Low socioeconomic status means worse health -- but not for everyone

Poverty is bad for your health. Poor people are much more likely to have heart disease, stroke, and cancer than wealthy people, and have a lower life expectancy, too. Children who grow up poor are more likely to have health problems as adults. 

But despite these depressing statistics, many children who grow up poor have good health. In a new article published in Perspectives on Psychological Science, a journal of the Association for Psychological Science, Edith Chen and Gregory E. Miller of the University of British Columbia suggest a possible reason: some children have role models who teach them to cope with stress. 

"Who are these bright spots who, despite a lot of adversity, make it through and do well?" Chen asked. She suspects the answer has to do with stress. Growing up poor can be stressful, and stress increases the risk of developing chronic diseases. Poor children are less likely to have a predictable routine and a stable home; their parents may have to work multiple jobs to make ends meet and may not be able to afford to fix a leaky roof, for example. Poor children are also more likely to experience violence. One study found that nearly 50% of low income youth had witnessed a murder. 

In the face of this stress, Miller and Chen propose a strategy that may work to reduce stress and improve health. They call it "shift-and-persist." The first part, "shift," means reappraising things that are stressful. For example, if you get fired from a job, you can feel miserable and lash out at people around you—or you can reassess the situation to find the bright side. "You think, 'I wouldn't choose this, but maybe it's an opportunity to end up in a better job down the line,'" Chen says. Research on children growing up in adversity has found that children do well if they can self-regulate like this. 

But it's not enough to accept stressful situations. The second part, "persist," has to do with staying positive in the longer term—"holding out hope and finding a broader meaning in your life," Chen says. Shifting perspective on a particular situation helps in the short term, but, she says, "You have to do that with the idea that there's a broader goal in mind." Many studies have found that finding meaning helps people get through difficult situations, like spinal injuries or collective traumatic experiences like the September 11, 2001 terrorist attacks. 

The way most children learn "shift-and-persist" may be through positive role models, Chen says. Parents, teachers, aunts, and other adults can model healthy ways of dealing with stress and also teach children a sense of optimism about the world. 

The goal, of course, is to extend this help to other children. There are some hints that it may be possible to use community leaders to improve health, Chen says. "For example, in kids with asthma, if you get people in the community to serve as lay coaches for the parents, that can be beneficial to the kids," she says. It may also be possible to use role models in the community to teach more children to reappraise their stress and think positively about the future.  

Source: Association for Psychological Science [March 21, 2012]

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Is modern medicine ill with dehumanization?

"Anyone who has been admitted into a hospital or undergone a procedure, even if cared for in the most appropriate way, can feel as though they were treated like an animal or object," says Harvard University psychologist and physician Omar Sultan Haque. Health care workers enter their professions to help people; research shows that empathic, humane care improves outcomes. Yet dehumanization is endemic. The results can be disastrous: neglect of necessary treatments or prescription of excessive, painful procedures or dangerous drugs. 

What are the causes and effects of dehumanization in medicine? And what can be done about it? In Perspectives in Psychological Science, a journal of the Association for Psychological Science, Haque and co-author Adam Waytz at the Kellogg School of Management of Northwestern University synthesize diverse literatures to distinguish when dehumanization is useful from when it is not. Then they recommend "simple, cheap, and effective" changes to "make medical institutions more humane and ethical, as well as efficacious in the service of improved health," says Haque. 

The structures of institutions and the psychological demands of providing care can cause professionals to treat patients as less than human. "Deindividuation"—doctors as a sea of white coats; patients as half-naked bodies in smocks, identified by their disease or procedure ("the gallbladder in Room 38")—allows staffs to avoid taking responsibility for each patient. "Impaired patient agency" refers to medical staffs' treatment of patients as incapable of planning their own care, which is both infantilizing and demoralizing. "Dissimilarity"—hierarchies of power, differences of race, class, and gender between staff and patients—have roots outside the hospital. Nevertheless, they cause miscommunication and alienation, even maltreatment. None of these practices serves good medical care. 

More complex are dehumanizing practices that may aid care. Diagnosis and treatment might necessitate "mechanization"—breaking the body into organs and systems. Scaling back empathy can diminish staff stress and burnout. Even moral disengagement can be adaptive. From giving a shot to slicing into the flesh to perform surgery, medical care often requires inflicting pain or invading the boundaries of the body in violation of deeply held human taboos. And patients may die after even the best of care. For the professional, guilt could be paralyzing. 

