Author: Matt Johnson

Health Disparity and Health Difference

The difference between health disparities and health differences lies in inequity and injustice. We might see differences in mobility between elderly individuals and teenagers as a normal difference in age, not related to ageism, though certainly elderly individuals face issues of ageism. However, differences in mortality rates between people of different social classes can be directly related to social and economic inequity. Hence, a health disparity is a health difference that results from inequity and injustice.

Returning to my example of HIV, PrEP, and queer men, we know that queer men have been identified as a high risk group for HIV, which is why targeting PrEP and other interventions at queer men is so important for public health interventions and control of the epidemic. However, we also know that HIV/AIDS was originally considered to be a “gay disease” and limited action was taken at the original outbreak because of the social undesirable position of queer men. This social inequity based on sexuality was stronger at the outbreak of AIDS, but it still persists today. The combination of HIV stigma, poor sexual health education (for everyone, but also specifically for queer individuals), and lacking health care for queer individuals (health care providers are uncomfortable asking about sexual history, don’t ask about sexuality, don’t take necessary precautions, aren’t aware of health needs of queer individuals, etc) directly results in a health disparity resulting in higher rates of HIV among queer men, especially black queer men.

However, public health interventions that continue to target queer men for behavior change seem to push the blame of this health disparity and social inequity on those facing inequity, rather than targeting the providers who are unprepared and improperly educated to effectively care for queer men. We know that providers are less likely to prescribed PrEP to black queer men, compounding on social inequity based on sexuality to add race. This stems directly from racial and gender stereotypes that influence providers and limit their ability to appropriately care for black queer men (Calebrese et al, 2014; 2017). Nonetheless, public health interventions exacerbate the disparity by focusing on queer men adopting different health behaviors instead of educating health care providers and sexual health educators to provide better care for queer men. The root is structural, rather than individual, and ignoring the structural inequity continues to harm queer men, especially black queer men.

PrEP for Life

Reflecting on the models of health discussed previously (part 1 & part 2), a queer man without human immunodeficiency virus (HIV; disregarding other illnesses) would be healthy, whereas a queer man with HIV would be unhealthy within the medical model of health. In the sociocultural model of health, both a queer man with HIV and without HIV would likely be considered healthy. Given current treatments, there would likely be no affect on an individual’s ability to perform the five activities of daily living. Finally, in the psychological model, we have no easy way to estimate beforehand.

However, within the “drugs for life” model, since queer men are identified within the public health discourse as high risk for HIV, they are immediately seen as bodies-at-risk. Within this model, being queer men can become a predisease for HIV. Much like pre-hypertension for hypertension, the predisease becomes an illness to be treated in itself. Here, we treat the predisease with public health interventions, but the predisease is the behavior of men having sex with men. However, with the best intentions, public health interventions and health communications campaigns can exacerbate the stigma within the queer community with regards to HIV and pre-exposure prophylaxis (PrEP).

Within this model, PrEP becomes another “drug for life.” There’s no point at which individuals can stop taking PrEP to prevent HIV. It has to be consistently taken in the same way that one would consistently take drugs after contracting HIV. Hence, the treatment for the disease and the treatment to prevent the disease have the same consequences. Presumably, patients would only stop taking PrEP after finding a long-term partner with whom they are monogamous (also presumably both partners would be HIV negative). However, this assumes compulsory monogamy and perhaps even compulsory matrimony. For queer men who don’t want to become monogomous or get married or who are worried about their partner’s (or partners’) infidelity might still be taking PrEP. This combination of high NNT (especially high NNT when we consider the effectiveness of condoms, which should still be used while taking PrEP, since it isn’t 100% effective) with the endless length of the prescription results in considerable profits for drug companies and a significant economic injustice for queer men.

Are You Healthy? (Part 2)

Previously, I discussed changes to our model of health due to randomized control trials and the pharmaceutical industry, as discussed in Joseph Dumit’s Drugs for Life. Here are the three primary models of health as discussed by Donald A. Barr in his book Health Disparities in the United States: Social Class, Race, Ethnicity, & Health. 

