I have not yet seen an argument for using curative health care as a direct
mechanism to correct for distributive inequities in health outcomes. Does
anyone have references to what and whom Adam is arguing against? thanks
-----Original Message-----
From: Oliver,AJ [mailto:[log in to unmask]]
Sent: Thursday, November 25, 2004 10:55 AM
To: [log in to unmask]
Subject: Re: Not Such A Quick Question
Mike
You are talking about improving equal access for equal need for curative
health care (which I agree to), rather than using curative health care as a
direct mechanism to correct for perceived inequities in the distribution of
'health outcomes' caused by the underlying socioeconomic structure (which I
don't agree to, and I doubt that most people would agree to this either, if
they fully understood all the implications). But I give up (for now).
Best,
Adam
-----Original Message-----
From: Mike Hughes [mailto:[log in to unmask]]
Sent: Thu 25/11/2004 01:20
To: [log in to unmask]
Cc:
Subject: Re: Not Such A Quick Question
True, this isn't such a quick question. (I also think Michael's
comments are
important, and Barbera's lecture is a must read)
I don't sign up to Adam's line that use "of curative health care to
deliberately narrow health outcomes" is morally reprehensible.
Curative
health care in the UK (and other developed nations) is actually
limited and
reactive in a way which does in fact narrow health outcomes.
It narrows health outcome in favour of the relatively priveleged
over the
relatively disadvantaged.
That is one reason why since the foundation of NHS and the the
free-at-the-point-of-delivery UK health system in 1946 the health
gap has
continued to widen, rather than narrow.
To get to the heart of the issue perhaps its easier to focus at
first, and
more narrowly, on acute ill health end of the health inequity
spectrum,
represented by universally identified disease.
Doing nothing about when, during the natural history of a disease,
curative
services impact on that disease is not a morally defensible
position.
Curative services need to work differently for different sections of
the
community - to ensure access at the same and best point of that
natural
history. That means it is OK to have have simple health marketing
and
passive, reactive services for those who are sensitive, aware of
and
responsive to their own health status and confident and able to
negotiate
appropriate and effective treatment. It means we need to have
pro-active
services for those who aren't. If the cases aren't going to come to
the
service in good time, the service must seek out the cases quickly.
I don't think this is rocket science, and it underpins the broader
inequity
argument - and I thought consensus - that one-size-fits-all services
not
only can't tackle inequity, but they exaccerbate it.
I appreciate Adam isn't directly arguing for one-size-fits-all
curative
services; but he is arguing for their actual irrelevance to
inequity. I just
don't buy it. All my experience and a growing body of evidence,
suggests to
me that discriminatory curative services are one of the root causes
of
inequity; from ethnocentricism, through institutional racism,
individual
practitioner discrimination, class discrimination and post/zip code
prescribing and preferrence of other sorts.
Mike Hughes
----- Original Message -----
From: <[log in to unmask]>
To: "Mike Hughes" <[log in to unmask]>
Cc: <[log in to unmask]>
Sent: Tuesday, November 23, 2004 4:08 PM
Subject: Not Such A Quick Question
>I agree with the comments below. There are actually two issues
with regard
> to non-urgent/scheduled care:
> the lack of a pro-poor gradient for many elective procedures
where
> normative or clinical "morbidity" is more common in the poor
> the existence of an SeC gradient in uptake of population-based
> preventative care (where by definition the poor cannot yet have
greater
> "morbidity")
>
> The underlying question is: what is supposed to be equal? Going
back to
> the tenets of needs assessment, are we talking about felt needs,
expressed
> needs or normative needs? What if disadvantaged populations are
in some
> cases not only less likely to express normative needs (because of
fatalism
> and health illiteracy), but, insofar as we can determine
externally by
> assessments of self-perceived health status, actually feel them
less?
>
> Michael Soljak
> Health Inequalities Unit
>
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