The Surgery of Poverty - Surgical Section of the National Medical

The Surgery of Poverty
William Schecter, MD
Professor of Clinical Surgery
University of California, San Francisco
Staff Surgeon
San Francisco General Hospital
The Pilgrim’s Progress by John Bunyan
Poverty Defined??
• SSA 1960’s definition: Annual Income
below the cost of a USDA basic diet
multipled by 3
• Several years later, income indexed to
inflation
• Current Poverty Line*:
– $18, 310.00 for a family of 3
– $22,050.00 for a family of 4
*The 2009 HHS Poverty Guidelines. One Version of the [U.S.] Federal Poverty Measure.:
Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and
Human Services.; Available from: http://aspe.hhs.gov/poverty/09poverty.shtml. Last accessed July 8, 2010.
US Poverty Rates
% Population
N (million)
2008
13.2
39.8
2009
14.3
44
Poverty, Policy and Politics
The Great Depression
• Social Security
• Minimum Wage
• Legal Recognition of Unions
Civil Rights Act 1964
Outlaws Discrimination in:
• Public Accommodation
• Employment
• Activities funded by Federal
Government
Economic Opportunity Act 1964
• Head Start
• Community Health
Centers
• VISTA
• Job Corps
• Community Action
Program
President Lyndon B. Johnson
Racial Unrest in the 1960’s
Poverty Rates of Africa Americans,
Latinos and Native Americans
approximately 2 ½ times that of
White Americans
DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage
in the United States: 2008. In: U.S. Census Bureau CPR, editor. Washington, DC:
U.S. Government Printing Office; 2009. p. 60-236.
Critique of War on Poverty
• Characterized as handouts
• Long term dependency
• No investment in publicly funded jobs
Aid to Families with
Dependent Children
• Federal welfare program enacted 1935
• Provided cash assistance to families
mainly headed by single mothers
Nixon Era
• Supplemental Security
Income
(SSI)
• Social Security indexed to
inflation
• Food Stamps
• Pell Grants
• Expansion of Medicare
and Medicaid
Stagnation for Lower Half of
Income Continuum
•
•
•
•
Automation
De-Industrialization
Factory re-location to the developing world
Median wage for all jobs
– 1973: $13.91/hour
– 2007: $15.11/hour
– Median net worth for U.S. families 2007**
top 10%:
$1,800,700.00
bottom 25%:
$1,200.00
*Mishel L, Bernstein J, Allegretto S. The state of working America 2008/2009.
In: Economic Policy Institute, editor. 1st ed. Washington, DC, 2008.
**Bucks BK, Kinnickell AB, T.L M, Moore KB. Change in U.S. family finances from 2004-2007:
Evidence from the Survey of Consumer Finances. Washington, DC: Federal Reserve Bulletin; 2009. p. A1-A56.
Growing Disparity in Income
Distribution over the past 40 years
• ½ of US economic growth between 19932007 accrued to top 1% of Americans
• CEO’s earned 275 times the wage of the
average worker in 2007
• Disparity greatest among minorities
Backlash Against “Welfare”
• Fair Housing
Act of 1968
• Emerging war
on drugs
• Reagan election
NY Times Vol CLX No. 55,197
Monday, October 18, 2010
Reagan Era
Clinton Era
• Promises to “end
welfare as we know it”
Contract on America
• Congress replaces
legal entitlement to
welfare with block
grants and a 5 year
lifetime limit
• Welfare rolls shrink
from 14.2 to 4 million
between 1994-2008
TANF: Total Number of Recipients, Fiscal and Calendar Year 2008. 2009. .
Washington, DC: U.S. Department of Health and Human Services;
Available from: http://www.acf.hhs.gov/programs/ofa/data-reports/caseload/afdc/1994/fycytotal94_ek.htm.
Last accessed July 10, 2010.
Parrot S. Welfare recipients who find jobs: What do we know about their employment and earnings?
Center on Budget and Policy Priorities.; 1998; Available from: http://www.cbpp.org/11-16-98wel.htm, pp. 1-43.
Last accessed August 2, 2010.
Bush Years
• Recession
– 2001
– 2008
• Increase in Poor
– 2000: 31.1 million
– 2009: 44.0 million
• Food Stamp Program
– 2000: 17 million
– 2009: 40 million
Klerman JA, Danielson C. Determinants of the Foot Stam Program caseload, RAND.
In: 50 CaCRN, editor. Washington, DC: U.S. Department of Agriculture; 2009.