The first model is the medical model or physical health model that focuses on the absence of symptoms or other signs of disease or illness. However, Barr mentions several issues with this model of health, noting “that this approach to defining health tells us what the concept of health is not. . .It does not tell us what health is” (2014, pp. 15). He expands on this later:

“What are we to make of a condition that has no abnormal symptoms? An important example of this is high blood pressure, also referred to as hypertension; persons with hypertension develop symptoms only after a number of years. Should we consider a person with somewhat elevated blood pressure to be unhealthy based on our knowledge that his blood pressure will eventually lead to further problems? What might be the consequences of labeling such a person as ‘unhealthy,’ even if he feels fine?” (Barr, 2014, p. 16)

These are the questions that Joe Dumit attempts to answer, looking beyond hypertension to guidelines about pre-hypertension and the prescriptions of statins with no understanding of when patients can stop taking them.

The second model is the sociocultural model or the model of health as functioning at a normal level. Barr looks at it in contrast to the medical model, which looks at absence, because the sociocultural model looks at the presence of an ability to function at a level that has been deemed normal (2014, p. 17). The ability to functional normally is defined in regards to one’s ability to completed five “activities of daily living (ADLs),” which are roughly, (1) eating, (2) bathing, (3) dressing, (4) using the bathroom, and (5) moving on one’s own (2014, p. 17). Of course, the entire premise of “normal functioning” is subjectively predicated on societal ideas of self-sufficiency that might vary from culture to culture or community to community.

The third model is the psychological model or the model of health as a feeling of well-being. In this model, individuals are able to assess themselves and their own health with the help of several developed measures (Barr, 2014, p. 18). However, Barr notes that these tests are often “time-specific” (Barr, 2014, p. 18). I would argue that health is always time specific and temporal. I may be healthy today, but I can quickly develop a health problem or injure myself, perhaps even resulting in a temporary or life-long disability, reaffirming the temporality of both health and disability.

According to Barr, these models can be combined to create a multidimensional model of health that presents a better picture of the health of an individual.

Trans Youth, Ethics, & Access to Healthcare

There are four primary principles for ethical decision-making in health care (respect for autonomy, 2. justice, beneficence, and non-maleficence); however, these four principles do not necessarily yield the most beneficial results for trans youth or bodies that exist in contradistinction to state controlled modes of life. Medical practice is able to manage the modes of life for trans youth, relying on non-maleficence and a paternalistic notion of future expectations to continually withhold medical intervention.

The duality of beneficence and non-maleficence has often been presented as the double effect, where a single action may have both positive and negative effects that must be weighed against one another (Veach, 2007). A common example is when providing morphine to a dying patient. The patient’s suffering will be limited, causing a beneficial effect; however, the morphine simultaneously slows the respiratory system, causing the patient to die more quickly, the harmful double effect.

In the case of trans youth, this double effect is often used as a way to withhold hormone treatment or other medical intervention because the state and the medical institution see the greater harm if trans youth “change their minds” about their gender. Further, medical professionals discuss the potential harms within a framework of compulsory reproduction. The harm of hormones is seen as an inability to reproduce later in life, which maintains the assumption that biology is destiny (Adkins, 2017).

As we approach these ethical issues, there are difficult power dynamics inherent in the biopolitical state that limits what modes of living are seen as livable. For instance, an inability to reproduce is seen as unlivable or unruly. To provide better care for trans youth, we need to deconstruct current notions about the lack of autonomy for young people broadly, and especially for trans youth.

Adkins, Deanna (2017). “Transgender medicine: A wealth of ethical dilemmas.” Presentation.

Veatch, Robert M. (2007) “How many principles for bioethics?” In R. Ashcroft, A. Dawson, H. Draper, and J. McMillan (Eds.) Principles of Health Care Ethics, Second Edition. Chichester: John Wiley & Sons.

Electronic Health Records and the Expert Patient

Electronic Health Records (EHR) are becoming more and more common as means for patient engagement. Medical practice has moved from a paternalistic mode of engagement to a mode of engagement that makes the patient active and directly involved. However, this process also demands more of the patients, both in terms of educating themselves and collecting and inputting data into an EHR.

