Andrew Haines

Poverty and Ill Health: Physicians Can, and Should, Make a Difference

Poverty and social inequalities may be the most important determinants of poor health world-wide. Socioeconomic differences in health status exist even in industrialized countries where access to modern health care is widespread [1]. In this paper, we make a formal argument for physician concern and action about poverty based on the following assertions. Physicians have a professional and a moral responsibility to care for the sick and to prevent suffering. Poverty is a significant threat to the health of both individual persons and populations; thus, physicians have a social responsibility to take action against poverty and its consequences for health. Physicians can help improve population health by addressing poverty in their roles as clinicians, educators, research scientists, and participants in policymaking. Concepts of Poverty and Health Poverty is a multidimensional phenomenon that can be defined in both economic and social terms. An economic measure of poverty identifies an income sufficient to provide a minimum level of consumption of goods and services. A sociologic measure of poverty is concerned not with consumption but with social participation [2]. Poverty leads to a persons exclusion from the mainstream way of life and activities in a society [3]. There is a difference between absolute poverty, which implies a lack of resources deemed necessary for survival in a given society, and relative poverty, which is defined in relation to the average resources available in a society. Economic measures are easy to obtain, but social measures may provide a better understanding of the causes and consequences of poverty. Steps have been taken toward the development of indices of deprivation, which have promising uses in health services and public health research [4]. In 1978, the World Health Organization (WHO), in the Alma-Ata Declaration, spelled out the dependence of human health (defined broadly) on social and economic development and noted that adequate living conditions are necessary for health [5]. Despite their knowledge of this, governments and major development organizations have largely continued to view health narrowly as a responsibility of the medical sector, outside the scope of economic development efforts. Consequently, governments have encouraged many large-scale but narrowly focused economic development efforts, ignoring the connection between poverty and health [6]. In developed countries, governments promote various practices, such as heavy pesticide applications, that are designed to increase economic development and competitiveness but that are environmentally unsound and personally unhealthy. Poverty Causes Death and Illness on a Massive Scale During the second half of the 1980s, the number of persons in the world who were living in extreme poverty increased. Currently, extreme poverty afflicts more than 20% of the worlds population. A recent report from WHO points out that up to 43% of children in the developing world-230 million children-have low height for their age and that about 50 million children have low weight for their height [7]. Micronutrient malnutrition (deficiencies of vitamin A, iodine, and iron) affects about 2 billion persons worldwide. It has been estimated that if developing countries enjoyed the same health and social conditions as the most developed nations, the current annual toll of more than 12 million deaths in children younger than 5 years of age could be reduced to less than 400 000. An average person in one of the least developed countries has a life expectancy of 43 years; the life expectancy of an average person in one of the most developed countries is 78 years [7]. This is not to deny that real gains in health have occurred in recent decades. For example, since 1950, life expectancy at birth in several developing countries has increased from 40 to more than 60 years. Similarly, worldwide, mortality rates for children younger than 5 years of age decreased from 280 to 106 per 1000, on average. Some countries show much sharper declines [7], but indices of health in these countries still fall far short of those in wealthier nations. Poverty and Sustainable Development The relation between poverty and health is complex, and we believe that it is best understood in the framework of a new notion of ecosystem health, which places poverty and health in the nexus of environment, development, and population growth [8]. Ecosystems provide the fundamental underpinning for public health in both developed and less developed countries, not only through food production, for example, but also through their roles in economic development. For instance, they supply forest resources and biomass fuels and serve as habitats for the vectors of disease [9]. Sustainability is produced by using resources in ways that meet the needs of current populations without compromising the ability of future generations to meet their own needs [10] and is predicated on the need to ensure a more equitable sharing of todays resources. Meeting the needs of the worlds poor implies limitation of the current use of resources by industrialized nations. Barriers to the benefits of development include rapid population growth, environmental degradation, and the unequal distribution of resources. At one extreme, traditional, preindustrial societies are characterized by relatively high birth rates coupled with high death rates attributable to acute infectious diseases and the hazards of childbearing; this leads to slow population growth. At the other extreme, in the most developed countries, population stability has occurred. In the intermediate situation, in less developed countries, population stability has not been reached, and the global population thus continues to increase. In some less developed countries, a demographic trap exists in which the development of resources cannot keep pace with the requirements of the growing population and poverty is worsened [11]. The most developed countries escape the trap by buying additional essential resources in the global marketplace to make up the difference. Environmental degradation exaggerates the imbalance between population and resources, increases the costs of development, and increases the extent and severity of poverty. For example, the need for fuel wood, timber for export, and farmland results in deforestation, which increases soil erosion, flooding, and mud slides and reduces agricultural productivity. As a result, biological diversity is lost, production becomes increasingly reliant on pesticides and fertilizers, and use of expensive fossil fuels increases. Water is a critical resource. In Punjab, the breadbasket of India, the major aquifer is decreasing at a rate of 20 cm per year, threatening health by reducing agricultural productivity and the supply of clean water [12]. Economic development without regard to long-term environmental and social consequences also threatens sustainability by damaging the systems that sustain healthy communities. Inequalities in Health Are Socially Determined The strong and pervasive relation between an individual persons place in the structure of a society and his or her health status has been clearly shown in research conducted over the past 30 years [13-16]. In 1973, Kitagawa and Hauser [17] published convincing evidence of an increase in the differential mortality rates according to socioeconomic level in the United States between 1930 and 1960. They found that rates of death from most major causes was higher for persons in lower social classes. In Britain, research into health inequalities was summarized in 1980 in The Black Report [18], which was updated in 1992 [19] and is currently under review by an official working group. The report was prepared by a labor government-appointed research working group chaired by Sir Douglas Black, formerly Chief Scientist at the Department of Health and, at the time, President of the Royal College of Physicians. The Black Report concluded that there are marked inequalities in health between the social classes in Britain (Figure 1). Marmot and colleagues, in the well-known Whitehall studies of British civil servants begun in 1967, showed that mortality rates are three times greater for the lowest employment grades (porters) than for the highest grades (administrators) and that no improvement occurred between 1968 and 1988 [20-22]. Figure 1. Comparison of standardized mortality ratios for men 15 to 64 years of age by social class over five decades in England and Wales. Such findings could, in theory, be due to differences in age, smoking, nutrition, types of employment, accident rates, or living conditions, but the Whitehall study participants were from a relatively homogeneous population of office-based civil servants in London. They had largely stable, sedentary jobs and access to comprehensive health care. A second observation of the Whitehall investigations, confirmed by the Multiple Risk Factor Intervention Trial (MRFIT) studies in the United States, is that conventional risk factors (smoking, obesity, low levels of physical activity, high blood pressure, and high plasma cholesterol levels) explain only about 25% to 35% of the differences in mortality rates among persons of different incomes (Figure 2) [23, 24]. Figure 2. Income and age-adjusted mortality rates among 300 000 white men in the United States. An equally striking finding is Wilkinsons observations of the relation between income distribution and mortality [25, 26]. Wilkinson assembled two sets of observations. First, he found no clear relation between income or wealth and health when comparisons were drawn between countries (for example, there is no relation between per capita gross domestic product and life expectancy at birth in comparisons between developed countries at similar levels of industrialization). But Wilkinson also showed a strong relation between income inequality and mortality within

