The socioeconomic impact of immigration is substantial. Between 2001-2011, immigration accounted for 40% of total population growth in the OECD. According to the International Migration Outlook 2013, high-income countries continue to attract immigrants and students from around the world since the global financial crisis of 2008. India, China, Poland and Romania are top countries of origin into OECD countries. In the face of rising unemployment, migrants’ labor market situation has worsened compared to natives over the past years particularly for Latin Americans in the US and migrants from North Africa in Europe. In a country such as the US, where immigrants are often young and the social safety net is not large, the effect of immigration is often more positive—increasing the GDP by 0.03 percentage points.
Strong sentiments against immigrants particularly unauthorized immigrants in the US and a dysfunctional Congress have delayed immigration reform legislation (S.744) which calls for an eventual pathway to citizenship for undocumented immigrants while ramping up border security measures. Certainly there is enthusiastic support for the recruitment, hiring and retention of highly-skilled foreign workers (H-1B visas) with economic implications. (How this policy is affecting the global health care workforce crisis is the subject of discussion another time).
Research and practice have highlighted the increased risk for disease, trauma and social stressors among this population (low-wage immigrants and refugees) from discrimination, substandard living and exploitative labor conditions. There is a growing public health literature that favors access to health care for immigrants but also one that is concerned with disease transmission (TB, HIV, STI) and national security threats (Viladrich, 2012). The public discourse on immigration comprises a full spectrum of model to undeserving immigrants, welfare-dependents to drivers of economic growth.
I would argue for a more “simplistic” view of immigrants. Migration is an undeniable fact of life. Of course there are differences in how our society regards undocumented immigrants and the native poor but our policy should aligned with the concern for social inequality and how we treat and provide for those less fortunate—all racial ethnic groups and no matter how they come to live in America. In hard times (economic or political upheavals), feelings and beliefs about self-sufficiency and individual responsibility trump justice and humanitarian consideration and create ethnic tensions pitching one group against another. Even the argument to provide immigrants with health care and social benefits for the sake of self-interest and return on investment seems like a weak cover for avoiding the discussion of poverty and social justice. If we use this same lens to approach vulnerable immigrants and low-income Americans then we are all better off on the road to policy and legislative reform that will benefits all Americans.
The current problem with the health care market place enrollment under ACA and the driver behind Obamacare beg the question of the role of government in our daily lives but particularly when it comes to improving health. Obamacare is essentially a conservative program, market-driven private insurance exchanges, built on means-testing, state decentralization and promise of billions of dollars in future subsidies to expand coverage for those in the lower income brackets. The ultimate beneficiaries might be insurance companies, corporate medicine and a relatively small number of Americans with new insurance coverage and fewer out of pocket spending.
Opponents to ACA cite cost, government bureaucracy, economic impacts but probably the core value and beliefs at stake are the role of government, charities and what we should do about inequalities in our society, if at all? I would like to tackle our love-hate relationship with charity.
Americans are known to be very charitable people globally as individuals, corporations, nonprofits and government. Republicans (speaking in generality) like charities but favor market-approach or they just don’t like governments to be the facilitator. Ricardo Salinas, founder and CEO of Grupo Salinas said in a recent interview by Charlie Rose: “Charity is limited….not self-sustaining.” He himself has supported a Mexican non-profit organization that promotes microfinancing and social responsibility. This issue has been and is currently studied and explored globally.
GiveDirectly is an organization that allows governments and foundations to provide direct cash transfer to the extreme poor. It collaborates with Innovations for Poverty Action (IPA) to conduct a RCT in western Kenya where recipients received an average of $500 over 9-12 months. Recipients were free to spend the transfer as they wished. The study (May 2011-Jan 2013) found that GiveDirectly’s transfers allow poor households to do home improvements, increase livestock holdings, spend on food, health care, education and social and family events which led to reduction in hunger and food insecurity and increase in psychological well-being. Transfers do not increase spending on alcohol and tobacco and have little impact on health or education over this short evaluation period.
A November 2013 publication in AJPH by Guanais examined the combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil from 1998-2010. There are 13 million families enrolled in the federal program as of 2010 which provides cash to poor families if they comply with regular school attendance and use of preventive care services. His analysis confirms earlier evidence that the primary health care expansion contributed to the reduction of the postneonatal infant mortality rate in Brazil and adds new evidence that conditional cash transfers from the Bolsa Familia Program may have helped to overcome important barriers to some forms of primary health care because of low family income.
