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Issue #2
December 2, 2008

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No more health disparities

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by LaTonya Bynum - USA

Health disparities are differences in the quality of health and/or health care that people experience as a result of social factors like race, ethnicity, age, income and class.

Health inequality reflects social inequality, including unequal access to health and social services.

How serious is it?

Disadvantaged populations suffer higher infant death rates, higher rates of chronic and disabling diseases, and lower life spans. Despite greater need, they are less likely to receive regular medical care and are more likely to receive inappropriate or insufficient care.

In the USA, compared with the White population:

  • African Americans suffer 10 times the rate of new AIDS cases, yet are less than half as likely to receive combination drug therapy. As a result, HIV infection is the leading cause of death for African Americans between the ages of 25 and 44.
  • African American infants die at a rate that is between two and three times higher.
  • American Indian and Alaska Native women are twice as likely to lack prenatal care.
  • Elderly Asians are half as likely to be immunized against pneumonia.

Why does health inequality matter?

Health inequality robs individuals of their health and vitality. Moreover, as health inequality increases, the health of the entire population suffers.

A study of 282 urban areas in the U.S. found that the greater the difference in income, the more the death rate rose for all income levels, not just for the poor. Researchers calculated that if income inequality could be reduced to the lowest level found in the United States, it would save as many lives as would be saved by eradicating heart disease or preventing all deaths from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide combined!(1)

What can we do?

There are three R’s to eliminate health disparities:

1) Recognize: We have to educate ourselves and others about the problem of health disparity.

2) React: We have to organize activist networks like IHWPOP, where we can learn from each other and work together to make an impact.

3) Reduce: We have to find ways to reduce health inequality at the local and international level.

All over the world, health workers see inequality in health and health care. These are serious problems that we can and must do something about. But we can't do much on our own. We need to organize.

One way that you can help is to join IHWPOP and forward this newsletter to others who might be interested. Together, we can work to eliminate inequality in health and in healthcare.

For more on health disparities see:
"Unnatural Causes: Is Inequality Making Us Sick?"
The American Medical Student Association
The Office of Minority Health and Health Disparities (OMHD)


Penny wise and pound foolish

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by Lucy Rosenblatt - USA

Recently, I testified at a public hearing before a committee set up by the Connecticut state legislature to evaluate health-care delivery in the state. I was given three minutes to tell my story. Here is my testimony:

My name is Lucy Rosenblatt, and I am a Licensed Professional Counselor and a Licensed Alcohol and Drug Counselor.

I began working in a residential alcohol and drug treatment program in 1982 that was part of a private psychiatric hospital here in CT. My work was challenging but rewarding. I treated all kinds of people – teachers, nurses, factory workers.

Addiction is an equal opportunity disease. That is not to say that everyone had equal access to our facility. If you were poor and had no insurance you were more likely to not get treatment, to end up in jail or to go to one of the State Hospitals.

Not everyone got better either. Addiction can be a chronic and recurring illness. But, if you had insurance, and if you were motivated you could get what you needed.

At that time, the staff/patient ratio was 1 to 5. Patients stayed for 28 days - more if they needed it. Treatment involved a full complement of therapies – individual, group, family, creative therapy, nutritional counseling – to name a few. Many of the patients had support in their workplaces from both the Employee Assistance Program and the union – if there was one – to help them transition back into their lives.

"Managed care"

Everything began to change in the early ‘90s with the introduction of “managed care” by the insurance companies. By the time I left in 2004, the institution had been bought and sold four times in an effort to remain profitable. The changes made with each sale did not benefit either the patients or the staff.

In 2004 staff/patient ratios were down to 1 to 15, patients were being authorized for only 5 to 10 days of residential treatment instead of 28, and people who still had jobs and homes had to fail at outpatient treatment, sometimes losing those jobs and homes, before they were  authorized for residential treatment.

The patients we did have needed MORE not LESS treatment, and yet the clinical program was reduced to bare bones. Many of the therapeutic modalities, such as creative therapy, recreational therapy and nutritional counseling, were cut to save money. And primary therapists like myself spent more and more of our time talking to insurance company representatives to justify another day or two of treatment for our patients rather than spending that time with the patients.