Nutrition Assistance Program Performance Report: United States Department of Agriculture. June Release
[cited 2010]; Available from: http://www.fns.usda.gov/fns/key_data/april-2010.pdf.
Last accessed June 9, 2010.
Obama Years
• 2009 American
Recovery and
Reinvestment Act
– $787 billion
– $200 billion earmarked
for low income people
ACA 2010
• Extends health insurance to 30 million
previously uninsured people
• Prevents insurance companies from
rejecting people for pre-existing conditions
• Estimated 10 year cost $938 billion
• Projected source of funds: MediCare and
taxes
ACA 2010
• Insurance to be purchased through
state based insurance exchanges
• The poor will be covered by an
expanded Medicaid Program.
ACA 2010 Assumptions
• ACA will result in $148 billion reduction in
Federal deficit
• Estimates based on Dartmouth Health Care
Analysis documenting large regional
variations in health care costs
• Dartmouth conclusions challenged
Poverty and Health
Socioeconomic Status Defined
“Income,
education and
occupational status”(1)
•
•
•
•
•
Human capital
Material capital
Social capital
Personal Capital
Cultural Capital (2,3)
1. Adler NE, T.B., Chesney MA, Cohen S, Folkman S, Kahn RL, et al. Socioeconomic status and
Health: the challenge of the gradient. American Psychologist. 1994(49):15-24.
2. Alvin DF, Wray LA. A life-span developmental perspective on social status and health.
The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 2005(60):57-514.
3. O’Rand AM, Ross BM. Stratification and the life course. In: Bustock RH, George LK, editors.
Handbook of Aging and Social Sciences. 5th ed. New York: Academic Press; 2001.
Human Capital and Health
• Strong association between high mortality rate and
low level of education
• Sharpest declines in survival in highly preventable
disease in people with < 15 years of education
• Some argue that education is prime drive in
relationship between SES and health.
Adler NE, Boyce WT, Chesney MA, Foldman S, Syme SL. Socioeconomic inequalities in
health. No easy solution. JAMA 1993 Jun 23-30;269(24):3140-5.
Phelan JC, Link BG, Diez-Roux A, Kawachi I, Levin B. “Fundamental causes” of social
inequalities in mortality: a test of the theory. J Health Soc Behav. 2004 Sep;45(3):265-85.
Mirowsky J, Ross CE. Education, Social Status and Health. Hawthorne, New Y ork:
Aldine de Gruyter; 2003.
Material Capital and Health
Los Angeles
Hospital Days and Household Income
Hospital Days per 1,000
1,250
1,000
Poor
750
4-fold
500
250
Rich
0
$0
$50,000
$100,000
$150,000
$200,000
Median Household Income
Lynch JW, Kaplan GA. Understanding how inequality in the distribution of income
affects health. J Health Psychology. 1997(2):297-314.
Per Capita GDP vs.
Life Expectancy at Birth
U.S.
Jordan
Life Expectancy
at Birth (years)
78
79
Per capita GDP
(U.S. $)
46,400
5,300
Rodgers GB. Income and inequality as determinants of mortality: An international cross
section analysis. Population Studies. 1979(29):231-48.
LeGrand J. Inequalities in health. European Economic Review. 1987(31):182-91.
•
•
•
•
Life expectancy not related to income above a certain
threshold (1)
People with incomes below the national average lose
more years of life than gained by people with higher
incomes (2)
Assymetric income distribution causes non-linear
relationship between national life expectancy and average
national income (1)
The greater the inequality of income distribution, the
higher the mortality rate (3)
(1)
Preston SH. The changing relation between mortality and level of economic
development. Population Studies. 1995(29):103-9.
(2)
Lynch JW, Kaplan GA. Understanding how inequality in the distribution of income
affects health. J Health Psychology. 1997(2):297-314.
(3)
LeGrand J. Inequalities in health. European Economic Review. 1987(31):182-91.
Measurement of Income Distribution
Distribution as Measured by Gini
Coefficient Over Time in the U.S.
