Social Injustice and Public Health
http://www.100md.com
《新英格兰医药杂志》
Medical advances often focus on adjusting biology to cope with hostile environments — repairing damage from infectious agents, fast food, tobacco, violence, automobile accidents, and other adversities. Laboratories around the world search in our genes for the causes of and cures for hypertension, diabetes, and even broken hearts.
In contrast, scant effort goes into altering environments that make us sick. Yet, sanitary measures have played a bigger role than antibiotics in ameliorating infectious diseases; a rising standard of living trumps sophisticated medical technology as a route to longevity; and the modern epidemics of diabetes, hypertension, and cardiovascular disease are man-made — these disorders were virtually nonexistent, even among the elderly, in preindustrial societies.
It is tempting to apportion causation between genes and environment as if slicing a pie; intuition says that if genetic predisposition explains 70 percent, only 30 percent is left for environmental factors. But intuition is wrong. Phenylketonuria is simultaneously 100 percent genetic and 100 percent environmental. Without the gene, the disease does not exist, and without dietary exposure to phenylalanine, there is no disease. In a similar way, no European had tobacco-caused disease before 1492, regardless of genetic propensities to smoke tobacco.
Power and position shape each person's environment. Some people purchase private environments insulated from noxious insults — lead-free homes in leafy suburbs where stores are stocked with designer vegetables. Others come of age amid crime, poverty, liquor stores, and McDonald's. For some, a high level of glycosylated hemoglobin means a personal trainer, gourmet salads, and meticulous glucose monitoring. For the homeless, it means eating whatever is available, feet that are often cold and wet, and no place to store insulin, much less a glucometer.
Social Injustice and Public Health is an invaluable primer on how inequity breeds ill health. In each chapter, distinguished scholars review one aspect of this overarching theme. The first section deals with specific populations, such as the poor, women, children, and prisoners. The second analyzes such mediators of ill health as violence, occupational hazards, and a lack of medical care. Each chapter closes with a brief section on "what needs to be done," a theme addressed more extensively in the final section's in-depth discussions of promoting medical justice through education, research, human-rights advocacy, and other methods.
This fine book challenges readers with innovative concepts and a wealth of eye-opening facts. The chapter exploring America's mass incarceration of the poor is particularly shocking. With only 5 percent of the world's population, we have 25 percent of the prisoners; 300,000 people are incarcerated for marijuana-related offenses annually; and 2.5 million schoolchildren have a parent in jail. Another chapter elucidates the historical roots of housing inequality: redlining by banks is only the latest in a long series of policies that have helped whites and blocked blacks from accumulating housing assets, reproducing the discriminatory effects of the Homestead Act of 1862 and the GI Bill of 1944. The international analysis documents inequities (the richest 1 percent of the world's population receives the same income as all those in the bottom 57 percent combined) and indicts international financial institutions that have forced poor countries to slash health spending. A chapter on inequities in U.S. medical care analyzes how private health insurers hold Americans hostage to an unfair and bureaucratic health care financing system and have muscled their way into the Medicare Part D program.
This book is ideal as a textbook for courses that address the social basis of ill health. It should be widely read by policymakers and practitioners looking for a passionate and scholarly review of societal changes that would avert enormous suffering.
Steffie Woolhandler, M.D., M.P.H.
David U. Himmelstein, M.D.
Cambridge Hospital
Cambridge, MA 02139
steffie_woolhandler@hms.harvard.edu(Edited by Barry S. Levy a)
In contrast, scant effort goes into altering environments that make us sick. Yet, sanitary measures have played a bigger role than antibiotics in ameliorating infectious diseases; a rising standard of living trumps sophisticated medical technology as a route to longevity; and the modern epidemics of diabetes, hypertension, and cardiovascular disease are man-made — these disorders were virtually nonexistent, even among the elderly, in preindustrial societies.
It is tempting to apportion causation between genes and environment as if slicing a pie; intuition says that if genetic predisposition explains 70 percent, only 30 percent is left for environmental factors. But intuition is wrong. Phenylketonuria is simultaneously 100 percent genetic and 100 percent environmental. Without the gene, the disease does not exist, and without dietary exposure to phenylalanine, there is no disease. In a similar way, no European had tobacco-caused disease before 1492, regardless of genetic propensities to smoke tobacco.
Power and position shape each person's environment. Some people purchase private environments insulated from noxious insults — lead-free homes in leafy suburbs where stores are stocked with designer vegetables. Others come of age amid crime, poverty, liquor stores, and McDonald's. For some, a high level of glycosylated hemoglobin means a personal trainer, gourmet salads, and meticulous glucose monitoring. For the homeless, it means eating whatever is available, feet that are often cold and wet, and no place to store insulin, much less a glucometer.
Social Injustice and Public Health is an invaluable primer on how inequity breeds ill health. In each chapter, distinguished scholars review one aspect of this overarching theme. The first section deals with specific populations, such as the poor, women, children, and prisoners. The second analyzes such mediators of ill health as violence, occupational hazards, and a lack of medical care. Each chapter closes with a brief section on "what needs to be done," a theme addressed more extensively in the final section's in-depth discussions of promoting medical justice through education, research, human-rights advocacy, and other methods.
This fine book challenges readers with innovative concepts and a wealth of eye-opening facts. The chapter exploring America's mass incarceration of the poor is particularly shocking. With only 5 percent of the world's population, we have 25 percent of the prisoners; 300,000 people are incarcerated for marijuana-related offenses annually; and 2.5 million schoolchildren have a parent in jail. Another chapter elucidates the historical roots of housing inequality: redlining by banks is only the latest in a long series of policies that have helped whites and blocked blacks from accumulating housing assets, reproducing the discriminatory effects of the Homestead Act of 1862 and the GI Bill of 1944. The international analysis documents inequities (the richest 1 percent of the world's population receives the same income as all those in the bottom 57 percent combined) and indicts international financial institutions that have forced poor countries to slash health spending. A chapter on inequities in U.S. medical care analyzes how private health insurers hold Americans hostage to an unfair and bureaucratic health care financing system and have muscled their way into the Medicare Part D program.
This book is ideal as a textbook for courses that address the social basis of ill health. It should be widely read by policymakers and practitioners looking for a passionate and scholarly review of societal changes that would avert enormous suffering.
Steffie Woolhandler, M.D., M.P.H.
David U. Himmelstein, M.D.
Cambridge Hospital
Cambridge, MA 02139
steffie_woolhandler@hms.harvard.edu(Edited by Barry S. Levy a)