Still, the authors argue, dehumanization is useful only in "specific contexts," such as acute care. Waytz says, "Dehumanization's functionality varies wildly across specialities from pediatrics to orthopedic surgery, so future research is needed to determine when dehumanization is most prevalent and most detrimental." In the meantime, the authors offer numerous humanizing fixes: Call patients by name, not numbers; discourage labeling people as diseases; personalize hospital rounds and pre-surgical preparation; eliminate opaque surgical masks; affix photos to CT scans and biopsies. Include patients in care planning. Let them choose their gowns—and design those gowns so they're no so humiliating. Increase physician diversity and hire people with good social skills. And, for med schools, perhaps most radical: Eliminate the "white-coat ceremony" when graduates don the mufti of the elect. 

Finally, "we should train medical professionals to think of themselves as mortal – sharing a common humanity and vulnerability with their patients," says Haque. Although dehumanization can be useful, "even functional dehumanization should be viewed like a potent, salutary, but dangerous drug that can have disastrous side-effects" when overprescribed. 

Source: Association for Psychological Science [March 19, 2012]

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Making Big Tobacco pay smokers' health bills: lessons from the United States

Reports that Nicola Roxon plans to encourage state governments to consider legal action to recover around A$31 billion in smoking-related health-care costs from the tobacco industry highlight the incoming attorney-general’s commendable commitment to reducing the impact of smoking-related illness and mortality. 

The legacy of the US Master Settlement Agreement holds significant lessons for policy makers in Australia [Credit: Razvan Caliman]

Such litigation is a potentially powerful way of countering the tobacco industry, but has been largely limited to the United States to date. As part of preliminary work on the proposal, Roxon has brought Matthew Myers, president of the leading US tobacco control organisation, Campaign for Tobacco-Free Kids, to Australia to discuss litigation with state officials. 

Myers, as The Australian points out, advised US attorneys-general during litigation against the tobacco industry in the late 1990s, and played a key role in negotiations that resulted in the controversial 1998 Master Settlement Agreement (MSA). 

While a spokeswoman for Roxon stated that Myers had been brought in to “share his extensive experience in tobacco-related litigation” and that the minister was “heartened by the support of such an esteemed anti-tobacco expert", the MSA has, in fact, had limited impact on the tobacco industry and effectively split the tobacco control community in the United States. 

Probably best known for its requirement that Philip Morris and other leading tobacco corporations make payments of US$246 billion to those states party to the settlement over a 25-year period, the MSA remains controversial within US tobacco control and broader public health circles, and it’s imperative that Australian officials consider the circumstances surrounding its progress carefully. 

The US Master Settlement Agreement 

The MSA was the result of secret negotiations between the tobacco industry, and attorneys-general and members of the tobacco control community including Myers. Critics of the negotiations claim the tobacco industry was on the defensive in the late 1990s – facing a combination of dozens of state lawsuits, damaging insights into its long-standing knowledge of the harms of smoking, and falling stock prices – and that state lawsuits should have been allowed to go to trial. In effect, the negotiations let the industry off the ropes. 

Under the terms of the MSA, the tobacco industry paid US$246 billion, agreed to fund a national initiative to reduce smoking and accepted limited restrictions on advertising. In return, outstanding litigation was dropped by the 46 states party to the settlement, and future state-level litigation was pre-empted. 

The final terms have been described by Allan Brandt, professor of history of medicine at Harvard Medical School and author of the book The Cigarette Century, as “a pale reflection” of earlier proposed settlements. As many had predicted, tobacco corporations passed the costs of the MSA on to consumers through sharp price hikes essentially making the agreement, Brandt contends, little more than a new excise tax on cigarettes. 

Settlement results 

Ostensible marketing restrictions in the agreement contained so many loopholes that spending on cigarette advertising and promotion has, in fact, increased dramatically in the United States since 1998. Not only has the MSA had virtually no impact on tobacco industry income or marketing practice, signatory states have realised little benefit from it. 

And while it may appear impressive, the agreed multi-billion dollar payment was insufficient to cover the costs of treating smoking-related illnesses and, more significantly, there were no assurances included in the settlement that monies received by the states would be dedicated to health-care and tobacco control programs. 

In many cases these funds have disappeared into general revenues, making state politicians reliant on this unexpected income, and effectively making the states partners of the tobacco industry. As Brandt argues, any new legal challenges to the industry have become “threats to the states' cash flow”. 

Australia’s tobacco control legislation is considerably more advanced than that in the United States, so concerns that the MSA does little to curtail industry advertising are largely irrelevant here. But the legacy of the MSA does hold significant lessons for policy makers in this country assessing the advisability of mounting legal action to secure compensation for smoking-related health-care costs. 