Year
1967 (first year reported)
Gini
Coefficient
0.397
1980
0.403
1990
0.428
2008
0.466
http://en.wikipedia.org/wiki/Gini_coefficient
Comparison of Income Distribution
(as measured by Gini Coefficient) per Capita GDP and
Life Expectance at Birth Among Countries
Country
Gini Coefficient
Per Capita GDP
Life Expectancy
at Birth (2009 est)
Haiti
0.592 (2001)
1,300
60.78
Peru
0.520 (2008)
8,600
70.74
Mexico
0.480 (2008)
13,500
76.06
United States
0.450 (2007)
46,400
78.11
Jordan
0.397 (2007)
5,300
79.85
Israel
0.392 (2008)
28,400
80.73
United Kingdom
0.340 (2008)
35,200
79.01
Canada
0.321 (2005)
38,400
81.2
Sweden
0.230 (2005)
36,800
80.86
Kaplan GA, Pamur ER, Lynch JW, Cohen RD, Balfour JL. Inequality in income and mortality in
the United States: Analysis of mortality and potential pathways. Brit Med J. 1996(312):999-1003.
Cooper RA, Getzen T, Johns MME, Ross-Lee B, Sheldon GF, Whitcomb ME. Physicians And Their Practices Under Health
Care Reform: A Report to the President and the Congress. Last accessed 09/14/2010. Boston, MA2009 [cited 2009];
Available from: http://oshpd.ca.gov/RHPC/Jobs/PhysiciansAndTheir%20Practices.pdf.
Geography, Poverty and Health
• Poor neighborhoods → ↑ death rate, ↑ functional
decline
• Effect due to depleted social and cultural capital
Anderson RT, Sorlie P, Backlund E, Johnson N, Kaplan GA. Mortality effects of community socioeconomic status.
Epidemiology. 1997 Jan;8(1):42-7.
Yen IH, Kaplan GA. Neighborhood social environment and risk of death: multilevel evidence from the Alameda
County Study. Am J Epidemiol. 1999 May 15;149(10):898-907.
Waitzman NJ, Smith KR. Separate but lethal: the effects of economic segregation on mortality in metropolitan
America. Milbank Q. 1998;76(3):341-73, 04.
Waitzman NJ, Smith KR. Phantom of the area: poverty-area residence and mortality in the United States. Am J Public
Health. 1998 Jun;88(6):973-6.
Borrell LN, Diez Roux AV, Rose K, Catellier D, Clark BL. Neighbourhood characteristics and mortality in the
Atherosclerosis Risk in Communities Study. Int J Epidemiol. 2004 Apr;33(2):398-407.
Poor Housing
• Increased prevalence of
–
–
–
–
–
Infection
Chronic disease
Injury
Poor nutrition
Mental illness
• Soiled carpeting/insect and rodent infestation
– Asthma
– Allergy
Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public
Health. 2002 May;92(5):758-68.
Rosenstreich DL, Eggleston P, Kattan M, Baker D, Slavin RG, Gergen P, et al. The role of
cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city
children with asthma. N Engl J Med. 1997 May 8;336(19):1356-63.
Phipatanakul W, Eggleston PA, Wright EC, Wood RA. Mouse allergen. II. The relationship of
mouse allergen exposure to mouse sensitization and asthma morbidity in inner-city children
with asthma. J Allergy Clin Immunol. 2000 Dec;106(6):1075-80.
Poor Climate Control
• Inadequate heating
– Poor health in elderly (1)
– Asthma and chronic pulmonary disease (2,3)
• Inadequate ventilation in summer
– Heat stroke (4)
– Depression, anxiety, social isolation (5)
1.
Collins KJ. Low indoor temperatures and morbidity in the elderly. Age Ageing. 1986 Jul;15(4):212-20.
2.
Bornehag CG, Blomquist G, Gyntelberg F, Jarvholm B, Malmberg P, Nordvall L, et al. Dampness in buildings and health. Nordic interdisciplinary review of the
scientific evidence on associations between exposure to "dampness" in buildings and health effects (NORDDAMP). Indoor Air. 2001 Jun;11(2):72-86.
3.
Peat JK, Dickerson J, Li J. Effects of damp and mould in the home on respiratory health: a review of the literature. Allergy. 1998 Feb;53(2):120-8.
4.
Heat-related deaths--Los Angeles County, California, 1999-2000, and United States, 1979-1998. MMWR Morb Mortal Wkly Rep. 2001 Jul 27;50(29):623-6.
5.
Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002 May;92(5):758-68.
Inadequate Housing
• Exposure to toxic substances (1-4)
• ↑ risk of preventable injury including burns
1.
2.
3.
4.
Cook DG, Strachan DP, Carey IM. Health effects of passive smoking. 9. Parental smoking and spirometric indices in
children. Thorax. 1998 Oct;53(10):884-93.