Effects of fish oil supplements in NIDDM subjects. Controlled study.

The aim of this study was to evaluate the effects of a fish oil preparation (MaxEPA) on hemostatic function and fasting lipid and glucose levels in non-insulin-dependent diabetic (NIDDM) subjects. Eighty NIDDM outpatients aged 55.9 yr (mean SD 11.5 yr) participated in a prospective double-blind placebo-controlled study of MaxEPA capsules (10 g/day) or olive oil (control) treatment over 6 wk. Patients received either MaxEPA or olive oil in addition to preexisting therapy. Metabolic and hemostatic variables were measured before treatment and after 3 and 6 wk. Platelet membrane eicosapentaenoic acid (EPA) content increased in the treatment group (P < 0.001). MaxEPA supplementation was associated with a significant fall in total triglycerides (P < 0.001) but did not affect total cholesterol (P = 0.7) compared with control treatment. Fasting plasma glucose increased after 3 wk (P = 0.01) but not after 6 wk (P = 0.17) treatment with MaxEPA. Spontaneous platelet aggregation in whole blood fell in the MaxEPA group (P < 0.02) after 6 wk, but there were no changes in agonist-induced platelet aggregation, thromboxane generation in platelet-rich plasma, or plasma P-thromboglobulin and platelet factor IV levels. An increase in clotting factor VII (P = 0.02), without changes in fibrinogen or factor X levels, occurred in the MaxEPA group. Similar reductions in blood pressure were observed in both groups. Dietary supplementation with MaxEPA capsules (10 g/day) in NIDDM subjects is associated with improvement in hypertriglyceridemia but with deleterious effects in factor VII and blood glucose levels. Most indices of platelet function are unaffected by this therapy.

Association of proinsulin-like molecules with lipids and fibrinogen in non-diabetic subjects — evidence against a modulating role for insulin

SummaryElevated concentrations of proinsulin-like molecules, other than insulin, may be associated with abnormalities of cardiovascular risk factors, promoting atherogenesis and thrombosis. Using specific assays we examined the relationship of levels of insulin, intact proinsulin and des-31,32 proinsulin to blood pressure, lipids, fibrinogen, factor VII and albumin excretion rate in 270 europids with normal glucose tolerance. After correcting for age and body mass index, fasting and 2-h insulin concentrations were significantly associated with those of total and LDL-cholesterol (r=0.18–0.22), HDL-cholesterol (both r=−0.20) and triglycerides (r=0.21 and 0.18), but not with blood pressure. Concentrations of intact and des-31,32 proinsulin showed significant associations with those of total and LDL-cholesterol (r=0.20–0.23), HDL-cholesterol (r=−0.31 and −0.32) and triglycerides (r=0.22 and 0.26). Fasting insulin and intact proinsulin concentrations were significantly associated with fibrinogen (r=0.15 and 0.18). Concentrations of proinsulin-like molecules comprised less than 10% of all insulin-like molecules, and so were calculated not to influence previously described relationships between insulin concentrations and cardiovascular risk factors measured using non-specific assays. In multiple regression analyses des-31,32 proinsulin concentration was more strongly associated with those of HDL-cholesterol (negatively), LDL-cholesterol and triglycerides than fasting insulin concentrations, while intact proinsulin replaced insulin concentrations in their relationships with fibrinogen. Our results show correlations between dyslipidaemia and proinsulin-like molecules at concentrations at which biological, insulin-like, activity appears unlikely. We also show relationships between LDL-cholesterol and fibrinogen and the proinsulin-like molecules. These results suggest that a causal relationship mediated by hyperinsulinaemia and insulin resistance is unlikely.

Working together to reduce poverty's damage.

Next week the Royal Colleges of General Practitioners, Nursing, and Physicians, the Faculty of Public Health Medicine, Action in International Medicine (an organisation of colleges and academies of health professionals with member institutions in 30 countries), and the BMJ will hold a conference on poverty and health. The conference will be part of worldwide professional activity to reduce the harmful effects of poverty. This week the BMJ publishes its fourth issue in two years that has clustered papers on inequalities in health. Why all the fuss? Some suggest that its because the BMJ is politically motivated. If that means the BMJ wants action on a major threat to health, its true. We would like all political parties in all countries to pay attention to inequalities in health. Many are reluctant to do so. They are more concerned to cut taxes and so win the votes of what the economist J K Galbraith calls the comfortable majority.1 We are publishing these special issues of the journal for four main reasons. Firstly, anybody interested in health has to pay attention to wealth. Its the single most important driver of health worldwide, even more important than smoking. Secondly, a great deal of research is under way into inequalities in health. It affects every part of medicine. We are beginning to understand that, for developed countries, relative poverty (having an income substantially below the mean for that society) is a more important influence on health than absolute poverty (lacking the basic means to live). 2 3 And this research is leading to important discoveries on how social pressures lead to disease outcomes.2 The BMJ receives many papers on inequalities in health, and many of them make it through our peer review process. It seems sensible to cluster them. Thirdly, things are getting …

Health care in Brazil.