Most importantly, the MSA demonstrates that litigation, once launched, will have to be pursued diligently and without recourse to negotiated settlements with the industry. 

The experience of US states also underlines the importance of installing a regulatory mechanism that ensures any monies recovered from the industry are used to underwrite health costs related to tobacco use. Given his central role in the MSA negotiations, Myers' best advice to Australian policy makers may well be about what not to do in future litigation. 

Author: Ross MacKenzie | Source: The Conversation [December 16, 2011]

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Disabled children do matter

Many disabled children fail to reach their full potential because they continue to be marginalised in schools, health and social care, according to new research funded by the Economic and Social Research Council (ESRC). 

"We found that disabled children often experience discrimination, exclusion and even violence," say Professor Dan Goodley and Dr Katherine Runswick-Cole, who implemented the study at the Manchester Metropolitan University. "The biggest barriers they meet are the attitudes of other people and widespread forms of institutional discrimination." 

"Disabled children are seldom allowed to play and act like other children because of concerns about their 'leaky and unruly' bodies. But our study shows that many children who don't fit the narrow definition of 'normal' have untapped reserves of potential and high aspirations which can be fulfilled when their families receive effective support. There are also many amazing families who should be celebrated for the way they fight for their children.” continues Professor Goodley. 

The aim of the Does Every Child Matter, post Blair? project was to find out what life is like for disabled children and young people in the context of policy changes set in motion by the New Labour Government after 1997. The Aiming High for Disabled Children policy agenda was intended to enable disabled children to be 'healthy', 'stay safe', 'enjoy and achieve', 'make a positive contribution' and 'achieve economic well-being'. 

The findings, which are based on a series of interviews with disabled children and their families, reveal numerous barriers to these goals, for example: 

• Disabled children are often perceived by educational and care professionals as “lacking” and as failing to fit in with the image of ‘normal’; 

• Families who do not match the norm are frequently excluded from friendships, education and work; 

• The support system is complicated and there are gaps in provision, particularly during the transition to adulthood; 

• Physical access and transport barriers to sport and leisure activities result in segregation, while participation in art and creative activities is limited; 

• Widespread discriminatory attitudes threaten to create a culture of bullying; 

• Families of children with life-limiting/threatening impairments often experience isolation and poverty 

The researchers call for a change of attitude towards disability so that diversity is not only valued, but promoted. "There is an 'epidemic' of labelling children as disabled," Professor Goodley and Dr Runswick-Cole warn. "Parents are repeatedly under pressure to talk about what their children can't do in order to access services and support, but sometimes the label can obscure the individual. Families should be asked what support their child requires, not what is the 'matter' with him or her." 

Their report recommends that policy should prioritise enabling disabled children to break down barriers by supporting their participation in education, the arts, leisure and their communities and by meeting their communication requirements. "We need to re-think the culture of individualism and performance which pushes disabled children out" continue the researchers. "Pressures on schools are getting worse. We found a case where parents of non-disabled children petitioned to exclude a disabled child. What does this say about the meaning of education and community?" 

The study found that bullying is often accepted as inevitable when disabled children are perceived as vulnerable. There were several layers of violence, from manhandling in school to psychological bullying, which often goes unnoticed by adults. Some children do however stand up to bullies and refuse to be limited by labels that are imposed upon them. 

One young person insisted on attending Brownies meetings alone, despite health and safety rules that required her mother to accompany her. "Kids seem to enjoy challenging people's expectations about their limitations," the researchers commented. 

Source: Economic and Social Research Council [December 02, 2011]

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New report calls for decriminalization of assisted dying in Canada

A report commissioned by the Royal Society of Canada, and published today in the journal Bioethics, claims that assisted suicide should be legally permitted for competent individuals who make a free and informed decision, while on both a personal and a national level insufficient plans and policies are made for the end of life. 

End-of-life decision-making is an issue wrapped in controversy and contradictions for Canadians. The report found that most people want to die at home, but few do; most believe planning for dying is important and should be started while people are healthy, but almost no one does it. And while most Canadians support the decriminalisation of voluntary euthanasia and assisted suicide, both remain illegal under the Criminal Code of Canada. 

The Royal Society of Canada (RSC), a national organisation of distinguished scholars, artists and scientists, believes the time has come for a national debate on end-of-life decision making as assisted dying is a critically important public policy issue, where opinion, practice and the law seem out of alignment. 

"The society commissioned us, a panel of six Canadian and international experts on bioethics, clinical medicine, health law and policy, and philosophy, to prepare this report both to trigger a national conversation on end of life issues and contribute material for those discussions," said Professor Udo Schuklenk, Co-Editor of Bioethics, Professor of Philosophy and Ontario Research Chair in Bioethics at Queen's University, Canada. 

