail Business News, 19.2.2015
Competing interests: No competing interests