Desiguals entre desiguals

 The persistence of health inequalities in modern welfare states: The explanationof a paradox

Dels treballs d'en Mackenbach ja n'he parlat anteriorment i m'ha interessat un article de fa poc. A Social Science and Medicine revisa el perquè de les desigualtats en salut. Sense ànim de ser concloent, en primer lloc mostra les teories que expliquen les desigualtats en salut:

The theories reviewed are: mathematical artifact, fundamental causes, life course perspective, social selection, personal characteristics, neo-materialism, psychosocial factors, diffusion of innovations, and cultural capital.

I alhora es pregunta quins són els motius potencials pels quals als països desenvolupats esdevé tant dificil reduir-les. Diu:

Based on these theories it is hypothesized that three circumstances may help to explain the persistence of health inequalities despite attenuation of inequalities in material conditions by the welfare state: (1) inequalities in access to material and immaterial resources have not been eliminated by the welfare state, and are still substantial; (2) due to greater intergenerational mobility, the composition of lower socioeconomic groups has become more homogeneous with regard to personal characteristics associated with ill-health; and (3) due to a change in epidemiological regime, in which consumption behavior became the most important determinant of ill-health, the marginal benefits of the immaterial resources to which a higher social position gives access have increased.

Al final ho acaba resumint en dues opcions, mala gestió (dels polítics) o mala sort (els canvis han portat a que les desigualtats es basin molt més en factors immaterials). Penso que parlar de mala sort s'allunya del que seria esperable com un motiu. Recordeu el post de l'Angus Deaton i els dels macacos i les desigualtats de salut, més material per pensar...

PS. I sobretot consulteu el darrer GCS, l'article d'en Guillem López-Casasnovas, va del mateix tema. Precís i pragmàtic.

PS. Si us interessa l'impacte redistributiu de la despesa sanitària pública, consulteu:  Evaluating the redistributive impact of public health expenditure using an insurance value approach. Conclusió:

Public health care expenditure in Spain acts progressively on income distribution. By adding the health benefit to disposable income of Spanish households, and ignoring possible behavioral responses, it turns out that poverty is reduced by almost 50 %. The average amount of in-kind subsidies received by households is considerable and its adequacy is good. Health care subsidy accounts for 59 % of household disposable income for the families in the first decile. Provision of public health care substantially reduces poverty incidence and poverty severity in Spain, granting a more equal distribution of living standards, as shown by a reduction in the Gini index by 5.4 percentage points.

Se m'escapen algunes coses, metodologia, dades?. No sé...

PS. Encara més motius per la desconnexió. Des del NYT, dedicat a tots aquells que encara no s'han decidit i aquells que ho volen comprendre.

PS. I encara més motius per fer-ho quan més aviat millor. Un video on es mostra com l'incompliment dels compromisos d'inversió i les lleis porta a un augment de la mortalitat relativa. Motius per denunciar l'Estat davant la fiscalia.

Quantes vegades vas al metge?

Income-Related Inequalities in Health Service Utilisation in 19 OECD Countries, 2008-2009

 La comparació de la distribució de la renda amb la necessitat de salut és l'objectiu d'anàlisi d'un paper recent de l'OCDE referit a 19 països. Els conceptes bàsics:

Inequality and inequity of care are two key concepts. Here, inequality in health care utilisation refers to the differences in use that can be observed between individuals or population groups,whereas inequity refers to those differences remaining after adjustment for need for health care. In thisstudy, adjustment for need has been made for doctor visits only, with equal need assumed for dental visits and cancer screening. Horizontal equity is the principle that requires that people in equal need of health care are treated equally, irrespective of individual characteristics such as income, place of residence or race.

