Monday, January 7, 2019

The poor ye shall always have among you (but not for as long as the rich)

In every corner of the world, the rich live longer than the poor. This is equally true in the United States. In mid-December, the Associated Press analyzed life expectancy collected by the National Center for Health Statistics by census tract. The 65,662 census tracts are geographic areas in which about 4000 people live. The AP found that high unemployment rates, low rates of graduation from high school, low household income and higher percentages of black or Native American residents all were associated with lower life expectancy. While life expectancy varied by state – Hawaii had the highest life expectancy at 82 years and Mississippi the lowest at 74.9, with the national average being 78.6 -the in-state variation by census tract was much more dramatic. In New York, children born in the northern half of Roosevelt Island between 2010 and 2015 had an estimated life expectancy of 59, while those born in Chinatown in lower Manhattan (6 miles away) were expected to live 93.6 years! Massachusetts is a generally wealthy and well-educated state, and the average life expectancy is 80.7 years, but within the state, huge variations also exist. In the census tract with the lowest life expectancy, 45% did not finish high school and 13% were unemployed; the people were evenly split between Hispanics and non-Hispanic whites. In the neighborhood with the highest life expectancy, only 1% did not finish high school, 2.7% were unemployed and the population were mostly white.
Why is this? For people to be healthy, it is clearly helpful to have adequate access to medical care. They need to have doctors and hospitals available, get immunizations, get appropriate screening tests and be able to afford their prescribed medications. They also need to have access to good food and housing and to have good health habits, including exercise, smoking avoidance and avoidance of excess alcohol and drugs.
The disparities are many and varied. A study published in JAMA Network Open in November 2018 found that people who suffered cardiac arrests in the poorest neighborhoods around the country had longer delays in getting emergency care than did similar patients in richer neighborhoods. Maternal morbidity, which I discussed in a prior blog, more often affects poorer black women. A study published in the journal Obstetrics and Gynecology found that severe morbidity occurred almost twice as often in black mothers than in non-Hispanic white mothers.
Living in a neighborhood with lots of trees and other greenery was found to improve many markers of cardiovascular health in a study published on-line in the Journal of the American Heart Association last month. Not only greenery but “greens” are important. People living in “food deserts,” as I describe in Prescription for Bankruptcy, have a higher burden of cardiovascular risk factors, and are much more likely to be readmitted to hospital after being treated for congestive heart failure.
Social media were abuzz in November when a 60-year old woman was denied being listed for a needed heart transplant because of her finances and was advised to start a fund-raising effort. After she raised more than $30,000 via GoFundMe, she was added to the transplant waiting list. Hospital officials defended their behavior, which is very common at all transplant centers, by noting that patients must be able to afford expensive medications after transplant to prevent rejection or the organ, which is in very limited supply, may be wasted.
Among the many diseases that disproportionally affect the poor, cancer may be the cruelest. The poor are less likely to get early screening and more likely to delay seeking care because of cost concerns. Cancer treatment often makes the patients unable to work, a huge problem for those with limited resources on which to fall back.
Gallup’s annual Health and Healthcare poll last year found that 29% of Americans held off seeking medical care because of financial concerns, and 19% said the delay involved a serious condition. Not surprisingly, this behavior varied by income. Those who said they delayed medical care due to cost were 22% when family income was $75,000 or more, 34% when it was $30,000-$74,999 and 38% when it was less than $30,000.
If we can bring the cost of care down closer to that of other Western democracies, we can surely see that all our fellow citizens have access to care. We must also begin to chip away at the social factors that play such a key role.

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