"It is clear that Canadians are not preparing adequately for the death we and all those we love will inevitably face," said Schuklenk. "Although most people think it is wise to make wishes for care at the end known (in case they are not competent to do so when the time comes) less than a third have some sort of formal advance directive, fewer than half have designated a substitute decision maker or even discussed their wishes with their families, and fewer than a tenth have discussed end of life care with their physicians." 

The report also reveals that quality palliative care is unavailable to many Canadians and that the scope of palliative care needs to continue to expand beyond cancer. There is also confusion and inconsistency around important aspects of care for the dying quite apart from euthanasia and assisted suicide. Palliative sedation and decisions to withhold or withdraw potentially life-sustaining treatments from patients against the wishes of their families require attention. Legal and clinical uncertainties around these practices cause much needless suffering for patients and stress for families and health care practitioners. 

"The issues only become more complex and contentious when confronting euthanasia and assisted suicide," said Schuklenk. "We carefully considered Canadian values, international experience in permissive regimes, and legal and ethical aspects of these practices and came to the unanimous conclusion that Canada should have a permissive yet carefully regulated and monitored system with respect to assisted death." 

Autonomy, or the capacity for self-determination, was also found to be a paramount value to Canadians in the RSC report. Respect for autonomy requires respect for competent individuals' free and informed decisions with respect to how and when they die. The RSC panel argue that the concept of dignity cannot provide a sound basis for either supporting or rejecting a permissive regime with respect to voluntary euthanasia or assisted suicide. 

"We discussed in considerable detail the arguments against assisted suicide. The evidence does not support claims that decriminalising voluntary euthanasia and assisted suicide poses a threat to vulnerable people," concluded Schuklenk. "The evidence does not support claims that decriminalisation will lead us down a slippery slope from assisted suicide and voluntary euthanasia to non-voluntary or involuntary euthanasia. The evidence does not support claims that decriminalisation will have a corrosive effect on access to or the development of palliative care. 

"Canadians must confront the difficult issues of our end of life care. As a society, we must do the same, acknowledging the need to formulate and enact a national approach to end-of-life decision-making that will bring compassionate clarity to this critically important issue of our time." 

Source: Wiley-Blackwell [November 15, 2011]

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Should doctors encourage people to donate a kidney to a stranger?

With three people on the kidney transplant list dying in the UK every day, should doctors encourage their patients to put themselves at risk for the benefit of others? Two experts debate the issue on bmj.com today. 

Associate Professor Walter Glannon from the University of Calgary argues that, although living kidney donation is relatively safe, "this does not imply that doctors should encourage healthy adults who are their patients to donate a kidney to a stranger." 

He points out that "doctors have an obligation of non-maleficence to their patients" and says: "It is one thing for a doctor to expose a patient to some risk in order to treat a disease; it is quite another to encourage a patient to put his or her own physical health at risk in order to benefit another." 

He adds: "There is nothing ethically objectionable about a competent adult initiating this process. But it is ethically objectionable when a doctor initiates it. 

Glannon believes that if a patient asks a doctor about living kidney donation, "then the doctor should do no more than provide information about the process in an impartial and unbiased way." But he warns that "encouraging these patients to be living kidney donors violates their obligation not to expose or incline them to a risk of harm." 

But Consultant Nephrologist, Antonia Cronin from the MRC Centre for Transplantation at King's College, London believes that encouraging altruistic donation is legitimate and that "living donor kidney transplantation must remain an integral part of the NHS strategy to save lives." 

Living donor kidney transplantation has an outstanding record, she writes, and donation to strangers now contributes 3% of the total UK living donor kidney transplant activity. The long term survival of living donors is good, and living donors express high levels of retrospective satisfaction with their decision to donate, she adds. 

She acknowledges that doctors do not have a moral obligation to encourage stranger kidney donations, but argues that "encouraging healthy competent adults to voluntarily donate one of their kidneys for the benefit of another by providing them with adequate information about the process involved and recognising the value of their donation is consistent with the ethos of the NHS, which exists for the common good." 

The key point, she concludes, is that "if something is not only not wrong to do but actually a good thing to do, then it cannot be wrong to encourage the doing of it." 

Source: BMJ-British Medical Journal [November 15, 2011]

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Doctors' own alcohol consumption colors advice to patients

Doctors who drink more themselves are more liberal in their advice to patients on alcohol consumption. They set higher thresholds for what is harmful, and while men who are heavy drinkers get to continue drinking, women are often advised to stop altogether, reveals a thesis from the Sahlgrenska Academy at the University of Gothenburg, Sweden. 