La probabilitat d'anar al metge al darrers 12 mesos es troba entre el 68% (USA) i el 91% (França). El més inequitatiu en accés és USA, i el menys Dinamarca. La inequitat en freqüencia de visites totals és màxima a Polònia, seguida d'USA i Espanya. La menor inequitat en freqüència torna a ser Dinamarca. La inequitat de freqüència a especialistes ve encapçalada per Espanya (i en el cas dels dentistes queda en segona posició).
El resum:

Horizontal inequities and inequalities in health care utilisation persist across the 19 OECD countries studied. After adjustment for needs for health care, the better-off are more likely to visit doctors - especially specialists - than those with lower incomes. With GP contacts, the scenario is different. In most countries, for the same level of need for health care, the worse-off are as likely as the better-off to contact a GP, and they visit more often. Income-related  inequalities in breast cancer screening appear in around half of all countries, with a higher rate among the better-off. Pro-rich inequalities in dental visits and in cervical cancer screening are present in almost all countries.

A la pregunta del dia, -quantes vegades vas al metge- cal respondre per aquí aprop, que depèn de si vas a l'especialista o al metge de família. En el primer cas, més concretament depèn de la butxaca, aquesta és la resposta de l'estudi. En el segon cas depén de la necessitat de resoldre un problema de salut. Comencen els jocs olímpics i ja s'ha adjudicat una medalla d'or i una altra de bronze.

PS. El desgavell del honoraris mèdics lliures a França, un excés de 2.400 milions d'euros en un any. A Le Monde. I a Le Monde diplomatique exploren altres vies per la sanitat pública (francesa).

PS. Els mercats encara són persones. Ho podeu contrastar Le Monde Diplomatique.

Rethinking income inequality and health (once again)

Income Inequality and Health: Strong Theories,Weaker Evidence

The inequality frame is usually flawed, and this is specially clear when the metholodogy and data to support the statements are biased. Let me suggest today this article that summarises perfectly common misunderstandings on this relationship. It would be a great input for a review and remake of recent papers.
The summary:

What is already known about this topic? A large body of research has examined the association between income inequality and average health. A separate body of research has explored income disparities in health. These two traditions should be seen as complementary, because high and rising income inequality is unlikely to affect the health of all socioeconomic groups equally. 

What is added by this report? Although plausible theories suggest that rising income inequality can affect both average health and health disparities, empirical tests provide only modest support for some of these theories. We argue that understanding the effects of income inequality on health requires attention to mechanisms that affect the health of different income groups, thus changing average health, disparities in health, or both. 

What are the implications for public health practice, policy, and research? Progress is likely to require disentangling direct effects of rising income inequality, which operate through changes in an individual’s own income, from indirect effects, which operate through changes in other people’s income. Indirect effects of rising income inequality may change a society’s political and economic institutions, social cohesion, culture, and norms of behavior, all of which can then affect individuals’ health even if their income remains unchanged.

PS. If someone needs an estimate of morbidity, please avoid inconsistent approaches. If someone needs policy guidance don't trust on cross-sectional data on such a difficult issue.

PS. My posts on health inequalities.

Les desigualtats justes

What does the empirical evidence tell us about the injustice of health inequalities?

En alguna ocasió he comentat que hi ha una indústria en l'anàlisi de les desigualtats en salut. Hi ha una producció continuada que no se sap ben bé on va ni quines implicacions pràctiques aporta, fins i tot és desconeix el consumidor de la recerca.
Hi ha una part necessària i fonamental de l'anàlisi que passa per la descripció, però el salt entre saber i què fer amb el que sabem és crucial. I aquí entren els mecanismes de causalitat, quines d'aquelles desigualtats són "injustes" i cal corregir. L'Angus Deaton ha fet un paper per posar ordre a les idees, cosa que s'agraeix, i diu:

Facts and correlations, without an understanding of causation, are neither sufficient to guide policy nor to make ethical judgments. Without getting causation right, there is no guarantee that interventions will not be harmful. It is also possible that an inequality that might seem to be prima facie unjust might actually be the consequence of a deeper mechanism that is in part benevolent, or that is unjust in a different way.