Although I wasn’t ready to retire, I could no longer continue to work in that setting. People relapsing – and sometimes dying – had always been part of the experience of doing this work. But, people relapsing and dying because it wasn’t profitable to give them what they needed – that was unconscionable.

Rising stress

Today, I work as a psychotherapist at an outpatient clinic in Hartford and in my own private practice in West Hartford.

The people I see are often dealing with troubling life stresses that lead to symptoms of anxiety and depression. For many of the people I see in Hartford, that life stress is the result of being at the bottom of an inequitable socioeconomic system. They are able to see me because they are receiving government-subsidized healthcare through Medicaid and Husky. But there are many more on long waiting lists due to under-funding of these programs.

In West Hartford, middle class people are increasingly worried about health care. Their health insurance premiums and co-payments keep rising, even though my rate of reimbursement has not increased. I’m also seeing more people who pay me out of pocket because they are afraid to use their insurance. They’re worried that if they lose their jobs and have to buy individual policies they’ll be denied insurance coverage due to pre-existing conditions. This is not an idle fear.

Psychotherapy is often seen as optional, so people stop coming or they come less often.  They get worse. They may have to be hospitalized, or they become physically ill and have to be treated for the many diseases and ailments that are caused by chronic stress.

Penny wise and pound foolish. I have seen this over and over again.

According to the World Health Organization, the United States spends 50 percent more on healthcare than any nation in the world, yet we rank 37th in healthcare performance and 72nd in overall level of health. That is INSANITY, doing the same thing over and over again and expecting different results.

We need affordable, accessible, quality healthcare for all that includes mental-health and substance-abuse treatment. I believe that can only be delivered by a single payer system that puts people over profits.


Job losses amid reckless spending


by Ned MacDermott - USA

On November 24, Doug Strong, CEO of the University of Michigan Hospital and Health Centers, sent an email to all hospital employees announcing plans to lay off nearly 80 workers within the next month. This comes after a selective hiring freeze instituted in late October for all "non-patient care" workers. Strong offered the following explanation for the hiring freeze,

"while we have a strong overall financial picture... our revenue is not keeping pace with our activity as we are experiencing less growth than expected... Every percent we fall short of our 3 percent target represents $19 million dollars... It’s the operating margin that drives our ability to grow our business for patients who seek care from our excellent faculty and staff."

Strong neglects to mention where these many millions of dollars are going.

Last year, the hospital opened a plush new Cardiovascular Center, a truly beautiful building, granted, but it's hard to justify $215 million for a building that houses only 48 inpatient beds.

Even more money is being blown on the new C.S. Mott Children's Hospital, the projected cost of which recently shot up from $523 to $754 million. The new hospital will have more than double the bed capacity of the current one. However, the current hospital is still perfectly good and rarely approaches full capacity.

"Non-patient care" workers include food service workers, transporters, clerks and custodial staff, among many others. Although we do not provide direct patient care, we play a vital role in ensuring patient safety and quality care.

The Univeristy of Michigan Hospital prides itself on putting "patients and families first." But by cutting the jobs of the workers who make this hospital run, Doug Strong is asking patients and families to accept a cut in the quality of care they receive.

Doug Strong's half-million dollar salary is a drop in a bucket compared to the billion dollars he has essentially wasted on two redundant facilities. Nevertheless, in these tough times, it's only fair that all “members of the hospital family” be asked to make sacrifices.

Mr. Strong, in the interest of helping our hospital resolve its financial troubles, would you be willing to take a 90 percent pay cut and live on a worker's salary? Fifty thousand dollars may not be much, but it’s more than many of those workers, who will lose their jobs next month, would make in a year.

Ned MacDermott is a "non-patient care" worker at the University of Michigan Hospital in Ann Arbor, Michigan.