Doctors who drink more themselves are more liberal in their advice to patients on alcohol consumption

Researchers at the University of Gothenburg's Sahlgrenska Academy have for the first time looked into how family doctors' own drinking habits affect their advice to patients. The study, which took the form of a questionnaire for doctors in the county of Skaraborg, revealed that those who drink larger amounts set significantly higher limits for harmful levels of consumption than those who are teetotalars or drink little. 

Gender plays a role 

Gender also plays a role in the advice doctors give. Where men and women present with the same health problem and consume comparable amounts of alcohol, male heavy drinkers are often advised to cut down on their drinking, while female heavy drinkers are urged to stop drinking altogether. 

Men less likely to be referred for treatment 

Heavy drinkers are also much less likely to be referred for treatment if they are men than if they are women – especially if the doctor is a man. "Doctors who drink more have a more liberal view of alcohol, but their attitude is also coloured by high consumption among men being the social norm," says Magnus Geirsson, doctoral student at the Unit of Social Medicine at the Sahlgrenska Academy and himself a family doctor in Skaraborg. 

More training, higher limits 

Doctors' alcohol training also plays a role, but perhaps not as one might expect. Nine out of ten doctors in the study set the limit for safe alcohol consumption below the Swedish National Institute of Public Health (FHI) recommendations of 14 units for men and nine for women. Interestingly, doctors who had the most alcohol-related training and considered themselves knowledgeable in the area set higher limits, but they were still below the FHI recommendations. 

Government project made no change 

"This may be because doctors feel that the FHI sets the limits too high, but it could also be that doctors who feel less confident in this area prefer to be more cautious", says Geirsson. 

His thesis also shows that the training activities carried out as part of the government's five-year Risk Drinking Project, which aimed to make alcohol-related issues a natural part of health care, have porobably not led to the desired effects of increasing the numbers of patients being adviced on alcohol, in spite of a considerable increase in the numbers of GPs and nurses that consider themselves to be more skilled in giving such advice. 

Source: University of Gothenburg [October 31, 2011]

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Obesity and depression independently increase health costs

Obesity and depression both dramatically increase health care costs, but they mainly act separately, according to a study published in the November 2011 Journal of General Internal Medicine by Group Health Research Institute scientists. Gregory Simon, MD, MPH, a Group Health psychiatrist and Group Health Research Institute senior investigator, led the research. 

“Previous research shows that both depression and obesity are associated with higher health care costs,” he said. “But depression and obesity often occur together, so it was important to know if the relationship between obesity and cost is really due to depression—or vice versa.” 

Simon and his colleagues tested whether depression confounds the increase in health care use that is associated with obesity. Confounding means an apparent connection—such as the link between increased health care costs and obesity—is influenced or even caused by a third factor. In this study, the authors tested if depression confounds the increase in health care seen in obese patients. 

The study used telephone interviews to determine obesity and depression, and Group Health’s extensive medical records to calculate health care costs for 4,462 women aged 40–65. All were enrolled in Group Health Cooperative, a nonprofit health care system in Washington and northern Idaho. Obesity was measured as body mass index (BMI), a standard obesity measure that is calculated from height and weight. A BMI below 25 is considered normal weight, 25-30 considered overweight, and over 30 is considered obese. Depression was measured with a 9-item American Psychiatric Association questionnaire. 

The researchers found: 

• In middle-aged women, health care costs increased with obesity. Specifically, costs increased 65 percent in women with a BMI of 30-35, and 157 percent in women with a BMI higher than 35, compared to women of normal weight. 

• The trend was similar for all types of health care that the researchers examined: primary care, outpatient prescriptions, specialist visits, inpatient care, and mental health care. 

• Health care costs increased with higher depression scores, but depression was a not a major confounder of the obesity results. 

• Even accounting for depression, health costs increased with every rise in BMI category. 

The study concluded that in this population of women, obesity is associated with higher health care costs, but not because of co-occurring depression. Similarly, depression is associated with higher costs, but not because of co-occurring obesity. These higher costs have an economic impact. Increased costs associated with depression were spread across all types of health care, not just mental health care. 

“Obesity and depression are both very common,” Dr. Simon said, “so the increased costs we find add up to a very large amount in the general population.” The relationships among obesity, depression, and chronic illness related to obesity are complex, as are the effects of depression on behavior and health. But one thing is clear, the study’s authors said: Effective obesity prevention is a crucial factor in tackling our rising health care costs. 

Source: Group Health Research Institute [October 31, 2011]

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