Walker E, Hay A. Carbon monoxide poisoning. BMJ. 1999 Oct 23;319(7217):1082-3. Rosen JF. Adverse health
effects of lead at low exposure levels: trends in the management of childhood lead poisoning. Toxicology. 1995 Mar
31;97(1-3):11-7.
Rosen JF. Adverse health effects of lead at low exposure levels: trends in the management of childhood lead
poisoning. Toxicology. 1995 Mar 31;97(103):11-7.
Landrigan PJ. Asbestos--still a carcinogen. N Engl J Med. 1998 May 28;338(22):1618-9.
Poor Neighborhood ↔
Social and Cultural Capital
• Exposure to high prevalence of
– Alcoholism
– Drug use
– Violence
• Deficient
– Public transportation
– Education
– Community infrastructure
Brown AF, Ang A, Pebley AR. The relationship between neighborhood characteristics and self-rated
health for adults with chronic conditions. Am J Public Health. 2007 May;97(5):926-32.
Low Social Capital and Health
• Increased risk of depression (1) and CAD (2)
• Lack of access to healthful food and opportunities
for exercise → obesity (3)
• 14.6% of U.S. households at risk for hunger (4)
1.
2.
3.
4.
Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to
social variations in coronary heart disease incidence. Lancet. 1997 Jul 26;350(9073):235-9.
Stansfeld SA, Fuhrer R, Shipley MJ, Marmot MG. Work characteristics predict psychiatric disorder: prospective
results from the Whitehall II Study. Occup Environ Med. 1999 May;56(5):302-7.
Lee H, Harris KM, Gordon-Larsen P. Life Course Perspectives on the Links Between Poverty and Obesity During the
Transition to Young Adulthood. Popul Res Policy Rev. 2009 Aug 1;28(4):505-32.
Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med. 2010;363:6-9.
Gender, Poverty and Health
• 53% of poor families led by single women1
• Child care can account for 1/3 of a family
budget 2
1. Shipler DK. The Working Poor: Invisible in America. New York City, NY. Location 29402947: Vintage Books; 2008.
2. Goodman PS. Cuts to child care subsidy thwart more job seekers. New York Times. 2010
May 24, 2010:A1, A16.
Race, Ethnicity, Poverty and Health
•
Life expectancy for African-Americans lower than for white Americans
(1,2)
•
Racial disparities for access to:
–
–
–
–
1.
2.
3.
4.
5.
6.
7.
8.
9.
Coronary A/G and angioplasty (3,4,5,6)
Cardiac Surgery
Vascular Surgery
Renal Transplantation (7,8,9)
Harper S, Lynch J, Burris S, Davey Smith G. Trends in the black-white life expectancy gap in the United States, 1983-2003.
JAMA. 2007 Mar 21;297(11):1224-32.
Satcher D, Fryer GE, Jr., McCann J, Troutman A, Woolf SH, Rust G. What if we were equal? A comparison of the black-white mortality gap
in 1960 and 2000. Health Aff (Millwood). 2005 Mar-Apr;24(2):459-64
Ayanian JZ. Heart disease in black and white. N Engl J Med. 1993 Aug 26;329(9):656-8.
Kressin NR, Petersen LA. Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription
for future research. Ann Intern Med. 2001 Sep 4;135(5):352-66.
Gornick ME, Eggers PW, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, et al. Effects of race and income on mortality and use of
services among Medicare beneficiaries. N Engl J Med. 1996 Sep 12;335(11):791-9.
Guadagnoli E, Ayanian JZ, Gibbons G, McNeil BJ, LoGerfo FW. The influence of race on the use of surgical procedures for treatment of peripheral
vascular disease of the lower extremities. Arch Surg. 1995 Apr;130(4):381-6
Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, et al. Comparison of mortality in all patients on dialysis, patients on dialysis
awaiting transplantation, and recipients of a first cadaveric
transplant. N Engl J Med. 1999 Dec 2;341(23):1725-30.
Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation.
N Engl J Med. 1999 Nov 25;341(22):1661-9.
Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, et al. Racial disparities in access to renal transplantation—clinically
appropriate or due to underuse or overuse? N Engl J Med. 2000 Nov 23;343(21):1537-44.
Race as a Marker for SES?
• Bleich SN, Thorpe RJ, Jr., Sharif-Harris H, Fesahazion R, Laveist TA.
Social context explains race disparities in obesity among women. J
Epidemiol Community Health. 2010 May;64(5):465-9.