Després repassa diferents factors, origen, edat, sexe, raça, status socioeconòmic, etc. Destaco, especialment per a entusiastes:

The health inequalities literature frequently argues that differences in incomes cause health differences, a position that I have argued is largely mistaken. A related but different view is that differences in income are themselves a risk factor for the level of health (as well as for the levels of other good social outcomes), so that the rich as well as the poor are hurt by large income differences

I la seva conclusió:

Health inequalities are a matter of great moral concern. But whether we see them as an injustice, and whether and how we design policy to correct them, depends on how they come about. In this essay, I have argued that childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes. Among adults, the main priority should be the design of schemes that prevent the impoverishment that can come from ill-health, through loss of the ability to work, or through the costs of treatment.

Resta molt per fer i encara més per reconduir.

PS. Podeu consultar el Martmot Indicators aquí

The coverage of health risk and the extent of generosity

The Right to Health A Multi-Country Study of Law, Policy and Practice

If we look at European Union, the right to health is heterogeneous. The size of the difference among countries depends on many factors, and path dependence explains mostly such diversity. If you want to check beyond EU, a new book explains how countries define health risck coverage under different arrangements.

Looking at health through a human rights lens tells us something about the nature of illness that epidemiology and biology cannot: it encourages us to consider to what extent illness is unjust. It also frames illness and disease within the political, social, cultural, and economic conditions that surround it; considers the power dynamics that perpetuate illness and disease; and focuses the attention on marginalized and vulnerable groups that may exist outside of medical research priorities or beyond the target demographics of political decisions, at greatest risk of becoming invisible. Worse still, history has shown us that in extreme situations medical professionals can be used as tools of the state to cover up or even inflict abuse. Considering the complex relationship between justice and health, using the international framework for the right to health offers the possibility of mitigating some of the effects of deeply embedded inequalities and discrimination and promoting environments in which anyone can achieve their highest level of health.

There is a major misunderstanding about the frame of the right to health. Somebody should specify that we are talking mostly of right to health care and state at the same time about the individual duties on health. Anyway, let's imagine a country that close to 2% of population are il.legal immigrants that have the right to health care accepted as any citizen, this is my country.  Unfortunately such unique level of generosity and solidarity you'll not find it in this book:

PS. Somebody should ask at the same time if going beyond such level of generosity is financially sustainable. However this is an inconvenient question, a politically incorrect one.

PS. Good post.This Economic Phenomenon Is Making Government Sick and this one

Public Health Priorities

Start Well, Live Better: A Manifesto for the Public’s Health. London: UK Faculty of Public Health, 2014

These are the 12 suggested priorities for public health in UK for the next 5 years:

Give every child a good start in life

• Give all babies the best possible start in life by implementing the recommendations of the 1001 Critical Days cross-party report
• Help children and young people develop essential life skills and make Personal, Social, Health and Economic, and Sex and Relationship Education a statutory duty in all schools

• Promote healthy, active lifestyles in children and young people by reinstating at least 2 h per week of physical activity in all schools

Introduce good laws to prevent bad health and save lives

• Protect our children by stopping the marketing of foods high in sugar, salt and fat before the 9 pm watershed on TV, and tighten the regulations for online marketing
• Introduce a 20% duty on sugar-sweetened beverages as an important measure to tackle obesity and dental
• caries—particularly in children
• Tackle alcohol-related harm by introducing a minimum unit price for alcohol of at least 50 p per unit of alcohol sold
• Save lives through the rapid implementation of standardised tobacco packaging
• Set 20 m.p.h. as the maximum speed limit in built-up areas to cut road deaths and injuries, and reduce inequalities

Help people live healthier lives

• Enable people to achieve a good quality of life, health and wellbeing—give everyone in paid employment and training a ‘living wage’
• Reaffirm commitment to universal healthcare system, free at the point of use, funded by general taxation

Take national action to tackle a global problem

• Invest in public transport and active transport to promote good health, and reduce our impact on climate change
• Implement a cross-national approach to meet climate change targets, including a rapid move to 100% renewables and a zero-carbon energy system

As you can see, many similar things with our PINSAP, the Health Policy Consensus and Health Plan. However, after yesterday news the pending issue of our public health is mainly alcohol abuse. We should focus on what works to reduce alcohol and addictive substance abuse. And first of all, we need to understand the foundations and best approaches to the problem. I would suggest you have a look at this book and specially this one:

PS. Binge drinking 'costing UK taxpayers £4.9bn'  Does anybody know how much does it cost here???

