Thursday, July 4, 2013

Health Disparities Should Be Taken to Heart

We were saddened by the death of actor James Gandolfini who died of a heart attack on June 19th, 2013. Interestingly, as is sometimes the case when a celebrity dies, his passing has been used as an opportunity to teach people about health and disease--in Gandolfini's case heart disease (think of Rock Hudson and HIV, Bette Davis and breast cancer). In my opinion, however, a big opportunity to teach about how disease and death really happen was missed by the coverage, and in one way the coverage was actually harmful. I'll write about that and what it has to do with public health in Mid-Michigan below, but first, how has the press covered Gandolfini's heart attack?

Writers like Ken Sepkowitz who wrote about Gandolfini in the Daily Beast on June 20th, and Maggie Fox writing for NBC on the 21st, appropriately used his death at the relatively young age of 51 to warn that heart disease remains the leading cause of death in the United States. As Sepkowitz wrote:

"The CDC tracks the impact of cardiac disease closely, and the numbers are staggering. According to their statistics, about 600,000 people in the U.S. die from heart disease each year, meaning heart attacks, heart failure, rhythm disturbances, and other problems. It’s the nation’s No. 1 killer. Of these deaths, coronary heart disease—the narrowing of the arteries that feed the heart—accounts for more than half the deaths."

The writers of these articles call for individuals to lead healthier lifestyles, for more awareness of heart disease, and laud improvements in medical technology. So, what's wrong with that?

One thing that is wrong is the perpetuation of the myth that a big killer like heart disease is not really a public health problem, but is more related to individual choices. It’s the idea that heart disease is happening because individuals are making "bad choices" and if they'd just stop it we'd be fine. The reality is that widespread heart disease is the result of public policies that harm people's health, and the solutions to it also lie in the public sphere.

Consider this: heart disease mortality rates have been cut in half in the past 35 years. In the jurisdiction of the Mid-Michigan District Health Department, heart disease deaths have declined from over 400 per 100,000 people in 1980 to 206 today.* This amazing drop is mostly due to the sharp decline in smoking--the rate of smoking was also halved during the same period. Significant reductions in smoking were only achieved after policies were enacted that prevent people from smoking in public places, workplaces, restaurants and bars. The other important contributing factor is advances in medicine--if you do get heart disease you are a lot less likely to die of it today--and these advances are largely the result of public, not private, investments. Thank goodness for these positive trends since as we know, other risk factors like obesity and hypertension have been moving in the wrong direction.

The other thing that is wrong is that the coverage continues to foster the belief that everyone needs to be equally concerned about heart disease. The reality is that heart disease, like most health threats, tends to prey on vulnerable, low-income people. Generally speaking, people of Mr. Gandolfini's stature, and others who are well-off (if not rich), are comparatively less likely to get heart disease than working class, unemployed, uninsured people and minorities.

For example, lower income people are twice as likely as those with higher incomes to be living with heart disease.  In Michigan, nearly 7 percent of those with incomes under $35,000 have been told by a doctor they have heart disease, while only 3.6 percent of those with incomes over $75,000 have heart disease.

Lower income people tend to have more risk factors for heart disease. Nearly 40 percent of adults with incomes under $35,000 have been told they have high blood pressure and 45 percent have high cholesterol. But among those with incomes over $75,000 only 26 percent have high blood pressure and 36 percent have high cholesterol.

Do low-income people really die at a higher rate from heart disease? Of course they do, and we see this at the Mid-Michigan District Health Department.  Consider one of our counties, Clinton County, which is one the state's wealthiest, with an average household income of over $58,000 dollars per year. Clinton has a very low heart disease mortality rate, only 181 per 100,000 people. In contrast Gratiot and Montcalm are lower income counties with household incomes right around $40,000. The heart disease mortality rate in Gratiot is 244 and it is 204 in Montcalm.

The failure to acknowledge these health disparities makes it very difficult for people to identify the kinds of actions that are truly necessary to improve health—actions that would reduce the economic and social inequality that cause so much poor health in the first place. For example, groups that are still called “minorities” (although they are majorities in some other parts of the country), like African Americans, Hispanics and Asians are still in the low single digits as a percentage of the population in Mid-Michigan. This leads some to say, “We don’t have diversity here”, or “We don’t have disparity here.” And if we don’t have diversity or disparity then health problems here must not be due to inequality, they must be due to “bad choices”.  How can Mid-Michigan elected leaders vote against the expansion of Medicaid to bring relief to their constituents who are suffering without affordable health care (Courageous Senator Roger Kahn is a notable exception)? Because, they think, around here we don’t have disparity, we have people who made bad choices who have to live with the consequences.

But the reality is we DO have disparity in Mid-Michigan: severe, lingering economic and social inequality that is all the more pernicious because it is invisible to some of us—invisible even though it is obvious in the unemployment statistics, the poverty rates and on the faces of our clients at the Health Department.

The best way writers like Sepkowitz and Fox can help Americans fight disease and death is to emphasize at every opportunity its economic and social causes. When we can see the inequality around us, then we’ll be able to embrace policies, like Medicaid expansion, that can change it.  

A happy, healthy Fourth, everyone! 

*The data used in this post come from the Michigan Department of Community Health and can be found at In particular look at the Behavioral Risk Factor Survey which has data broken out by income.