• Chu QD, Burton G, Glass J, Smith MH, Li BD. Impact of race and
ethnicity on outcomes for estrogen receptor-negative breast cancers:
experience of an academic center with a charity hospital. J Am Coll
Surg. 2010 May;210(5):585-92, 92-4.
• Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the
quality of care and racial disparities in Medicare managed care. N Engl
J Med. 2005 Aug 18;353(7):692-700.
Poverty and Malignancy
52 y.o woman presenting with Stage 4 rectal cancer—palliative APR after preop chemo/Rad Rx
Poverty and Malignancy
• Poverty is a
carcinogen
Dr. Samuel Broder
Greenlee RT, Howe HL. Country-level poverty and distant stage cancer in the United States.
Cancer Causes Control. 2009 Aug;20(6):989-1000.
Poverty and Cancer Risk Factors
• Infections
–
–
–
–
1.
2.
3.
4.
5.
HPV (1)
HBV
HCV
Helicobacter Pylori (2)
• Smoking (3)
• Alcohol (4,5)
Markowitz LE, Sternberg M, Dunne EF, McQuillan G, Unger ER. Seroprevalence of human papillomavirus types 6, 11, 16, and 18 in the United
States: National Health and Nutrition Examination Survey 2003-2004. J Infect Dis. 2009 Oct 1;200(7):1059-67.
Kruszon-Moran D, McQuillan GM. Seroprevalence of six infectious diseases among adults in the United States by race/ethnicity: data from the third
national health and nutrition examination survey, 1988--94. Adv Data. 2005 Mar 9(352):1-9.
Siahpush M, Singh GK, Jones PR, Timsina LR. Racial/ethnic and socioeconomic variations in duration of smoking: results from 2003, 2006 and 2007
Tobacco Use Supplement of the Current Population Survey. J Public Health (Oxf). 2009 Nov 5.
Polednak AP. Geographic pattern of cancers related to tobacco and alcohol in Connecticut: implications for cancer control. Cancer Detect Prev.
2004;28(4):302-8.
Cerda M, Diez-Roux AV, Tchetgen ET, Gordon-Larsen P, Kiefe C. The Relationship Between Neighborhood Poverty and Alcohol Use: Estimation by
Marginal Structural Models. Epidemiology. 2010 May 21.
Poverty and Cancer Risk Factors
• Obesity (1,2)
• Exposure to chemical carcinogens (3,4)
1.
Reeves GK, Pirie K, Beral V, Green J, Spencer E, Bull D. Cancer incidence and mortality in relation
to body mass index in the Million Women Study: cohort study. BMJ. 2007 Dec 1;335(7630):1134.
2. Loomba R, Yang HI, Su J, Brenner D, Iloeje U, Chen CJ. Obesity and alcohol synergize to increase
the risk of incident hepatocellular carcinoma in men. Clin Gastroenterol Hepatol. 2010 Jul 8.
3. Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, et al. Cancer disparities by
race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004 Mar-Apr;54(2):78-93.
4. Brawley OW, Berger MZ. Cancer and disparities in health: perspectives on health statistics and
research questions. Cancer. 2008 Oct 1;113(7 Suppl):1744-54.
Poverty and Outcome after
Diagnosis of Malignancy
• Indigent patients have a higher risk of dying
of cancer (1)
• Disparities are increasing (2)
1.
Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, et al. Cancer disparities by race/ethnicity and
socioeconomic status. CA Cancer J Clin. 2004 Mar-Apr;54(2):78-93.
2.
Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in U.S. cancer incidence, mortality,
stage, treatment, and survival, 1975-1999. Bethesda, MD: National Cancer Institute 2003.
Late Presentation
with Advanced Cancer
• Poverty rate > 20%, ↑ late stage Ca diagnosis (1)
• Low SES neighborhood, ↑ metastatic disease (2)
• ↑ poverty area, ↑ prevalence distant stage prostate
and female breast cancer (2)
1.
Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in U.S. cancer incidence, mortality, stage,
treatment, and survival, 1975-1999. Bethesda, MD: National Cancer Institute 2003.
2.
Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, et al. Cancer disparities
by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004 Mar-Apr;54(2):78-93.
Poverty and the Quality
of Cancer Screening
• Lack of access to routine screening (1,2)
• Inadequate follow-up after screening (3,4,5,6,7)
• Lack of access to sophisticated studies (8)
1.
2.
3.
4.
5.
6.
7.
8.