PS. In Spain, publicly funded health expenditure reached 64.150 million € in 2012,the amount for financial system bailout was 101.283 million € (p.24). Don't forget it: these are the priorities.

Diferències en salut

New trends in health inequalities research: now it’s personal
M'ha interessat en Mackenbach al Lancet. Algú ho havia de dir, i pocs podien pensar que fos ell qui finalment ho fes tan explícit.
Les diferències en salut tenen a veure amb les persones a més de l'entorn social, ambiental i molts altres factors.
Aquest paràgraf esdevé clau:

Health inequalities researchers are no longer reluctant to include personal characteristics of individuals in their explanatory research. 10–20 years ago, this approach was unpopular because it was thought to detract from structural explanations of health inequalities, such as inadequate income, health risks in the environment, or no access to health care.
Some investigators feared that focusing on personal characteristics, such as lifestyle behaviours, personality traits, or cognitive ability, would reinforce politically conservative views, which suggest that social inequalities result from ignorance, irresponsibility, or other forms of irremediable individual failure

.
Un avís per a navegants que encara resten ancorats a paradigmes rancis. Venint de qui ve cal tenir-lo en compte. Una precaució tant sols en la recomanable lectura de l'article, l'èmfasi en temes cognitius cal situar-lo en el punt just, i l'èmfasi en els nens és obvi. La responsabilitat envers la salut és en primer lloc individual.

A primer on health economics and policy

Social values in health and social care

In just 38 pages Tony Culyer explains  the basics of health policy. It is not a review, these are a collection of key insights that basically come from his book. This is the outline:

• Introduction
• Liberalism versus libertarianism
• The market versus the state
• Public versus private insurance
• Equity versus equality
• Inequalities of health versus inequalities of health care
• Equity versus efficiency
• Needs versus wants
• Prices versus rationing
• Financial protection versus quality of life
• Public versus private
• Agents versus principals
• Universality versus selectivity
• Comprehensiveness versus limited benefit bundles
• Centralisation versus decentralisation
• Competition versus collaboration
• Experts versus citizens
• Mixing values and other things
• Key messages 

Take this sentence, as an exemple:

Cost is also a value and no mere matter of accountancy. If we introduce a new
health care procedure, the cost will have to come out of expenditure elsewhere
in the NHS –unless there is a concurrent increase in the NHS budget. But less
expenditure elsewhere will normally imply reduction of service elsewhere and
a consequential health loss. The true cost of getting more care (and hence
health) in one area of activity is therefore the minimum necessary loss of care
(and loss of health) elsewhere. This is the important notion of opportunity cost.

Many politicians don't want to hear such messages. I stronlgy suggest you to read this booklet from Kings' Fund.
.

Reforming NHS (once again)

 LSE–Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19

Any reforms starts with a good diagnosis, therefore it's good to check how inequality indicators differ across countries.

And these are the recommendations:

Recommendation 1: increase investment in the NHS, social care, and public health

Recommendation 2: improve resource management across health and care at national, local, and treatment levels

Recommendation 3: develop a sustainable, skilled, and inclusive health and care workforce to meet changing health and care needs

Recommendation 4: strengthen prevention of disease and disability and preparedness to protect against threats to health

Recommendation 5: improve diagnosis, in circumstances where evidence exists to support early diagnosis, for improved outcomes and reduced inequalities

Recommendation 6: develop the culture, capacity, and capabilities of the NHS and social care to become a national learning health and care system

Recommendation 7: improve integration between health, social care, and public health and across different providers, including the third sector

I

Integrated care and population health

Population health Systems: Going beyond integrated care

In this blog I have mentioned several times the works by Kindig on population health. If integrated care makes sense, it is because it improves population health. Otherwise we should talk about diferent things.
A new report by the King's Fund sheds some light on several experiences of integrated care. It's worth reading, because you'll see that there is not only one way to achieve the final goal, and the tool -better coordination- has to be suited to the specific setting.

