Poverty, “Risky Behaviour”, and the Virtuous Healthy-Sick-Person Interrogation

WA Today reports that poor people who have been seriously ill die sooner after hospital discharge than wealthy people do. No surprises there – we all know that poor people have poorer health outcomes across the board.

The results of a survey of people who had a stay Western Australian intensive care units and survived to hospital discharge shows that low SES (socio-economic status) correlates with shorter survival after hospital discharge. This effect remained after correction for age, co-morbidity (the presence of other illnesses), the severity of the acute illness, indigeneity, and geographical access to services.

So what underlies the gap? The author of the study, Kwok Ho, is quoted as identifying two main categories of inequality. He divides obviously, but not explicitly, into “not their fault” and “their fault”:

“Financial and cultural access to some services may have a significant effect on rehabilitation and long-term survival after critical illness,” he said.

“Lower socioeconomic status is also associated with some risk factors for poor health outcomes, including smoking, alcohol misuse, poor nutrition, overcrowded accommodation and inadequate physical activity.”

WA Today then interprets his conclusion thus:

Dr Ho said more intensive targeting of risky behaviours among poorer patients could potentially improve their long-term outcomes.

“Intensive care services are expensive and it would be a waste of resources if the aim of the treatment were only to discharge patients alive from the hospital without optimising their long-term outcome,” he said.

Huh? Did I miss something?

I don’t know whether WA Today has omitted an entire category of possible interventions here in lazy editing. Interventions aimed at maximising the services and healthcare available to ill people, interventions improving housing and reducing overcrowding, interventions to improve the food quality available to poor people (especially in remote areas), interventions to improve leisure opportunities and reduce social isolation for older people and people with disabilities – all of these are ignored.

Instead, they should stop smoking, the lazy greedy sickies. How dare they keep taking up our hard-earned taxes by not looking after themselves?

This narrative of individual blame, of lack of “self-control”, pervades the public health rhetoric in the media, in research, in the conversations you hear every day. As soon as someone is sick, we look for blame within their actions – did they smoke? Eat hamburgers? Get fat? Expose themselves to plasticisers? Fail to power-walk for thirty-five minutes a day? Drink too much red wine? Drink not enough red wine? Not take their pills? Take too many pills? Have bad posture? Eschew mouthwash? Fail to book into a wellness centre monthly for stress reduction and massage therapy?

When you get sick, the entire world will scream, “WHAT DID YOU DO? You did something to make yourself sick, didn’t you? You’re really to blame, at heart, aren’t you?”

Not only are you a moral failure if you don’t come out squeaky-clean in the Virtuous Healthy Citizen Interrogation, but you’re a civic failure: you are costing your countryfellows money, they begrudge you every cent of it, and the world will never stop letting you know this.

Maybe Kwok Ho did address structural and cultural issues leading to the poverty-mortality link. Maybe he wrote in detail on the need for governments and communities to address inequality. Maybe he didn’t just blame those low-class pariahs and their “risky behaviours” and “bad choices”. But the article’s not quite published yet. It will be in the next Medical Journal of Australia.

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Edit 6 July 08: The MJA issue wasn’t available at the time of writing, but it’s now up at the site (free registration required).

“The effect of socioeconomic status on outcomes for seriously ill patients: a linked data cohort study”

MJA 2008; 189 (1): 26-30

Here’s a direct quote from the relevant part of the paper:

As far as we are aware, ours is the first study to investigate the effect of SES [socio-economic status] on long-term outcomes for a heterogeneous group of seriously ill patients. The final Cox model confirmed some of the known risk factors for long-term patient mortality, such as comorbidities and Indigenous status, but also showed that lower SES was independently associated with poorer health outcomes. There are at least two possible explanations.

First, although we adjusted for geographical accessibility of essential services, financial and cultural barriers to some services (especially specialist medical services) may have a significant effect on rehabilitation and long-term survival after critical illness. The role of specialist medical services in reducing the long-term mortality of seriously ill patients may be particularly important for patients who are recovering from a life-threatening illness, especially if they also have significant comorbidities.

Second, lower SES is associated with some risk factors for poor health outcomes that we did not adjust for in our study. These include smoking, alcohol misuse, poor nutrition, overcrowded accommodation and inadequate physical activity. More intensive targeting of such preventable or reversible risk factors in lower-SES patients could potentially improve long-term outcomes for these patients.

Now that’s interesting, and not at all surprising. “Risky behaviours” was very clearly the journalist’s choice of words, not the authors. The word “behaviour”, in fact, appears nowhere in the paper. The shift from statistical correlation and structural issues to individualist narrative took place somewhere in the journalist’s mind.

Note also that SES was measured purely by the Index of Relative Socioeconomic Disadvantage (IRSD), a very approximate measure indeed, in which SES is allocated according to residential postcode. The authors note that this is a limitation of the data. The IRSD is explained further by the Australian Bureau of Statistics in this downloadable PDF.

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1. Hutton’s Ontario Homebirth/Hospital Birth Study
2. What the media isn’t asking about that private hospital birth study (or, Bayes’ Theorem for Dummies)
3. Quick hit: Second Shift for the Sick
4. Fetal presentations: an economist’s guide
5. Today’s fabricated panic: “Delayed” birth interventions causing childhood obesity?