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'Punchily written ... He leaves the reader with a sense of the gross injustice of a world where health outcomes are so unevenly distributed' Times Literary Supplement 'Splendid and necessary' Henry Marsh, author of Do No Harm, New Statesman There are dramatic differences in health between countries and within countries. But this is not a simple matter of rich and poor. A poor man in Glasgow is rich compared to the average Indian, but the Glaswegian's life expectancy is 8 years shorter. The Indian is dying of infectious disease linked to his poverty; the Glaswegian of violent death, suicide, heart disease linked to a rich country's version of disadvantage. In all countries, people at relative social disadvantage suffer health disadvantage, dramatically so. Within countries, the higher the social status of individuals the better is their health. These health inequalities defy usual explanations. Conventional approaches to improving health have emphasised access to technical solutions – improved medical care, sanitation, and control of disease vectors; or behaviours – smoking, drinking – obesity, linked to diabetes, heart disease and cancer. These approaches only go so far. Creating the conditions for people to lead flourishing lives, and thus empowering individuals and communities, is key to reduction of health inequalities. In addition to the scale of material success, your position in the social hierarchy also directly affects your health, the higher you are on the social scale, the longer you will live and the better your health will be. As people change rank, so their health risk changes. What makes these health inequalities unjust is that evidence from round the world shows we know what to do to make them smaller. This new evidence is compelling. It has the potential to change radically the way we think about health, and indeed society.
In Baltimore's inner-city neighborhood of Upton/Druid Heights, a man's life expectancy is sixty-three; not far away, in the Greater Roland Park/Poplar neighborhood, life expectancy is eighty-three. The same twenty-year avoidable disparity exists in the Calton and Lenzie neighborhoods of Glasgow, and in other cities around the world. In Sierra Leone, one in 21 fifteen-year-old women will die in her fertile years of a maternal-related cause; in Italy, the figure is one in 17,100; but in the United States, which spends more on healthcare than any other country in the world, it is one in 1,800 (and now, with the new administration chipping away at Obamacare, the statistics stand to grow even more devastating). Why? Dramatic differences in health are not a simple matter of rich and poor; poverty alone doesn't drive ill health, but inequality does. Indeed, suicide, heart disease, lung disease, obesity, and diabetes, for example, are all linked to social disadvantage. In every country, people at relative social disadvantage suffer health disadvantage and shorter lives. Within countries, the higher the social status of individuals, the better their health. These health inequalities defy the usual explanations. Conventional approaches to improving health have emphasized access to technical solutions and changes in the behavior of individuals, but these methods only go so far. What really makes a difference is creating the conditions for people to have control over their lives, to have the power to live as they want. Empowerment is the key to reducing health inequality and thereby improving the health of everyone. Marmot emphasizes that the rate of illness of a society as a whole determines how well it functions; the greater the health inequity, the greater the dysfunction. Marmot underscores that we have the tools and resources materially to improve levels of health for individuals and societies around the world, and that to not do so would be a form of injustice. Citing powerful examples and startling statistics (“young men in the U.S. have less chance of surviving to sixty than young men in forty-nine other countries”), The Health Gap presents compelling evidence for a radical change in the way we think about health and indeed society, and inspires us to address the societal imbalances in power, money, and resources that work against health equity.
In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.
Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients' and providers' attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider-patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.
We hear plenty about the widening income gap between the rich and the poor in America and about the expanding distance separating the haves and the have-nots. But when detailing the many things that the poor have not, we often overlook the most critical—their health. The poor die sooner. Blacks die sooner. And poor urban blacks die sooner than almost all other Americans. In nearly four decades as a doctor at hospitals serving some of the poorest communities in Chicago, David A. Ansell, MD, has witnessed firsthand the lives behind these devastating statistics. In The Death Gap, he gives a grim survey of these realities, drawn from observations and stories of his patients. While the contrasts and disparities among Chicago’s communities are particularly stark, the death gap is truly a nationwide epidemic—as Ansell shows, there is a thirty-five-year difference in life expectancy between the healthiest and wealthiest and the poorest and sickest American neighborhoods. If you are poor, where you live in America can dictate when you die. It doesn’t need to be this way; such divisions are not inevitable. Ansell calls out the social and cultural arguments that have been raised as ways of explaining or excusing these gaps, and he lays bare the structural violence—the racism, economic exploitation, and discrimination—that is really to blame. Inequality is a disease, Ansell argues, and we need to treat and eradicate it as we would any major illness. To do so, he outlines a vision that will provide the foundation for a healthier nation—for all. As the COVID-19 mortality rates in underserved communities proved, inequality is all around us, and often the distance between high and low life expectancy can be a matter of just a few blocks. Updated with a new foreword by Chicago mayor Lori Lightfoot and an afterword by Ansell, The Death Gap speaks to the urgency to face this national health crisis head-on.
Health Sciences & Professions
Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others.
Mental, neurological, and substance use disorders are common, highly disabling, and associated with significant premature mortality. The impact of these disorders on the social and economic well-being of individuals, families, and societies is large, growing, and underestimated. Despite this burden, these disorders have been systematically neglected, particularly in low- and middle-income countries, with pitifully small contributions to scaling up cost-effective prevention and treatment strategies. Systematically compiling the substantial existing knowledge to address this inequity is the central goal of this volume. This evidence-base can help policy makers in resource-constrained settings as they prioritize programs and interventions to address these disorders.
An essential text for courses in public health, health policy, and sociology, this compelling book is a vital teaching tool and a comprehensive reference for social science and medical professionals.
A thought-provoking and evocative account that considers both the policies we think of as "health policyand those that we don't, The Political Determinants of Health provides a novel, multidisciplinary framework for addressing the systemic barriers preventing the United States from becoming the healthiest nation in the world.