Medical Humanities Blog

Call for Applications: Clinical Ethicist, University of Texas Medical Branch

The Institute for Medical Humanities at the University of Texas Medical Branch, where I am a graduate student, has put out a Call for Applications for a non-tenure track faculty position in clinical ethics.  You may download the call here (PDF): Download clin_bioethicist_ad1.pdf.

On Income Inequality and Population Health

Orin Kerr, in response to a comment of mine on Concurring Opinions, asks:

Just to be clear, when you refer to the correlation between income inequality and health, you mean that societies with low inequality tend to have better physical health than societies with high inequality, right? If so, is the idea that they correlate with something else, or that inequality determines physical health? (And if the latter, how?)

As is my wont, I began to ramble, so I figured it would be better to hog this blog space rather than the CoOp comments:

You ask a number of pertinent questions, and I hope it's clear that there remains a great deal about the correlation that has yet to be unpacked.  But the basic idea is that, as Daniels, Kennedy, and Kawachi put in the title of their 1999 essay (turned into a 2000 book), "justice is good for your health."  Greater distributive justice -- lower socioeconomic disparities -- is not just good for the health of the less affluent, but has a demonstrable effect in improving population health even for those who sit on top of the social gradient.

Perhaps the most interesting aspect of this gradient, most directly attributable to Marmot's work, is that it is not simply the case that the wealthy are healthier than the poor.  No one doubts this.  But an impressively linear relationship tends to exist across the social gradient.  Thus the really well-off are healthier than the slightly less well-off, who in turn are healthier than the slightly slightly less well-off, and so on and so forth.

This relationship has been demonstrated in local, state/provinicial, national, and global levels, in widely different societies and cultures.  There are a number of scholars working on explaining the impressive consistency of these social gradients, which gets to your second question -- that inequality is a prime determinant of health.

Really, this idea is not altogether novel.  As I note here, Ramazzini observed the relationship between socieconomic conditions and health as long ago as 1713, and it was a prime motivation for the sanitarians' public health reforms of the late 19th-early 20th century.

But as for the specific mechanism, there are a number of theories.  In my view -- and I want to be careful to avoid privileging reductionist, scientistic explanations here -- some of the most interesting and compelling accounts tie poor health outcomes to inequality in context of the neuroendocrine system.  Basically, it turns out we're not supposed to have the fight-or-flight response turned on all the time.  Where we do -- b/c of socioeconomic conditions, for example -- we maintain very high levels of stress hormones like cortisol.  There is excellent evidence that sustained high levels of cortisol causes all manner of health problems, and is linked to just about every major chronic disease (except for many cancers) you'd care to name (CAD, CVD, diabetes, mental health problems, to name but a few).

It's particularly harmful to developing brains, which suggests a molecular reason for the evidence that really early childhood development is absolutely crucial to flourishing across the lifespan.  (i.e., lower socioeconomic status in childhood seems to produce -- and the causation here is incredibly complex and admittedly poorly understood -- what some refer to as a "cascade" of health problems, each building on the other to increase morbidity and lower life expectancy, along with a number of other poor health measures).

I guess one of your implicit questions is how wider socioeconomic disparities causes poor health even for those on top of the social gradient.  This is a really complex question, and I'm not sure there are a lot of really developed answers out there -- though I am no epidemiologist or sociologist, both of whom tend to dominate the technical work in these fields -- but one example is that even African-Americans who sit atop the social gradient by any measure (education, income, neighborhood, you name it), suffer more disease and have lower life expectancy than Caucasians in the same position on the gradient.

Nancy Krieger, among others, has advanced a theory, with (IMO) credible data that racism in and of itself, after controlling for virtually every conceivable confounder, seems to have an inimical effect on health.  Thinking about this in terms of the neuroendocrine system mentioned above may help process this idea, which, on a purely anecdotal basis, I've seen seems to generate widespread disbelief (though I'm not really sure why -- if it isn't hard to understand why systematic discrimination and prejudice might significantly contribute to higher levels of depression and anxiety, why it is to hard to believe that consistently higher levels of such problems contribute significantly to poor health outcomes over the lifespan?).