So what’s the connection to Americans and Obamacare? We are not the same as Africans and Brazilians you say. By the way, we call cash transfers by government/tax payers to poor people welfare and entitlement programs; cash transfers by foundations/corporations charity, gifts, donations; by business groups and non-profits: social enterprise. We disdain the first category and glorify the latters. Contrary to the views of many, Obamacare is NOT really an entitlement program. What do you call cash transfers from government to corporations? As a whole, we don’t have the patience to wait and reap the impacts of cash transfers to the poor. We accept the fact that as our economy is recovering, US income inequality is still on the rise. We accept random acts of kindness over large-scale programs in the name of libertarian ideals and personal responsibility. We (speaking as a country) did not endorse health care as a human right and so single payer system. In health care, we need to innovate beyond neoliberal ideology because confined within that framework, we got Obamacare and all its mess (and it’s just the beginning).
Putnam warned over 10 years ago that we had become more disconnected from family, friends and neighbors, and he thought we could revitalize our civic and religious engagement and rebuild our social capital.
Pantell and colleagues reported in the September issue of the AJPH that social isolation is a predictor of mortality comparable to traditional clinical risk factors such as hypertension and smoking! They imply that clinicians and their staff, health plans should screen for social isolation asking 4 questions such as:
1. Marital status
2. In a typical weeks, how many times do you talk on the phone with family, friends or neighbors?
3. Do you attend church or religious services 4 or more times per year?
4. Do you participate or belong to a club or organization such as a church group, union, fraternal or athletic group, or school group?
It is questionable whether these are easily modifiable risk factors and whether interventions will result in reduction in mortality. There was a study (and probably more since) which showed impaired transcription of glucocorticoid response genes and increased activity of pro-inflammatory transcription control pathways providing a functional genomic explanation for elevated risk of inflammatory disease in individuals who experience chronically high levels of subjective social isolation. Would health plans reward members for activities that decrease their social isolation?
On a separate topic and totally my venting regarding the government shutdown: under the rules of the federal government shutdown, members of Congress will continue to receive their salaries--even as hundreds of thousands of government workers are furloughed without pay! talking about fairness and inequality!!!
Many economists and researchers have written about the growing inequality in the US. Tyler Cowen's latest book: Average Is Over like many others supports the theme of widening gap between rich and poor. How does inequality manifest in medicine or health care? Most physicians cite lack of access! Health services researchers tend to focus on behaviors (e.g. adherence) and health systems factors such as quality indicators and cultural competency. More and more, our society (“regular folks,” politicians, even public health advocates and health care providers recognize the importance of providing equal opportunities for all Americans, support growth of the middle class and on issues such has housing, jobs, education (social determinants of health) BUT increasingly accept that we
as a country thrive on a compassionate survival of the fittest mentality.
Let me give you an example, abeit a more extreme one. I just came off a 2-week inpatient service and my team worked with a patient who has a substance use as well as a chronic pain problem. He has to remain in the hospital for 6 weeks of IV antibiotics because home health would not accept him due to past behavioral issues. All hospital staff and consultants have advised against giving him opioids because of repeated positive urine drug screen for cocaine and as a high risk candidate. In my opinion, he
has pain due to current vertebral osteomyelitis and multiple back
surgeries. He does not see himself as an addict (self-denial possible) but use crack/cocaine to alleviate the pain. I have treated, crossed
paths with several patients struggling with addiction and certainly some have benefited from second chances—government initiatives, private and faith-based programs BUT more and more, our society has made it tougher for people to have additional second chances. When someone does not make it in life, it is attributed to their moral and behavioral failings and not social and environmental factors modifiable through policy and
structural changes. Sometimes, it does not even require such momentous efforts, just a few individuals getting together agreeing on doing the right thing.
I have dabbled in social support interventions over the years through the Pittsburgh Caregiver Support Network, involvement with patient navigator/advocacy activities and peer support groups but a phone call with a patient earlier today brought reality to a complex issue in American society. I called my patient whom I've known for over 10 years to inform her that the blood culture obtained the day before from urgent care has turned positive and that she needed to be directly admitted. Her partner completely broke down on the phone. Through the anger and despondent sobbing, I could make out: who is going to watch our daughter...you know you can't trust leaving L. in the hospital without someone watching over her. They'll give her the wrong medications...and it's July, all those new interns...and my mother, I have to take care of my mother. Can you arrange for the antibiotics at home...will the ID doc see her on a holiday? Dozens of questions hurled at me, most of which I do not have answers although I do know that I could get more blood culture drawn, IV line and empiric antibiotics started in the hospital. Could I say for certain that she would be safer in the hospital than at home? guilt and embarrassment choked up inside me...
What my patient and her partner need is what is labeled an informal social support--family, friends and trustworthy sources. A formal social support, in contrast, is usually more bureaucratized, stigmatizing, costly, less personalized and accessible. How do you engender trust and perception of support in formal social support network? How do we promote public policy that build family social support? These are some of the programs compiled by the RWJF and County Health Rankings & Roadmaps.
