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April 26, 2016

On Death and Money: History, Facts, and Explanations

Author Affiliations
  • 1Princeton University, Princeton, New Jersey
JAMA. 2016;315(16):1703-1705. doi:10.1001/jama.2016.4072

The finding that income predicts mortality has a long history. Nineteenth-century studies include Villermé1 on Paris, France, in 1817, Engels2 on Manchester, England, in 1850, and Virchow3 on Upper Silesia in 1847 through 1848. Modern analyses include the Whitehall study of British civil servants, whose status was measured by income,4 as well as similar findings for other European countries.5 Indeed, the mortality gradient by income is found wherever and whenever it is sought. Virchow’s statement3,6 that “medicine is a social science, and politics is nothing but medicine at a larger scale” has lost none of its resonance. By contrast, the medical mainstream, looking back to Koch rather than Virchow, emphasizes biology, genetic factors, specific diseases, individual behavior, health care, and health insurance.

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2 Comments for this article
ZIP Codes As Powerful Predictors
Mat Reidhead | Missouri Hospital Association
This research helps inform and expand on the growing body of evidence of the pervasive links between health, longevity and sociodemographic status. It reinforces the evidence of a strong, if not deterministic relationship between one’s community and health outcomes, further supporting the notion that an individual’s ZIP code can be more predictive of health than their genetic code.

Recently released research from the Hospital Industry Data Institute and Missouri Hospital Association illuminated the pernicious relationship between diabetes, geography and sociodemographic status in communities throughout the state. Although statewide in nature, some of the most compelling differences were found in
the state’s metros. This included two communities within the St. Louis area where a distance of ten miles leads to opposite ends of the socioeconomic spectrum, and marks a difference of 18 years in expected longevity.

Because of various barriers to access, many residents in low-income communities have limited health care choices. They rely on safety net hospitals across the continuum of care — primary to quaternary. This new research will be foundational to understanding the social complexities under which health care providers work to balance the idiosyncratic needs of a society and its implications for healthy life years.

Safety net providers should not be penalized for treating patients with the disease of poverty. The systems used to risk-adjust for this comorbidity are inadequate and the incentive programs designed to rate the quality of care delivered to low SDS populations could harm the institutions doing the most to bend the curve toward value. This could further impose perverse incentive structures around a system that is already stacked against society’s disadvantaged, reducing access further and deepening the chasms of wellness and life currently found between communities separated by miles, but worlds apart for health.

Link to HIDI research: http://bit.ly/1VIJ0Jw

Link to St. Louis area infographic: http://web.mhanet.com/userfiles/com.mha/image/Sociobiologic_Diabetes_STL_1500x3882___Source.png
CONFLICT OF INTEREST: Missouri Hospital Association
Health Inequity in India
Professor Dr Pranab Kumar Bhattacharya, Dr Sumana Mukherjee; Subrata Majumdar , Upasana Bhattacharya, Rupak Bhattacharya Ritwick Bhattacharya, | Professor of Pathology, Calcutta School of Tropical Medicine, Kolkata-700073, West Bengal, India --- Now Professor of Pathology at Murshidabad District Medical College, Berhampore, Station Road
In India, 63 million people sink into poverty yearly due to unaffordable health cost in paradoxical health care system, since independence 1947. In 1950, central government designed national health programme. Severe variations amongst states economic development, social & religious conditions, familial income inequities, political governance and willing led wide disparities in access to health services and population health. India initially accepted public sector led model, where services were free to all, emphasizing rural health care, when private sectors were limited to general practioners and charity run hospitals . It was pyramidal structure connected PHCs to S-D to district to government run tertiary medical colleges. Since 1947 economic planning regarded health expenditure was non-productive, poorly recorded. Public health needs to meet health of expanding population particularly in areas of stroke, CVD, cancer, diabetes, respiratory diseases, mental illness, suicide, HIV, tropical and infectious diseases and other chronic diseases and stressed health system beyond their capacity and private sectors proliferated, large corporate hospitals opened in urban aggregation and non engagement with primary health care providers, do not provide basic essential health care to largest sections of rural, suburban population & these are centres of all kinds of malpractices. Unaffordable for most Indians, with weak regulatory system, failing to set and enforce quality, cost standard inadequate, inappropriate, unethical care & cure. Health insurance available to small proportions of workers and when poverty level is very high i.e. 10% of health care expenditure is out of pocket spending.

All these are because economist & policy makers do not recognize health as essential for economic development and health is not a legislated right in India. NRHM focuses on maternal & child health. No attention is even paid to communicable, non-communicable, tropical & mental diseases which lead to largest death & disability in India. In 2012-2017 planning Government of India focussed & recommended increased public finances from 1% of GDP to 2.5% of GDP through toy funding supplemented by ESI & EPJ & free provision of essential drugs & diagnostics and referral system. India must address the enactment of right to health through parliamentary legislation and allow the state what services that the right should translate into welfare scheme. India & West Bengal must engage community care instead of mushrooming growth of private care. Improvement of public care & cure, improvement of quality health care personnel, Generalists, Specialists, nurses, GDAs, shortfalls & more training institutions.

 Per Capita (US $) 61
 Percentage of GDP 4
 Amount of pocket private health expenditure 86
 Public services(% of total) 33
 Percentage of population insured in 2015 17 (Government 12%+ employee 3%+ individual 2%)
 No of Physician per 1000 population in 2015 7
 Life expentancy at birth 66
 Annual no. of death per 1000 population 17
 No. of infant death per 1000 live birth 8
 No. of death per 1000 live birth in 2014 41
 No.of maternal death per 100000 live birth in 2014 190