Finally, Richard Wilkinson, among others, has produced a large body of evidence showing that societies with significant income inequalities report much higher levels of violence, and that the relationship is proportional.  Also, such violence occurs within positions on the socioeconomic gradient, not just between levels.  (So domestic violence -- presumably between families and communities of similar SES is significantly higher in societies with high income inequality, in addition to what we might expect, that violence between social positions is more common in such societies).

Anyway, none of this is to suggest that all of this has been figured out and is widely understood.  As I tried to indicate in my initial comment, that so much of the relationship remains somewhat cloudy is at least partially why the correlation remains an object of such intense study across so many different disciplines.  (For example, though I'm no methodologist, I do a lot of ethics and public health policy work, and bringing this evidence to bear and thinking about the moral implications of this evidence is vitally important, IMO).  But I also don't want to suggest we are totally in the dark.  The relationship exists.  It is robust, it is persistent, and we have some interesting and evidence-based accounts of how income inequalities produce lower population health.  It's very difficult, in my view, to claim that wide income inequalities are productive of "good" population health.

Of course, none of this exhausts the normative inquiries.  What constitutes good health? How much inequality should we tolerate? How much should we encourage? If not all inequality is bad-- and I agree that it is not -- where do we draw the line?

These are obviously all viable questions.  But it's odd to me that so many seem either to reject the mountains of data suggesting, by virtually any health indicia you might care to use, the U.S. has very poor health relative to its health expenditures, or to express puzzlement at the reasons why this might be so.  This is the basic subject of Kawachi and Kennedy's book on the health of nations.

Hope this helps.

Romancing Opiates

The title of this post is the title of a recent book by Theodore Dalrymple: Romancing Opiates: Pharmacological Lies and The Addiction Bureaucracy (New York: Encounter Books, 2006). Wikipedia introduces our author: "Anthony (A.M.) Daniels (born 1949) is a British writer and retired physician (prison doctor and psychiatrist), who generally uses the pen name Theodore Dalrymple. He has written extensively on culture, art, politics, education and medicine, drawing upon his experience as a doctor and psychiatrist in Zimbabwe and Tanzania, and more recently at a prison and a public hospital in Birmingham, in central England."

In a brief description of the views that animate his writing, the entry notes that Daniels "contends that the middle class abandonment of traditional cultural and behavioural aspiration has, by example, fostered routine incivility and ignorance among members of the working class. Occasionally accused of being a pessimist and misanthrope, his defenders praise his persistently conservative philosophy, which they describe as being anti-ideological, sceptical, rational and empiricist."

I happen to be an unabashed Marxist in economics (along the lines, in part, of the 'analytical Marxists'), while, at the same time, subscribing to many of the values and principles found in the Liberal tradition of political philosophy. Nevertheless, risking inconsistency and contradiction, I feel free to draw upon, say, classical Greek thought, the natural law tradition, and even anarchist political philosophy if it suits my fancy. And this is only the political and economic parts of my worldview: the broadly philosophical and spiritual parts are principally of Asian provenance. In short, my own worldview is a hodgepodge, a motley, in the words of the late Ninian Smart: "Our values and beliefs are more like a collage than a Canaletto. They do not even have consistency of perspective" (From Religion and the Western Mind, 1987, p. 17). All of this by way of accounting for the fact that while Daniels is clearly a consistent conservative, that does not preclude me from finding this particular book persuasive on many counts, a reminder that, at least on what are sometimes confusingly called "cultural matters," I too am fairly conservative.

For some inscrutable and unjustifiable reason, the book lacks notes of any kind, which is inexcusable, especially with regard to the extensive quoted material of others, nor is there a bibliography, and the index is far from complete. As I was digesting the argument it called to mind in many respects Herbert Fingarette's controversial but equally provocative and, by my lights, well-argued book, Heavy Drinking: The Myth of Alcoholism as a Disease (1988). It turns out that Dalrymple/Daniels thought so too, for near the end of his book we learn that "What Fingarette said of alcoholism can be applied with equal force to opiate addiction," as he quotes a passage from Heavy Drinking that supports his contention that "the addict has a problem, but it is not a medical one: he does not know how to live. And on this subject the doctor has nothing, qua doctor, to offer."