I attended the 2013 PNCIS conference recently and am struck by the problem of blight in the Mon Valley. According to one spokesperson, in the North Braddock neighborhood which has close to 2000 properties, about 300 are “abandoned.” I wonder about what revitalization efforts are going on in these communities? Where the bulldozers are probably the most effective tool accordingly to some experts. Some cities and municipalities are focusing on local arts and gardens or urban agriculture. Another speaker talked about increased in 911 calls, police and fire service in blight neighborhoods. I thought about health effects on surrounding residents (more later on this topic). For educators, the NYTimes has a great resource to examine urban decay and renewal for public health students.
It is exciting to see the development of open data in city government but I would love to see the connection with health databases (ACHD, academias, health systems) recognizing the barriers to this process. The day will come...
A new TED book, The Upstream Doctors, by Rishi Manchanda, also urged health care practitioners to look upstream for the sources of our problems, rather than simply go for quick-hit symptomatic relief. It has a nice introduction by Paul Farmer.
Suicide rate has increased about 28% among middle-aged adults (baby boomer generation) in the US over the last decade as published in the CDC MMWR 5/3 issue. Among racial/ethnic populations, the greatest increase were observed among American Indian/Alaska Natives and whites with mechanism ranging from suffocation, poisoning and firearms.
The report acknowledged that most suicide research and prevention efforts have focused on youths and older adults rather the 35-64 age groups. Economic challenges, job loss, social support, community connectedness, intimate partner problems or violence, the stress of caregiver responsibilities (often for children and aging parents), mental health, substance use, and declining health or chronic health problems are key issues to address.
Unfortunately, for those who are socioeconomically depressed, they are also being reminded of their political disadvantages--examples of the selective budget sequestration effects and actions or lack of by Congress. The poor will experience hardship from funding cuts to programs like Head Start, food pantries, Meals on Wheels and unemployment benefits while many of us are thankful for swift action to prevent furloughs for FAA personnel and flight delays.
Sequestration and cancer treatment, Medicare cuts...that's an
My friend Joe mentioned to me that he was in a Steelers bar in Seattle and amused by my amazement and football naivete, he went on to explain about the imploding of the steel mills in the late 70s, job lost and migration of loyal Steeler fans out of Pittsburgh to major cities…
The latest Bureau of Labor Statistics revealed both the number of unemployed persons at 11.7 million, and the unemployment rate, at 7.6% in March, 2013. About 46.2 million Americans lived below the official poverty level in 2010 and about 10.5 million individuals were among the “working poor.” The working poor are individuals who were in the labor force for at least 27 weeks during the year but still had incomes below the official poverty level. Our work affects our health in many ways and vice versa (check out the issue brief by RWJF on work and health).
Work and workplace provide us with income, benefits, opportunities to obtain food, housing, medical care but also a source of stress and potential exposure to physical risk and hazards, all with implications for physical and mental health. Americans are known to work longer hours compared to most Europeans and the US is one of the few developed nations without universal paid sick days. There is also another disheartening statistics: since 1977, the life expectancy of male workers retiring at age 65 has risen 6 years in the top half of the income distribution, but only 1.3 years in the bottom half (not surprising).
There are a number of work-based strategies to improve health—smoke-free workplace, lifestyle management/wellness, screening, prevention, flexible work (Yahoo, Best Buy no more?), retraining, etc. However, tough time has a way to erode many of these programs from the decline in unions to work-place-based education and training and better wages…As a physician (not an occupational health doc), having daily encounters with patients burdened by work-related health problems in some form or another although this is rarely ever their primary complaint, what should be my role? Particularly workers in lower-status and lower-wage jobs? Are they empowered to make change? Could I facilitate this process, provide access to the right skills and resources to break this vicious cycle of unemployment or work environment and poor health. I’m back to the question: What doctors can do about social determinants of health?
There are perhaps 3 factors in question 1) lifestyle--fast food, increase in consumption of food away from home, decreased physical activity, occupation 2) agricultural subsidies and 3) growth in agricultural productivity (smaller % of household food budget, global phenomenon). Studies are not definitive. Economic simulations have found that removing subsidies for grains and oilseeds would have negligible effects on caloric consumption and eating habits (Rickard B. Health Econ. 22: 316-339 (2013). There are also a number of other plausible contributors--sleep deprivation, pharmaceutical-induced weight gain (see this comprehensive review article). This is a complex question and is probably multifactorial with the BIG 2 most targeted at this time. (
"I wish to do something Great and Wonderful, but I must start by doing the little things like they were Great and Wonderful"