The "recipe":

At a practical level, developing a population health systems perspective requires the following elements as a minimum:
• pooling of data about the population served to identify challenges and needs
• segmentation of the population to enable interventions and support to be targeted appropriately
• pooling of budgets to enable resources to be used flexibly to meet population health needs, at least between health and social care but potentially going much further
• place-based leadership, drawing on skills from different agencies and sectors based on a common vision and strategy
• shared goals for improving health and tackling inequalities based on an analysis of needs and linked to evidence-based interventions
• effective engagement of communities and their assets through third sector organisations and civil society in its different manifestations
• paying for outcomes that require collaboration between different agencies in order to incentivise joint working on population health.

FT on cancer drugs pricing

Cost-effectiveness of public health interventions

The case for investing in public health

The evidence shows that a wide range of preventive  approaches are cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening. The evidence in this report shows that prevention is cost-effective in both the short and longer term. In addition, investing in públic health generates cost-effective health outcomes and can contribute to wider sustainability, with economic, social and environmental benefits.

Cost-effectiveness studies  are usually focused towards treatments. This report shows some examples related to public health. Unfortunately,  this is not so common. Up to now my reference on this tòpic was this article. Now I'm adding this report by WHO Euro. And the question remains: if these interventions are so cost-effective, why are we waiting for their implementation?

It is recognized that a comprehensive strategy needs to include a combination of population and targeted individual preventive approaches, but it should be noted that, on average, individual-level approaches were found to cost five times more than interventions at the population level (WHO, 2011a). In general, evidence also shows that investing in upstream population-based prevention is more effective at reducing Health inequalities than more downstream prevention (Orton et al., 2011). Meanwhile, the National Institute for Health and Care Excellence in the United Kingdom found thatmany public health interventions were a lot more cost-effective than clinical interventions (using cost per QALY), and many were even cost-saving (Kelly, 2012).

The fifth wave in population health

For debate: a new wave in public health improvement

Required reading.UK CMO et al. in The Lancet say:

A fifth wave of public health development is needed, and needed now, as a consequence of shifts in the burden of disease and persisting health inequalities, but also against the background of emergent features of modern society. In consideration of the previous waves, there has been a shift from the top-down approach involving structural changes (such as the public works of the 19th century), towards a positing of shared responsibility for health. This shift mirrors changing political ideology and increasing understanding of the contribution of individual behaviours and lifestyle choices to health outcomes.

PS. Health spending around the world in The Economist.
PS. Piketty under scrutiny, in WSJ.

Inequality in the winner-take-all society

A recent op-ed by Joseph Stiglitz on "Innovation enigma" brought me to retrieve a book of 1995 by Robert H. Frank, "The Winner-Take-All Society: Why the Few at the Top Get So Much More Than the Rest of Us". Nowadays, the issue of raising inequality is on headlines, and often it is considered as a consequence of economic crisis. 
Frank argued two decades years ago that more and more the current economy and other institutions are moving toward a state where very few winners take very much, while the rest are left with little. He attributes this, in part, to the modern structure of markets and technology. It was written before the impact of internet on business and it was a clear alert about what has happened.
Now Thomas Piketty in his book "Capital in the 21st century" argues additionally that when the rate of capital accumulation grows faster than the economy, then inequality increases. And inequality is not an accident but rather a feature of capitalism that can be reversed only through state intervention. The book thus argues that unless capitalism is reformed, the very democratic order will be threatened.
If you combine both perspectives, you must be convinced that it is not only an issue of state intervention, I can't imagine certain parts of global markets ("winner-take-all" ) being abolished or reformed without a global government. That's why I'm not sure about the size of the current threat and when it will explode.
Stiglitz adds an uncertain landscape for innovation, and therefore for future dynamic efficiency of markets (Shumpeter style).
Taking all these pieces together, there is no clear recommendation. Today I just want to state again that correlation is not causation. Inequality and crisis are a contemporary fact, though the trend goes back a long way and it is very much deeper. Avoiding reductionist perspectives is my first suggestion.