Ahmed NU, Fort JG, Fair AM, Semenya K, Haber G. Breast cancer knowledge and barriers to mammography in a low-income managed care population.
Cancer Educ. 2009;24(4):261-6.
Born W, Engelman K, Greiner KA, Bhattacharya SB, Hall S, Hou Q, et al. Colorectal cancer screening, perceived discrimination, and low-income
and trust in doctors: a survey of minority patients. BMC Public Health. 2009;9:363.
Wujcik D, Fair AM. Barriers to diagnostic resolution after abnormal mammography: a review of the literature. Cancer Nurs. 2008 Sep-Oct;31(5):E16-30.
Gwyn K, Bondy ML, Cohen DS, Lund MJ, Liff JM, Flagg EW, et al. Racial differences in diagnosis, treatment, and clinical delays in a population-based
study of patients with newly diagnosed breast carcinoma. Cancer. 2004 Apr 15;100(8):1595-604.
Haas JS, Cook EF, Puopolo AL, Burstin HR, Brennan TA. Differences in the quality of care for women with an abnormal mammogram or breast complaint.
J Gen Intern Med. 2000 May;15(5):321-8.
Strzelczyk JJ, Dignan MB. Disparities in adherence to recommended followup on screening mammography: interaction of sociodemographic factors.
Ethn Dis. 2002 Winter;12(1):77-86.
Yabroff KR, Breen N, Vernon SW, Meissner HI, Freedman AN, Ballard-Barbash R. What factors are associated with diagnostic follow-up after abnormal
mammograms? Findings from a U.S. National Survey. Cancer Epidemiol Biomarkers Prev. 2004 May;13(5):723-32.
Coughlin SS, Wilson KM. Breast and cervical cancer screening among migrant and seasonal farmworkers: a review. Cancer Detect Prev. 2002;26(3):203-9.
• Steinberg ML. Inequity in cancer care: explanations and solutions for
disparity. Semin Radiat Oncol. 2008 Jul;18(3):161-7.
Disparities Increase with
Complexity of Care
• Poor less likely to receive surgery for Stage I
and Stage II Cancer (1)
• Poor breast cancer patients less likely to
receive adjuvant therapy (2,3)
• Similar discrepancies document for
pancreatic, colon and rectal cancer (4,5)
1.
2.
3.
4.
5.
Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in U.S. cancer incidence, mortality, stage,
treatment, and survival, 1975-1999. Bethesda, MD: National Cancer Institute 2003.
Kimmick G, Anderson R, Camacho F, Bhosle M, Hwang W, Balkrishnan R. Adjuvant hormonal therapy use among insured, lowincome women with breast cancer. J Clin Oncol. 2009 Jul 20;27(21):3445-51.
Bickell NA, LePar F, Wang JJ, Leventhal H. Lost opportunities: physicians' reasons and disparities in breast cancer treatment. J
Clin Oncol. 2007 Jun 20;25(18):2516-21.
Hao Y, Landrine H, Jemal A, Ward KC, Bayakly AR, Young JL, Jr., et al. Race, Neighborhood Characteristics, and Disparities in
Chemotherapy for Colorectal Cancer. J Epidemiol Community Health. 2009 Dec 3
Cheung MC, Yang R, Byrne MM, Solorzano CC, Nakeeb A, Koniaris LG. Are patients of low socioeconomic status receiving
suboptimal management for pancreatic adenocarcinoma? Cancer. 2010 Feb 1;116(3):723-33.
The Poor are Less Likely to be
Enrolled in Clinical Trials
•
El-Rayes BF, Jasti P, Severson RK, Almhanna K, Philip PA, Shields A, et al.
Impact of Race, Age, and Socioeconomic Status on Participation in Pancreatic
Cancer Clinical Trials. Pancreas. 2010 May 7.
•
Baquet CR, Ellison GL, Mishra SI. Analysis of Maryland cancer patient
participation in National Cancer Institute-supported cancer treatment clinical
trials. J Health Care Poor Underserved. 2009 May;20(2 Suppl):120-34.
•
Gross CP, Filardo G, Mayne ST, Krumholz HM. The impact of socioeconomic
status and race on trial participation for older women with breast cancer.
Cancer. 2005 Feb 1;103(3):483-91.
Poverty and Supportive Cancer Care
• Decreased access to reconstructive surgery (1,2)
• Decreased access to prescription analgesics (3,4)
• Decreased access to hospice services (4)
1. Gore JL, Saigal CS, Hanley JM, Schonlau M, Litwin MS. Variations in reconstruction
after radical cystectomy. Cancer. 2006 Aug 15;107(4):729-37.
