Poverty and Health - University of Utah - School of Medicine

Poverty and Health
William Schecter, MD
Professor of Clinical Surgery
University of California, San Francisco
San Francisco General Hospital

Year
2008
2009
2010
US Poverty Rates
% Population
13.2
14.3
15.1
N (million)
39.8
44
46.6

Poverty and Health

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.

Material Capital and Health
Hospital Days per 1,000
1,250
1,000
750
4-fold
500
250
Los Angeles
Hospital Days and Household Income
Poor
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
Life Expectancy
at Birth (years)
Per capita GDP
(U.S. $)
U.S. Jordan
78
46,400
79
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
• People with incomes below the national
average lose more years of life than
gained by people with higher incomes
• The greater the inequality of income
distribution, the higher the mortality rate
Preston SH. The changing relation between mortality and level of economic development.
Population Studies. 1995(29):103-9.Lynch JW, Kaplan GA. Understanding how inequality in
the distribution of income affects health. J Health Psychology. 1997(2):297-314.

Measurement of Income Distribution

Distribution as Measured by Gini
Coefficient Over Time in the U.S.
Year Gini Coefficient
1967 (first year reported) 0.397
1980 0.403
1990 0.428
2008 0.466
http://en.wikipedia.org/wiki/Gini_coefficient

Country
Comparison of Income Distribution
(as measured by Gini Coefficient)
per Capita GDP and Life Expectancy
at Birth Among Countries
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

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 and
CAD
• Lack of access to healthful food
and opportunities for exercise →
obesity
• 14.6% of U.S. households at risk
for hunger

Race, Ethnicity, Poverty and
Health
• Life expectancy for African-
Americans lower than for white
Americans
• Racial disparities for access to:
– Coronary A/G and angioplasty
– Cardiac Surgery
– Vascular Surgery
– Renal Transplantation

Poverty, Trauma and
Emergency Surgery

Poverty, Race, Ethnicity and
Trauma
• Poor at increased risk for intentional
and unintentional injury
• African-American patients have
poorer outcome
• Race may be a surrogate for SES

* p =
Schecter SC et al. AAST 2011
* p = 0.03
0.03

Schecter SC et al. AAST 2011

Zip Code
A
94965.
94117.
94560.
94564.
94107.
94134.
94571.
93436.
94608.
94607.
Schecter SC et al. AAST 2011
Median Family Income by Zip Code
0 50000 100000 150000
Median Family Income

• 15% of trauma
admission at
Johns Hopkins
between
1997-2004 were
recidivists
Trauma Recidivism
• Risk factors for
recidivism
– Alcohol
– Mental illness
– Drug use
– Poverty
– Homelessness
– Youth gang
member
– Criminal Activity

The Abused Child
• 1460 children died due to abuse in 2005
• 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

Poverty and
Intimate Partner Violence
• 24.8% of women and 7.8% of men
have been raped or otherwise
assaulted
• 37-54% of women ED patients
report IPV in past.
• Recidivism in poor neighborhood
increases the risk

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