PS. Since the implications of wealth inequality and health are huge as I explained in this post, my today comment maybe adds more shades instead of light.

PS. "Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health." The Marmot Review: Fair Society Healthy Lives

PS. If you want to know why Messi's salary has increased this week, have a look at Frank's book, the answer is there.

Searching for a healthy ageing

The Biology of Inequalities in Health

The Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. 

 The impact of socioeconomic condition on premature aging is mediated by known behavioral and clinical factors and intermediate molecular pathways that Lifepath studies have revealed, including epigenetic clocks (age acceleration), inflammation, allostatic load, and metabolic pathways—highlighting the biological imprint (embodiment) of social variables and strengthening causal attribution.

 There is still a wide gap between social and natural sciences, both on methodological and conceptual grounds. Natural sciences focus in particular on biological mechanisms and outcomes, i.e., they address “zoe” (biological life), while social sciences address “bios” (biographical life), if we refer to the terminology used by Ronald Dworkin. In fact, epidemiologists aim to connect zoe and bios in meaningful ways, though this attempt has rarely become explicit. An exception is the work of Nancy Krieger who proposed the concept of “embodiment.” Biology and biography (124) meet in the health status of an individual, depending on social position at a given age. These concepts start to be incorporated into epidemiological research, via the integration of social contexts and biomarkers in a life-course approach. The results from analyses carried out within Lifepath suggest that the socioeconomic environment, from early life and across the life-course, is an important risk factor for health and exerts its effects via intermediate biological mechanisms.

Great research!

PS. Austin Frakt in NYT Putting a Dollar Value on Life? Governments Already Do

Edward Hopper

Social differences in health and health systems

Health for Everyone?
Social Inequalities in Health and Health Systems

I still don't know why do we talk about inequalities, I've always thought that we should care about differences. The word inequality drives your mind towards equality, and we all know that this will not happen. Therefore, there are differences that are unfair and avoidable, and these are the ones we have to be concerned.
And when we talk bout social determinants, maybe we should focus on commercial determinants and it would help. Why commercial? Because these factors are more actionable compared to others.
You will not find all these reflections in the new report by OECD. Anywasy it is worth reading to confirm it, though the perspective is the standard one (Marmot) and not new.
What you really have to read is the notice at the begining of each chapter that says:

Note by Turkey:
The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of the United
Nations, Turkey shall preserve its position concerning the “Cyprus issue”.
Note by all the European Union Member States of the OECD and the European Union:
The Republic of Cyprus is recognised by all members of the United Nations with the exception of Turkey. The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus.

Shame on Turkey. This notice is an example of the decision that needs to take the OECD urgently: to exclude Turkey from his organization. It is really unacceptable what Turkey has done and it is doing in Cyprus. Europe and OECD are avoiding the conflict saying "The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus". The conflict should be solved as soon as possible with the withdrawal of Turkey from Cyprus. That's all.

PS. What I said in the blog on Cyprus 8 years ago:

PS. Carta de lluny. Tot d'una passejant pel carrer Ledra vaig topar amb una frontera. Em trobava a una capital europea, dividida, envaïda. L'illa de Xipre va quedar escapçada el 1974. Aquella invasió va provocar 200.000 desplaçats que van perdre-ho tot fins el dia d'avui. El genocidi cultural i el saqueig posterior encara dura. He tingut ocasió de visitar dues exposicions que mostren l'espoli que s'està produint a la regió de Morphou (pot visitar-se al Banc de Xipre) i el rescat d'algun botí d'antiquari de l'any passat a Alemanya (Makarios Foundation). Vaig quedar tocat en veure-ho. Tresors artístics destruits per tal que la cultura d'altres desaparegui definitivament. Molt fort.
La situació política és delicada després de l'explosió de l'arsenal de Limassol a mitjans de juliol. Vam assistir a concerts on l'electricitat la subministràven amb generadors, i a Limassol moltes  botigues no tenien llum. Tenen una bombolla urbanística com una catedral i està a punt d'esclatar.
L'escapada cap al Nord va tenir tres destins: Salamina, Famagusta i Kyrenia. Arribar a Salamina suposava fer un visat i assegurança del cotxe però el difícil era arribar-hi perquè no hi havia cap cartell. Salamina és un complex interessant però descuidat i menystingut. Famagusta té una mescla que em va sobtar visualment, catedrals gòtiques escapçades amb minarets. Havia de ser extraordinària però s'han encarregat deliberadament de destruir-la, s'observa clarament quan passeges. Kyrenia va ser un descans, lloc acollidor. Al port amb una calor sofocant vam passar una bona estona. Vam oblidar per pocs moments el país envaït on ens trobàvem.
Crec que els governs que faciliten, impulsen o s'inhibeixen davant del genocidi cultural haurien de ser exclosos del circuit, pena d'infàmia, cosa que per ara no fa ningú.
Hem tingut ocasió de visitar Pafos, els Troodos i les esglésies patrimoni de la humanitat, Kourion, i molts altres llocs. El menjar i en especial la qualitat del peix és envejable. Un bon record i una experiència més per a compartir.