Brazil has great geopolitical importance because of its size, environmental resources, and potential economic power. The organisation of its health care system reflects the schisms within Brazilian society. High technology private care is available to the rich and inadequate public care to the poor. Limited financial resources have been overconcentrated on health care in the hospital sector and health professionals are generally inappropriately trained to meet the needs of the community. However, recent changes in the organisation of health care are taking power away from federal government to state and local authorities. This should help the process of reform, but many vested interests remain to be overcome. A link programme between Britain and Brazil focusing on primary care has resulted in exchange of ideas and staff between the two countries. If primary care in Brazil can be improved it could help to narrow the health divide between rich and poor.

A Randomized Trial of Evidence-Based Outreach (EBOR): Rationale and Design

There is increasing interest in evaluating the methods used to implement the findings from medical research. This paper describes the Evidence-based OutReach (EBOR) trial, which is the first large randomized study in the United Kingdom that will evaluate the effectiveness and efficiency of educational outreach visits by trained pharmacists who are delivering messages derived from four evidence-based clinical practice guidelines. General practices form the unit of allocation and analysis. The study design addresses important factors that may influence the effectiveness of the intervention, such as the pharmacist who delivers the messages, the health authority in which practices are located, and the size of a practice.

The angiotensin-converting enzyme gene and the angiotensin II type I receptor gene as candidate genes for microalbuminuria. A study in nondiabetic and non-insulin-dependent diabetic subjects.

Familial clustering of microalbuminuria with cardiovascular disease suggests a possible common genetic antecedent. We have tested the hypothesis that the angiotensin-converting enzyme (ACE) DD genotype and the angiotensin II type I receptor (AT1R) gene C allele represent the common link between microalbuminuria and coronary heart disease. The frequency of polymorphisms of the ACE and AT1R genes were investigated in 509 nondiabetic white subjects and in 86 non-insulin-dependent diabetic white patients. There was no significant difference in albumin excretion rate between the genotypes in nondiabetic subjects on either a daytime or an overnight sample or in diabetic subjects expressed as a normalized albumin concentration on an untimed morning urine collection. We have found no evidence for an association between polymorphism of the ACE or AT1R genes and microalbuminuria in two groups of subjects without insulin-dependent diabetes.

Majority view of climate scientists is that global warming is indeed happening

Editor—Gardner states that the scientific basis of climate change is uncertain and that there are major differences of opinion among climatologists about whether climate change is likely to occur and its potential magnitude. 1 Inevitably, with an issue of such complexity there is bound to be scientific debate, but the Intergovernmental Panel on Climate Change, which we quoted in our articles, is a major international collabora› tion: it has involved the participation of over 2500 scientists from around the world. Many of the most vociferous sceptics have received funding from fossil fuel industries, which clearly have a vested interest in opposing changes in policy that might result in shifts away from fossil fuels. 2

How the cycle of poverty and ill health can be broken.

EDITOR—To paraphrase a well known remark—wars are too serious to be entrusted to generals—public health, especially among poor people in developing countries and in the inner cities of industrialised countries, is too serious to be left to doctors and nurses alone. We say this quite deliberately as medical doctors on the staff of the World Health Organisation, of the Maryland department of health and mental hygiene, of universities, and of non-governmental organisations in Britain, Colombia, and Kenya. Our conviction is based on many years of work in the field in Africa, Asia, and Latin America, as well as in inner cities of the developed countries of Europe and North America. The number one health problem is poverty. For the poorest countries, the health sector alone cannot ensure better health even if it were able to function at maximum effectiveness. We have to accept that we can no longer deal with health …

Promoting clinical effective practice. Attitudes of fundholding general practitioners to the role of commissioning

Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995‐1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence‐based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically‐driven policy or they will resist it.