2. Christian CK, Niland J, Edge SB, Ottesen RA, Hughes ME, Theriault R, et al. A multiinstitutional analysis of the socioeconomic determinants of breast reconstruction: a
study of the National Comprehensive Cancer Network. Ann Surg. 2006 Feb;243(2):2419.
3. McNeill JA, Reynolds J, Ney ML. Unequal quality of cancer pain management:
disparity in perceived control and proposed solutions. Oncol Nurs Forum. 2007
Nov;34(6):1121-8.
4. Hughes A. Poverty and palliative care in the US: issues facing the urban poor. Int J
Palliat Nurs. 2005 Jan;11(1):6-13.
Poverty, Trauma and
Emergency Surgery
Poverty, Race, Ethnicity and Trauma
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Poor at increased risk for intentional and unintentional injury (1)
Initial diagnosis at Level I trauma centers the same for all (2)
African-American patients have poorer outcome (3)
Race may be a surrogate for SES (4-6)
1.
Gillespie CF, Bradley B, Mercer K, Smith AK, Conneely K, Gapen M, et al. Trauma exposure and
stress-related disorders in inner city primary care patients. Gen Hosp Psychiatry. 2009 NovDec;31(6):505-14.
Shafi S, Gentilello LM. Ethnic disparities in initial management of trauma patients in a nationwide
sample of emergency department visits. Arch Surg. 2008 Nov;143(11):1057-61; discussion 61.
Bowman SM, Martin DP, Sharar SR, Zimmerman FJ. Racial disparities in outcomes of persons with
moderate to severe traumatic brain injury. Med Care. 2007 Jul;45(7):686-90.
Dozier KC, Miranda MA, Jr., Kwan RO, Cureton EL, Sadjadi J, Victorino GP. Insurance coverage is
associated with mortality after gunshot trauma. J Am Coll Surg. 2010 Mar;210(3):280-5.
Greene WR, Oyetunji TA, Bowers U, Haider AH, Mellman TA, Cornwell EE, et al. Insurance status is a
potent predictor of outcomes in both blunt and penetrating trauma. Am J Surg. 2010 Apr;199(4):554-7.
Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE, 3rd. Race and insurance status as
risk factors for trauma mortality. Arch Surg. 2008 Oct;143(10):945-9.
Rosen H, Saleh F, Lipsitz SR, Meara JG, Rogers SO, Jr. Lack of insurance negatively affects trauma
mortality in US children. J Pediatr Surg. 2009 Oct;44(10):1952-7.
2.
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Epidemic of Firearm Injury
Among Urban Youth
• 110% increase in pediatric GSW’s in Philadelphia
1986-1995 *
• Mean age 12.8 years *
• African-American children most likely to be
injured.
* Nance ML, Stafford PW, Schwab CW. Firearm injury among urban youth during
the last decade: an escalation in violence. J Pediatr Surg. 1997 Jul;32(7):949-52.
Trauma Recidivism
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15% of trauma admission at Johns Hopkins between 1997-2004 were recidivists (188)
Risk factors for recidivism
– Alcohol (1)
– Drug use (2)
– Homelessness (3)
- Mental illness (5)
- Low SES (6)
- Youth gang member (7)
– Criminal Activity (4)
1.
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Brooke BS, Efron DT, Chang DC, Haut ER, Cornwell EE, 3rd. Patterns and outcomes among penetrating trauma recidivists: it only
gets worse. J Trauma. 2006 Jul;61(1):16-9; discussion 20.
Hayman AV, Crandall ML. Deadly partners: interdependence of alcohol and trauma in the clinical setting. Int J Environ Res Public
Health. 2009 Dec;6(12):3097-104.
Ramchand R, Marshall GN, Schell TL, Jaycox LH, Hambarsoomians K, Shetty V, et al. Alcohol abuse and illegal drug use amongLos
Angeles County trauma patients: prevalence and evaluation of single item screener. J Trauma. 2009 May;66(5):1461-7.
Kramer CB, Gibran NS, Heimbach DM, Rivara FP, Klein MB. Assault and substance abuse characterize burn injuries in homeless
patients. J Burn Care Res. 2008 May-Jun;29(3):461-7.
Claassen CA, Larkin GL, Hodges G, Field C. Criminal correlates of injury-related emergency department recidivism. J Emerg Med.