A cause and consequence of progress

The Great Escape: Health, Wealth, and the Origins of Inequality

I have spent this long weekend reading the last book by Angus Deaton. It appeared in the list of FT business books of the year, although was not shortlisted. You may find a short reference at The Economist and an article by the author at Foreign Policy. As you know, I'm a follower of his works. You'll find references in previous posts 1, 2.
The book is worth reading. The topic and the author deserves spending time on it. And specially right now, with dubious prospects about economic growth and how it will affect to inequality.
Let me highlight some paragraphs from the book.
On inequality paradox:

Inequality is often a consequence of progress. Not everyone gets rich at the same time, and not everyone gets immediate access to the latest life-saving measures, whether access to clean water, to vaccines, or to new drugs for preventing heart disease. Inequalities in turn affect progress. This can be good; Indian children see what education can do and go to school too. It can be bad if the winners try to stop others from following them, pulling up the ladders behind them. The newly rich may use their wealth to influence politicians to restrict public education or health care that they themselves do not need.

On efficiency and the economists:

Economists—my own tribe—think that people are better off if they have more money—which is fine as far as it goes. So if a few people get a lot more money and most people get little or nothing, but do not lose out, economists will usually argue that the world is a better place. And indeed there is enormous appeal to the idea that, as
long as no one gets hurt, better off is better; it is called the Pareto criterion. Yet this idea is completely undermined if wellbeing is defined too narrowly; people have to be better off, or no worse off, in wellbeing, not just in material living standards. If those who get rich get favorable political treatment, or undermine the public health or public education systems, so that those who do less well lose out in politics, health, or education, then those who do less well may have gained money but they are not better off. One cannot assess society, or justice, using living standards alone. Yet economists routinely and
incorrectly apply the Pareto argument to income, ignoring other aspects of wellbeing.

On inequality and what to do about it:

Inequality can spur progress or it can inhibit progress. But does it matter in and of itself? There is no general agreement on this: the philosopher and economist Amartya Sen argues that even among the many who believe in some form of equality, there are very different views about what it is that ought to be made equal. Some economists and philosophers argue that inequalities of income are unjust, unless they are necessary for some greater end. For example, if a government were to guarantee the same income for all of its citizens, people might decide to work a lot less so that even the very poorest might be worse off than in a world in which some inequality is allowed. Others emphasize equality of opportunity rather than equality of outcomes, though there are many versions of what equality of opportunity means. Yet others see fairness in terms of proportionality: what each person receives should be proportional to what he or she contributes. On this view of fairness, it is easy to conclude that income equality is unfair if it involves redistributing income from rich to poor.

On Aid and Politics, (chapter 7).

The arguments about foreign aid and poverty reduction are quite different from the arguments about domestic aid to the poor. Those who oppose welfare benefits often argue that aid to the poor creates incentives for poor behavior that help to perpetuate poverty. These are not the arguments here. The concern with foreign aid is not about
what it does to poor people around the world—indeed it touches them too rarely—but about what it does to governments in poor countries. The argument that foreign aid can make poverty worse is an argument that foreign aid makes governments less responsive to the needs of the poor, and thus does them harm.