Desperate needs, no funding

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by Sarah Anne Edwards - USA

"I think the insurance companies are trying to put us out of business," my colleague told me recently over lunch. She can't get them to pay for the counseling sessions to which her clients are entitled. Months go by after she submits the necessary information, and she can't track down anyone to address the endless delay.

I recently decided to venture into the world of third-party payments for mental-health counseling. Like many of my colleagues, I had tried to avoid dealing with the endless red tape, treatment limitations and the medical-model approach to mental health imposed by insurance companies.

Few people have insurance coverage for mental-health problems, and this may not change despite recent passage of the Mental Health Parity Act. But as more people lose their jobs, their homes and their health coverage, they desperately need counseling to help them deal with the paralyzing stress, pressing decisions and basic changes they must make to survive. Barely managing to keep a roof over their heads, they have little or no discretionary income to pay for counseling.

In an effort to serve more people in my area, I began the difficult and time-consuming process of negotiating the piles of forms needed to qualify to receive payment from private insurance companies, Medicaid (a California assistance program) and Medicare.

Months later, as I wait for the necessary paperwork and approvals to be completed, I must agree with my colleague. Not only are the insurance companies blocking our efforts to be paid for our services, so are the various levels of government that should be helping us.

In my area, only one agency offers mental-health counseling through Medicaid. That agency is located in another town and refuses to use the services of independent counselors like me and my colleague who could help clients here in our community.

We decided to use a billing service, so we can be paid to provide treatment for people who qualify. If that doesn’t work, we will be forced to find other sources of income, and help those in need “in our spare time.” But that's not a real solution.

Given that the nation and most counties, cities and states are running financial deficits, I don't see how we can solve this problem. Nevertheless, the four mental-health practitioners in our small community are coming together to support each other and discover ways to increase the availability of mental-health services in our area.

Read more about the Mental Health Parity Act


Las desigualdades sociales matan a la gente

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por Sergi Raventós - España
Publicación original

El informe de la comisión de los determinantes sociales de la salud

La justicia social no es sólo una cuestión ética o de filosofía política, sino de vida y muerte. "La combinación nefasta de pobres políticas sociales y circunstancias económicas injustas está matando a la gente a gran escala", afirmó el presidente de la Comisión de la Organización Mundial de la Salud (OMS), Sir Michael Marmot, al presentar el Informe sobre Determinantes Sociales de la Salud el pasado 28 de agosto en Ginebra.

El documento recoge que "no existen razones biológicas" para que la esperanza de vida varíe hasta más de 40 años de país en país o en varias decenas de años en una misma ciudad dependiendo del barrio en el que viva una persona (1). "Las condiciones sociales en las que la gente nace, vive y trabaja son el determinante más importante para tener una buena o mala salud, o una larga vida productiva o una de corta y mísera", señaló la directora de la OMS al recibir el informe de la Comisión.

El número de personas que ha intervenido en este Informe ha sido muy numeroso: científicos, expertos de la OMS y otros organismos de la ONU, políticos y también miembros de distintas ONGs.

La desigualdad en salud es la peor epidemia de nuestro tiempo

El impacto de la desigualdad social en la salud es terrible. En el informe hay muchos ejemplos: una niña de Lesotho en Sudáfrica vive media vida en comparación con una nacida en Japón. El riesgo de que una mujer sueca muera durante el embarazo o el parto es de 1 entre 17.400, mientras que el de una afgana es de 1 entre 8. En Uganda, 200 de cada 1.000 niños nacidos en los hogares más pobres morirán antes de su quinto cumpleaños, mientras que en los países ricos sólo morirán 7 de cada 1.000.

Salud mental y trabajo

También  los problemas de salud mental aparecen correlacionados con la precariedad en el empleo (contratos de trabajo temporal, trabajo sin contrato y trabajo a tiempo parcial) y el estrés laboral está relacionado con el 50% de las cardiopatías coronarias (2).

