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Research Article

The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States

  • Majid Ezzati mail,

    To whom correspondence should be addressed. E-mail: majid_ezzati@harvard.edu

    Affiliations: Harvard School of Public Health, Boston, Massachusetts, United States of America, Initiative for Global Health, Harvard University, Cambridge, Massachusetts, United States of America

    X
  • Ari B Friedman,

    Affiliation: Initiative for Global Health, Harvard University, Cambridge, Massachusetts, United States of America

    X
  • Sandeep C Kulkarni,

    Affiliations: Initiative for Global Health, Harvard University, Cambridge, Massachusetts, United States of America, University of California, San Francisco, California, United States of America

    X
  • Christopher J. L Murray

    Affiliations: Harvard School of Public Health, Boston, Massachusetts, United States of America, Initiative for Global Health, Harvard University, Cambridge, Massachusetts, United States of America, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America

    X
  • Published: April 22, 2008
  • DOI: 10.1371/journal.pmed.0050066

Reader Comments (9)

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Some historical and social perspective for these findings

Posted by plosmedicine on 31 Mar 2009 at 00:25 GMT

Author: Kelly Rusinack
Position: Ph.D. Candidate
Institution: University of Miami History Dept.
E-mail: kellyrusinack@yahoo.com
Submitted Date: April 23, 2008
Published Date: April 24, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Is it beyond the scope of your study to take into account the rise in HMOs as the standard in healthcare since the late-1980s? Prior to the advent of HMOs, almost everyone had a POS that paid for all claims. Most employers paid 100% of employee premiums. Doctors were able to do all that was necessary for their patients without threat of being second-guessed.¶
While your findings are fascinating, they inherently blame the decedents' lifestyles. While the issue of prevention is part of your conclusion, HMOs do not focus on prevention, they focus on illness and injury. Especially in the 1990s, HMOs were stubbornly opposed to providing coverage for tests and treatments that actually prevented disease or caught it in its early stages. One had to be deep in the throes of disease in order to receive any tests or treatments, if they did at all. It is still that way. Patients don't automatically receive the best or most appropriate diagnostic tools, they receive the least expensive ones.¶
The conditions that you list as having the greatest impact on life-expectancy are also ones that are generally untreatable or hard to reverse once a patient is symptomatic. In poorer counties, not only are people forced to work and bring home a paycheck regardless of how sick they feel, they also do not receive the medical benefits that would help them understand and prevent these diseases, and are turned away by their HMOs when they first start to complain of symptoms.¶
Prevention is also a white-collar concept. Dietary changes are just not affordable for many people. The most affordable food available is the worst food for one's health. In economically depressed areas, people don't make enough money to pay for fresh produce and natural foods; eating healthy is expensive. And academicians most likely have never had to live on an average worker's wages to understand how exhausting these jobs are and how little money they can put towards taking care of themselves. Who has time, energy, or money to make those lifestyle changes? I've been on both sides of the fence and I can tell you that the majority of people in the poorer areas of any county do not.¶
The roles of women in our society since the early-'80s also play a factor in this problem. In 1983, many women still only held full-time jobs in the home. By the 1990s, more women were in the workforce, but they still had those jobs waiting for them at home. The burdens that women face in our society contribute to their lack of time and energy to pursue a healthy lifestyle and healthcare prevention. Women also tend to ignore the signs of disease, pass it off as the normal strain of life, until it is almost too late. And even then, studies have shown that many husbands still lack the empathy necessary to take over part of the load, or to care for a woman when she is ill. The "traditional values" of marriage are more pronounced in poorer areas, where women depend upon the man's paycheck so much (due to disparity in wages) that they put up with much more misery, emotional and physical, than more affluent women.¶
All of this doesn't even include how overworked and underpaid doctors are when they participate in HMOs. It is well-documented that this leads to a cattle-call atmosphere in healthcare. Doctors are forced to patch patients up and get them out of treatment as soon and cheaply as possible. The poorer the county, the worse this practice is. This leads to missed or late diagnoses, and lack of time to educate patients about disease prevention.¶
This is most likely way beyond the scope of your study. However, future researchers can use this study for further research into why this situation has proliferated. I firmly believe that gender roles, socioeconomic factors, and limitations placed on doctors and patients today in order to save a dime for HMOs and PPOs, play a great role in the untimely deaths of millions of people, especially women. These issues need to become part of this dialogue.

No competing interests declared.