Aid is a controversial issue, and Deaton was criticised for it at NYT .  You may find here a recent example that supports anecdotically the argument of Angus Deaton. It's up to you, the final view on this difficult topic.

PS. On inequality in our days, at NEG.

Health disparities

We all know that there are differences in health and health services throughout geography. If you want to check the extent of such differences, I suggest you have a look at Interactive atlas of health inequalities that WHO has published. You can select the country and you´ll find the comparison.
The number of variables is limited, but is a first step in the right direction since OECD only publishes data at a state level.

Exercise as a socially contagious activity

Exercise contagion in a global social network

Disciplines as diverse as economics, sociology, medicine, computer science, political science and physics have recently become interested in the interdependence of behaviours across the human social network. In particular, scientists have begun to ask whether our health and other behaviours are contagious, in that our decisions and actions affect the decisions and actions of our peers. If behavioural contagions exist, understanding how, when and to what extent they manifest in different behaviours will enable us to transition from independent intervention strategies to more effective interdependent interventions that incorporate individuals’ social contexts into their treatments

A new  study offers some of the first hard evidence that health-related habits can spread — and so perhaps could be deliberately seeded and encouraged — by social influence and peer pressure. Previous research has sought such a contagious effect in factors such as obesity and smoking, but the results have been inconclusive.

Studies in social differences in health have a a new hurdle to tackle. How to boost social permeability? As Mackenback said in The Lancet on health inequalities: now it's personal.

PS. These are the results of the study in one figure:

Is nudging ethical?

The challenges and opportunities of ‘nudging’

A forthcoming Editorial in the Journal of Epidemiology and Community Health provides some amunition for those interested on nudging.

The answer to the question if nudging is an ethically acceptable way of governing people’s behaviour depends on the ethical principles one adheres to. Our core point is that there is no magic trick, any form of policy intervention will impose a criterion against someone’s will, and democracy requires: (1) transparency from the political system in terms of the values selected in deciding and designing an intervention; (2) and at least an evidence-based justification of choice.

If the preferences of an individual change, then we cannot state that his first choice is better/equal/worse than his second one without introducing a ranking among his preference systems. As a result, value-free interventions cannot be defined.

If no magic bullet is available on the policy side, the same applies to research. In the domain of health, behavioural approaches must cope with the challenge of not neglecting the socioeconomic and contextual determinant of health inequalities

We argue that neglecting socioeconomic variables would be clearly a mistake also in the design of nudge. However, our point is precisely that behavioural science (and nudge as its policy implication) can incorporate an analysis of social and cultural factors, and avoid cognitive universalism.

Easier said than done. For an op-ed, it fits with the audience, for a strict and concrete policy recommendation requires further elaboration. I can't see  a practical and concrete applicable approach nowadays. Let's continue waiting.

PS. Must read, on medical devices in BMJ.A systematic review of new implants in hip and knee replacement

PS. A flawed PNAS article unveiled. Again and again, where is peer-review?

Jordi Pintó at Galeria Banadas

Digital health next to you

Bringing health care to the patient: An overview of the use of telemedicine in OECD countries 

Benchmarking deployment of eHealth among general practitioners

EHEALTH TREND BAROMETER: ANNUAL EUROPEAN EHEALTH SURVEY 2019

Several reports have been recently released. I would like to highlight the first one by the OECD, it reviews the current state of telemedicine and explains what works. In my opinion we do need an assessment of cost effectiveness of telemedicine, otherwise technology driven change is not enough.

Telemedicine services have the potential to improve effectiveness, efficiency and equity in health care, helping policy makers respond to increasing patient demands and needs. However, telemedicine interventions can also introduce new risks and amplify existing inequalities. In order for countries to maximise the benefits and limit the risks, telemedicine services need to improve the quality of care and provide clear benefits for patients. Telemedicine programmes that do not have benefits for patients are not worth pursuing and detract attention from other more effective interventions.

Josep Segú - Central Park