Las causas

Las causas de la salud y la desigualdad son múltiples. Para la que podemos denominar “ideología biomédica dominante” las principales causas que en la actualidad producen los problemas de salud y por extensión la desigualdad en salud, tienen que ver con las causas genéticas, las “elecciones personales”, como las prácticas dietéticas o el hábito de fumar o, en otro plano, con el acceso y calidad de los servicios sanitarios disponibles. Sin embargo, todas esas causas no pueden explicar las desigualdades en la salud de la población. Las causas fundamentales se encuentran en otra parte, en el complejo entramado de factores económicos y políticos presentes en cada comunidad. (3)

A quién afecta más las desigualdades en la salud?

 En general, afecta sobre todo a los grupos más explotados, oprimidos o excluidos de la sociedad. Es decir, a los trabajadores y trabajadoras más pobres, a las clases sociales más explotadas (por ejemplo en situación de precariedad laboral). Y esto no es ningún secreto. Hace ya tiempo que hay abundante investigación al respecto. Las desigualdades se producirían porque las clases sociales más bajas estarían más expuestas a situaciones menos saludables que las clases sociales altas. Las clases sociales más bajas trabajan en ocupaciones que están más sometidas a factores de riesgos físicos, químicos y psicosociales, habitan en residencias de menos calidad y viven en áreas de más contaminación ambiental (4).

Llamamiento urgente a los gobiernos

Los autores del informe instan a los gobiernos, a la sociedad civil, a la OMS y otras organizaciones a unirse para adoptar medidas encaminadas a mejorar la vida de los ciudadanos, y plantean el objetivo de lograr la equidad sanitaria "en el lapso de una generación". "Pero si continuamos como hasta ahora, no tenemos ninguna posibilidad de lograrlo", advierten.
La combinación tóxica de factores sociales, demuestra la Comisión, daña la salud de las personas en peor situación social y empeora también otros factores de riesgo ya que, por ejemplo, las clases sociales más pobres tienen menos recursos y oportunidades de alimentarse adecuadamente, fuman y beben en exceso con mayor frecuencia debido a su estrés, sus servicios sanitarios son más incompletos y de menor calidad. Todo ello daña a su biología, genera enfermedad y aumenta el riesgo de fallecer. (5).

Perspectivas del informe

A pesar de los datos apabullantes que se exponen en el informe y de la importancia que puedan tener en cuanto a reconocer que existen desigualdades en salud, que se producen fundamentalmente por causas económicas y políticas y que también podemos actuar políticamente para cambiar esa realidad, es difícil poder pensar que en un contexto como el actual de crisis hipotecarias y financieras, de dedicación de miles de millones al rescate de la banca, de cierre o ajustes de empresas y de pérdidas de miles de puestos de trabajo, este informe vaya a tener un papel muy importante en la agenda política, a pesar de la estrecha relación existente entre los factores sociales y económicos con la salud, que se ponen bien de manifiesto en dicho documento.

Diferencias con otros informes?

En éste informe, a diferencia de otros, se llegan a decir algunas cosas bastante claras, sin tantas ambigüedades (muy característico de estos informes): “Esa distribución desigual de experiencias perjudiciales para la salud no es, en ningún caso, un fenómeno “natural”, sino el resultado de una nefasta combinación de políticas y programas sociales deficientes, arreglos económicos injustos y una mala gestión política”. Y las orientaciones también son concisas: “la comercialización de bienes sociales esenciales como la educación y la atención médica genera inequidad sanitaria. La prestación de tales bienes sociales esenciales ha de estar regida por el sector público, y no por la ley del mercado.” O también, en el mismo, podemos encontrar  más adelante: “A medida que aumenta la globalización y la interdependencia entre los países, los argumentos a favor de una estrategia mundial en materia de impuestos cobran mayor peso.”(6)

Transformar las estructuras

Ahora bien, como señalan Joan Benach y Carles Muntaner: “sin transformar la estructura económica y política a nivel nacional e internacional, es decir las desigualdades de poder y de recursos económicos que atenazan al planeta no será posible reducir las desigualdades en salud.