2007 Feb;32(2):141-7.
Wan JJ, Morabito DJ, Khaw L, Knudson MM, Dicker RA. Mental illness as an independent risk factor for unintentional injury and
injury recidivism. J Trauma. 2006 Dec;61(6):1299-304.
Crandall M, Sridharan L, Schermer C. Injury and health among toddlers in vulnerable families. J Trauma. 2010 May;68(5):1128-33.
Zun LS, Downey L, Rosen J. Who are the young victims of violence? Pediatr Emerg Care. 2005 Sep;21(9):568-73.
Pediatric Trauma
• Children from “vulnerable” families have a 10%
rate of injury in the first year of life (1)
• Poor housing independently associated with
childhood injury (2)
• Low SES most important predictor of injury (3)
1.
2.
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Crandall M, Sridharan L, Schermer C. Injury and health among toddlers in vulnerable families. J Trauma. 2010
May;68(5):1128-33.
Shenassa ED, Stubbendick A, Brown MJ. Social disparities in housing and related pediatric injury: a multilevel
study. Am J Public Health. 2004 Apr;94(4):633-9
Durkin MS, Davidson LL, Kuhn L, O'Connor P, Barlow B. Low-income neighborhoods and the risk of severe
pediatric injury: a small-area analysis in northern Manhattan. Am J Public Health. 1994 Apr;84(4):587-92.
The Abused Child
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1460 children died due to abuse in 2005 (1)
75% < four years old
70% of deaths caused by one or more parents
Children of families with income < $18,000/year
22 times more likely to be abused (2)
1. USDHHS. Child Maltreatment 2007. Washington, DC: U.S. Department of Health and Human
Services; Available from: http://www.acf.hhs.gov/programs/cb/pubs/cm07/index.htm.
Last accessed August 4, 2010.
2. American Humane. America’s Children: How are they doing? .
Available from:
http://www.americanhumane.org/about-us/newsroom/fact-sheets/americas-children.html.
Last accessed July 14, 2010.
Poverty and
Intimate Partner Violence
• 24.8% of women and 7.8% of men have been raped or
otherwise assaulted 1
• 37-54% of women ED patients report IPV in past. 2,3
• Recidivism in poor neighboorhood increases the risk 4
1. Tjaden P, N. T. Prevalence, incidence and consequences of violence against women:
Findings from the National Violence Against Women Survey. 1998 [11/1998];
Available from: www.ojp.usdoj.gov/nij/pubs-sum/17.
2. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women.
Incidence and prevalence in an emergency department population. JAMA. 1995 Jun 14;273(22):1763-7.
3. Dearwater SR, Coben JH, Campbell JC, Nah G, Glass N, McLoughlin E, et al. Prevalence of
intimate partner abuse in women treated at community hospital emergency departments.
JAMA. 1998 Aug 5;280(5):433-8.
4. Goodman LA, Smyth KF, Borges AM, Singer R. When crises collide: how intimate partner violence and poverty
intersect to shape women's mental health and coping? Trauma Violence Abuse. 2009 Oct;10(4):306 29.
Surgical Response to Poverty
• Volunteer Care
• Surgeons and Surgical Trainees Support Volunteer
Care (1, 2)
• Domestic Volunteer Organizations
• Operation Giving Back
1.
2.
McGinigle KL, Milano PM, Rich PB, Viera AJ. Volunteerism among surgeons: an exploration of attitudes and barriers. Am J
Surg. 2008 Aug;196(2):300-4.
Warshaw AO, Beyer FC, Furman RW, German JC, Guyton SW, Hubbard II GW, et al. The American
College of Surgeons Volunteerism and Giving Back to Society among Surgeons Project: Phase
Three -- Survey of ACS Fellows. Boston, Massachusetts: Institute for Health Policy of the
Massachusetts General Hospital and Partners Healthcare System.; 2002; Available from:
http://www.facs.org/about/governorhttp://www.facs.org/about/governors/phase3givingback.pdfs/
phase3givingback.pdf. Last accessed August 9, 2010.
Summary
Acknowledgment
Anthony G. Charles, M.D., M.P.H.
University of North Carolina at Chapel Hill
Edward E. Cornwell, M.D.
Howard University
Peter Edelman LL.B.
Georgetown Law Center
John E. Scarborough, M.D.
Duke University Medical Center
George F. Sheldon, M.D.
University of North Carolina at Chapel Hill
Karyn Stitzenberg, M.D., M.P.H.
University of North Carolina at Chapel Hill