While the goal of the EHR is better patient outcomes, we should think about accessibility. For patients who might not have access to a computer, the internet, or any means of collecting their own health data, it might be impossible to access an EHR or other patient portal. Additionally, patients with low health literacy or health information literacy might struggle to understand the information being provided to or asked of them.

Aside from difficulties directly using the EHR, patients are pushed into an expert patient role through the same attempt at creating active patients. While this might help with patient engagement, the need to gather information about one’s own health, illness(es), and medication(s) increases the burden on the patient. Being an active participant in one’s own medical care, requires labor on the part of the patient.

While this may improve patient outcomes, it might be impossible for many patients to gather additional health information either because they don’t know where to look or don’t have the time to search. The active patient model and the electronic health record are both features of a modern medical practice that require additional labor from patients and focus on an patient with certain means and abilities. Surprisingly, it may well be increasing the health disparities divide.

These are all considerations that practitioners should keep in mind with regard to electronic health records and the demands placed on their patients.

Are You Healthy?

To understand whether or not your healthy, you have to first understand what it means to be healthy. It seems straightforward, but in the modern age, this is a complex question.

We might at first be inclined to think that being healthy means that you don’t have any illness or injury. But is this always true? What if you have an illness that is managed by medication? What if a person has a disability but the disability doesn’t disrupt their daily life? What if you’ve been diagnosed with pre-hypertension but have no symptoms?

Joseph Dumit, Director of Science and Technology Studies and Professor of Anthropology at the University of California, Davis, discusses various changes to our view of health and illness since the rise of the randomized control trial in his book Drugs for Life: How Pharmaceutical Companies Define Our Health (Duke University Press, 2012). He argues “that being at risk for illness is often treated as if one had a disease requiring lifelong treatments, drugs for life” (6).

Dumit discusses a few prediseases in depth, looking at pre-hypertensive, pre-diabetes, and borderline high cholesterol. “Literally, a disease-sounding syndrome is produced by correlating risk factors and naming it in such a way that it becomes common sense to think about treating ‘it’ as a disease in and of itself” (165). Hence, health becomes a matter of risk where we are all bodies constantly at risk of disease. If you have pre-diabetes, are you healthy? How do we understand our health in a risk economy of health?

This intersects interestingly with Donald A. Barr’s claim, in his book Health Disparities in the United States: Social Class, Race, Ethnicity, & Health, that despite investing so much of our economy in health, US health indexes rank rather low; “[p]erhaps, our basic assumption–that more health care will lead, necessarily, to better health–is flawed.”

Apps, Websites, mHealth, Oh My!

Mobile health applications have taken off as opportunities for public health intervention coinciding with the increasing usage of mobile phones and mobile phone applications in everyday life. A search for “mobile app” in the Journal of Medical Internet Research returns over 1,000 results.

While some of these applications are certainly changing the way we approach our health and lifestyles, some of them can also do more harm than good. As a result, the FDA has developed guidance for the development of these applications to ensure their safety.

However, mobile applications aren’t the only option for providing health information and interactive experiences to users on mobile devices, though they’ve become an incredibly popular option. Many mobile applications could likely be created as websites using responsive web design to make them easily viewable from computers, tablets, smartphones, and so on.

This is especially important when thinking about your target audience. While younger audiences might use their phones regularly, older individuals might be less inclined to use a mobile app, but they might visit a website from their computer or tablet.

A website with responsive web design will also work across platforms (so users can switch between their phone, tablet, computer, or other devices) and will likely take less time and money to develop. They’re also easier to update and maintain for longer periods of time.

Also, if any of your users are like me, they might hate downloading yet another app to take up space on their phone. Apps contribute to clutter on your mobile devices and take up storage space that could be used for pictures, music, emails, and other content.

In a rush to utilize new technologies and meet users where they are, some of these mobile health applications have come out poorly.

Turner-McGreivy, et al. (2016), available from PubMed Central, provide a great comparison of responsive-design websites versus mobile applications, including an easy-to-use table.