Algunas propuestas inmediatas

Por ello hace falta empezar por aumentar la igualdad social con un reparto más equitativo de la riqueza y una redistribución más igualitaria del poder internacional.”Necesitamos por tanto políticas fiscales progresivas y políticas sociales que reduzcan el desempleo, la precariedad laboral y la marginación y que incrementen el acceso y la calidad de la educación, la vivienda y los servicios sanitarios entre quienes más lo necesitan… si lo que se quiere conseguir es que la población mejore sustancialmente su nivel de salud y se reduzca la desigualdad, inevitablemente habrá que hacer frente a intereses muy poderosos y cambiar de forma drástica la mayoría de los sistemas políticos y económicos actuales” (7). Unas palabras que exponen claramente cuál es el camino por donde tendrán que ir de verdad las mejoras para la población. Opción que no parece que sea la prioridad de los representantes políticos, en estos momentos de rescates millonarios de la banca.


(1)  Este informe se puede consultar

(2) El resumen del informe puede leerse en castellano

(3) Ver entrevista con Carles Muntaner y Joan Benach

(4) Davey Smith G. et al. (1996): “Socioeconomic differentials in mortality risk among men screened for multiple risk factor intervention trial: I White men”. Am. J. Public Health 86: 486-496.

(5) Ver resumen del informe en castellano

(6) ibid.

(7) Ver entrevista con Carles Muntaner y Joan Benach

Sergi Raventós trabaja en una Fundación sociosanitaria de salud mental en Barcelona desde hace años, de la cual es representante sindical. Actualmente realiza el doctorado en Sociología en la Universidad Autónoma de Barcelona.


Stop drugging our children!

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by Susan Rosenthal - Canada

Between 2000 and 2007, prominent psychiatrist Dr. Joseph Biederman was paid over $1.6 million by drug companies. Biederman’s work is credited for the explosive rise in the use of powerful anti-psychotic medicines in children.

During the same period, Dr. Frederick K. Goodwin – former Director of the National Institute of Mental Health and host of the popular public radio program “The Infinite Mind” – received more than $1.3 million from drug companies. Dr Goodwin denied being biased. Because he consulted for so many drug companies, he could not be accused of favoring any one of them! (1)

The drugging of adults and children has gone hand-in-hand with rising inequality.

Inequality gets worse with economic crisis. Those at the bottom of the social ladder are more likely to be laid off, to lose their homes and to suffer severe financial stress. Their health and their children’s health suffers.

Instead of helping those in need, the system enforces compliance by incarcerating and drugging those who protest the unfairness of their lives.

Say yes to OUR drugs

In the 1980s, the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) was created to allow the drugging of children who won’t sit still and pay attention in school. Prescriptions for school-aged children peak in September, when school starts, and drop in June when school ends.

The drugs most commonly prescribed for children with ADHD are amphetamines and methylphenidate [Ritalin]. According to the U.S. Drug Enforcement Administration (DEA),

“In clinical studies…neither animals nor humans can tell the difference between cocaine, amphetamine, or methylphenidate when they are administered the same way at comparable doses. In short, they produce effects that are nearly identical.”

In 1993, 275 children out of every 100,000 were taking psychiatric drugs. By 2002, this number was five times higher. In some deprived areas, one in four school-aged children is being drugged.

Child drugging is now so acceptable that access to insurance benefits, medical treatment and social services can depend on “having a diagnosis.” Courts can force children to take drugs. Parents who refuse to drug their kids have been charged with child abuse and threatened with the loss of their children.

From the mouths of babes

In the story of the emperor who wore no clothes, only a child spoke the truth. The adults all agreed that the emperor was wearing fine garments, but the child could see that he was stark naked. The child was scolded for revealing what the adults feared to acknowledge.

Today, when children protest that their needs are not being met, they are silenced with medical labels and mind-numbing drugs.

This is outrageous. Children must come first. They are the only future we have.

See also Mental Illness or Social Sickness?

Susan Rosenthal is a physician-psychotherapist who works in the Toronto area

All of the material in this newsletter is made available to the public under the terms of the Creative Commons Code. Readers are welcome to share and use this material for non-commercial purposes, as long as they acknowledge the author(s) and International Health Workers for People Over Profit



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