According to Daniels, "The temptation to take opiates, and to continue to take them..., arises from two main sources: first, man's eternal existential anxieties, to which there is no wholly satisfactory solution, at least for those who are not unselfconsciously religious; and second, the particular predicament in which people find themselves. Modern societies have created, or at least resulted in, a substantial class of persons peculiarly susceptible to what De Quincy calls 'the pleasures of opium.'" Now it is the second source that Daniels elaborates upon in the following:

"...[I]n most western societies, there is now a class in which tedium vitae is very common, almost normal. This is the class from which the great majority of heroin addicts now comes....

The young of this class are disaffected, and have good reason to be so. They are for the most part poor, though not of course in the absolute sense. On the contrary, they are healthier, better fed, dressed, and sheltered than the great majority of the world's population, past and present, and dispose of appurtenances whose sophistication would have astonished our forefathers. But they are poor in the context of their own societies (which is what counts psychologically [such 'relative poverty' counts in other ways too, as Amartya Sen has recently argued]) and they are so badly educated (this time in the absolute sense) that any historical or geographical comparison, by means of which they might put their poverty in some kind of perspective, is completely beyond them.

They have no interests, intellectual or cultural. The consolations of religion are closed to them. As for their family lives, loosely so-called, it is usually of an utterly chaotic nature.... Their sexual relationships are a kaleidoscope of ephemeral couplings, often with abandoned offspring as a result, motivated by an immediate need for sexual release and often complicated by primitive egotistical possessiveness leading to violence and conflict. Their emotional life is intense but shallow, and their interactions with others governed by power rather than any kind of principle. Life is a matter of doing what you can get away with.

Their economic prospects are poor. They are unskilled in countries in which the demand for unskilled labour is limited. [....] Any work that they do will be repetitive and dull; and while a man might once have derived satisfaction from performing a menial task well, from leading a life of modest usefulness to others, this is not an age when such humility is very common.

In large part, this is because people live to a quite unprecedented degree in the virtual world of so-called popular culture. From the very earliest age, their lives are saturated with images of celebrities, whose attainments are often modest but who have been whisked by good fortune into a world of immense and glamorous luxury. This comparison with their own surroundings, squalid if not poor in the literal sense, is not only stark but painful, and is experienced as an open wound into which salt is continually rubbed. It is also experienced as an injustice, for why should people with tastes and accomplishments not so very different from their own lead a life of fairy-tale abundance? The injustice of which they feel themselves to be the victim reduces any lingering inhibitions against causing harm to society, which means in practice individual members of society. Crime ceases to be crime, but is rather restitution or justified revenge. And the fact that the abundance they so desire is itself empty and leads to dissatisfaction and boredom entirely escapes them.

The end result is that, while profoundly dissatisfied with their present lot, they do not have ambitions towards which they might actually work in a constructive fashion, but daydreams, in which every thing is solved at once in a magical way, daydreams from which the emergence into reality is always painful. Any aid to the perpetuation of the state of daydreaming (or reverie, as Coleridge and De Quincy call it) is therefore greatly appreciated."

Highly recommended. [Cross-Posted at the Ratio Juris Blog]

Patrick S. O'Donnell

On Stigma

And we're back! Sorry for the total darkness, but 125 pages of writing in 5 days will keep anyone busy. 

More substantive blogging is forthcoming, but for now, take a look at the latest issue of Social Science & Medicine, where the theme is stigma, an extremely important topic in the medical humanities and in health care in general.

(h/t SDOH Listserv)

Slow Blogging

Extremely slow blogging this week -- I'm writing my qualifying exams.  I don't think we'll be totally dark, however . . .

Health Wonk Review

This week's Health Wonk Review is up at Health Affairs Blog.  We made the Review, and, as always, it's worth checking out.

Conference: New Perspectives in Pharmaceutical History

The American Institute of the History of Pharmacy will host a conference entitled New Perspectives in Pharmaceutical History on Oct. 17-18, 2008, at the University of Wisconsin - Madison.

Here is the description from the web site:

The evolution of the modern pharmaceutical enterprise over the long twentieth century—from its early intersection with the image and later the structure of scientific research, to its dramatic postwar expansion and late-century saturation of medical and marketing media—has implications that stretch far beyond the traditional history of pharmacy and medicine to impact  broader social, cultural, economic, business, legal, regulatory, and political developments.  This conference seeks to foster and reflect on the growing body of pharmaceutical scholarship across historical disciplines and encourage novel theoretical and methodological developments by featuring newer scholars alongside more established figures in the field.

Some travel funds will be available for graduate students, and established scholars interested in using the resources of the American Institute of the History of Pharmacy can apply for travel funds through the Sonnedecker Visiting Scholar Program of the UW-Madison School of Pharmacy (click here for Special Sonnedecker Grants for Visiting Researchers information).  AIHP Conference Planning Committee: Jeremy Greene, Dominique Tobbell, Arthur Daemmrich, Michael Flannery, Elaine Stroud, and Greg Higby.

Call for Papers: Southern Association for the History of Medicine and Science

The Southern Association for the History of Medicine and Science (SAHMS) invites paper proposals for its eleventh annual meeting on March 6-7, 2009 in Birmingham, Alabama.  The meeting will be hosted by the University of Alabama at Birmingham.

SAHMS welcomes papers on the history of medicine and science, broadly construed to encompass historical, literary, anthropological, philosophical and sociological approaches to health care, including race and gender studies.  While some sessions will relate to the American South, SAHMS is open to a wide range of topics.  Past meetings have included ancient, medieval, modern European, African and Asian presentations.  Scholars from all areas and disciplines are welcome.  MD/PhD students may submit works in progress and should indicate their graduate student status.

Participants may propose individual papers or panels of several papers on a particular theme.  In general each presenter is limited to 20 minutes, with additional time for questions and discussion.  Please do not submit papers that have already been published, presented or scheduled for presentation at another meeting.  All participants are responsible for their own travel and registration costs.

Electronic submissions as e-mail attachments in MSWord or other readily supportable format are required (see e-mail below).  Submit a one-page abstract of the paper (about 250 words) stating the general thesis, sources used, research findings and general conclusions.  Include a one-page C.V. and cover sheet available on the website for each presenter.  Proposals should be submitted by September 30, 2008.  The program will be announced November 1, 2008 on our website-http://www.SAHMS.net.  All attendees will be expected to register for the meeting.

Students note: SAHMS offers a limited number of modest travel grants for student presenters to attend the meeting.  Those interested should submit to the program committee chair (1) a letter justifying his or her request at the time of the paper submission, (2) along with a letter of support from a faculty member with whom he or she works (this may be emailed directly to the program chair).  In no case does this exempt these or any students from paying the stated registration fee.

Send proposals to the Program Committee Chair: Mary E. Gibson, meg2e@virginia.edu.

(Note: In the past, the SAHMS has seemed quite receptive to proposals from graduate students).

(H/t H-SCI-MED-TECH Listserv)

On Socioeconomic Status and Health

Maybe there is hope after all.  A primary theme of MH Blog over the last 6-8 months has been the relative lack of attention paid to the social determinants of health in thinking about health policy.  However, when the New England Journal of Medicine runs an Editorial entitled Beyond Health Care -- Socioeconomic Status and Health (free full-text), co-authored by a social epidemiologist, no less, perhaps there is reason for cautious optimism.

Indeed, there are some signs that the policyscape may be shifting trajectories ever so slightly, what with the Commission to Build a Healthier America's focus on SDOH, the recent Health Affairs theme issue, Steven Woolf's recent article in JAMA.  Whether this discourse will translate into actual policy change remains, unfortunately, quite cloudy, IMO.  And in a society in which we cannot even marshal the support needed to insure basic care for its residents, I admit to skepticism that we can effect the wholescale changes in conception, allocation, and understanding (of health and illness) that would need to happen to bring about change in this arena.

Call for Papers: Prescribing Gender in Medicine

Call for Contributions to essay collection: Prescribing Gender in Medicine and Narrative.

The collection, under contract with a scholarly press, investigates gendered perceptions and representations of healers and patients in fiction, popular literature, poetry, film, television, and visual art.

To round out the collection, we are seeking additional papers on the following topics:

• gender in non-western healing
• men’s health issues
• reproductive health
• gender and healing in medieval culture/narrative responses to gender in medicine in the visual arts

Please submit completed papers and short CVs to angela.laflen@marist.edu and mblock@princeton.edu by August 15, 2008.

Papers should between 5,000 and 10,000 words (including Works Cited) and follow Chicago format. For more information please contact Angela Laflen and Marcelline Block at angela.laflen@marist.edu and mblock@princeton.edu.

(H/t H-Net-Disability Listserv)