Institute for Health and Aging

Over two hundred years of anecdotal, epidemiological, and experimental evidence indicate that poverty breeds disease. This holds true for type 2 diabetes, which both in the United States and other developed nations disproportionately occurs, cripples, and kills among the poor. In this article we examine rhetorical strategies used in 30 journal articles indexed under type 2 diabetes and poverty. As we show, poverty is rarely highlighted in this literature as a causal factor. Instead, explanations for diabetes among poor people overwhelmingly emphasize features of patients—their biology, behaviors, psychology, culture, or other “risk factors”—while ignoring, reframing or neglecting the links between poverty and disease. By so doing, these discursive strategies naturalize higher rates of diabetes among poor persons, legitimize relations of domination in the larger society, and encourage only research projects, treatment practices and health and social policies that do not challenge existing social relations. We discuss the implications of these discursive practices for medical research and care, and for social and public health policies.

In this paper I analyze the concept of heritability as used technically in medical research. I use diabetes as a paradigmatic “common disease” whose heritability is computed with a view to disentangling the relative contributions of “nature” and “nurture”. I show what heritability measures and what it does not, and theorize about the scope of application of this measurement for diabetes-relevant medical research, health care practices, and public health policies. I argue that this analysis applies to heritability studies of comparable diseases and complex phenotypes, concerning which heritability estimates shed little if any light on the nature-nurture question, and provide no information relevant to medical practices and public health policies that we do not already have. I conclude that what is interesting about heritability studies in diabetes and similar human contexts is not what they tell us, or fail to tell us, about the relationship between nature and nurture, but what they show about the social and political nature of the practice of medicine and behavioral sciences.

Objective: Empirically examine medicine and public health partnership factors that are associated with partnership success.

Methods: 329 medicine and public health partnership informants were interviewed to assess factors associated with success in achieving partnership goals.

Results: Partnership formation; partner recruitment; barriers to collaboration; and leadership/governance variables were not predictive of partnership success. Partnership duration was significant in predicting success in achieving outcomes.

Conclusions: Factors identified in the literature are not as salient as believed in insuring the success of medicine and public health partnerships. The longer a partnership can remain intact (i.e., minimally longer than one year), irrespective of the particularities of the formation and structure of the partnership, the greater the probability that the partnership will achieve its desired outcomes.

The Centers for Disease Control and Prevention (CDC) estimate that influenza causes 36,000 deaths in the United States every year, and results in direct medical care costs of over $4.6 billion annually. Influenza and pneumonia are responsible for 8,800 deaths per year in California alone, making it the sixth leading cause of death among adults in the state, yet the illnesses are largely preventable by immunization.

The California Adult Immunization Coalition (CAIC) is comprised of more than 20 organizations across California who are working together to increase immunization rates for influenza and pneumonia in adults. The CAIC analyzed influenza vaccination rates in California using data from the 2001 California Health Interview Survey (CHIS), and compared the results to the national Healthy People 2010 goals for adult immunization. The national goals specify that 90% of older adults (age 65 and over) should be immunized against influenza annually by the year 2010 (i.e., less than 10% should remain unimmunized).

To deepen our understanding of this important public health issue, the CAIC has added several specific questions concerning adult immunizations to the 2003 CHIS survey. Results of this most recent survey will be available next year. Increasing California’s adult immunization rates to reach the national goal requires the persistent efforts of multiple sectors including vaccine suppliers, health departments, and individual health clinics and health providers’ offices.

Key findings are:

• 32.6% of older adults (age 65 and over) in California for whom annual flu shots are recommended did not get immunized in 2001. • Immunization rates among older adults varied by region; rates were found to be lowest in the Los Angeles region (63.9%) and highest in the Sacramento region (77.0%). However, no regions in California came close to meeting the national goal that 90% of older adults be immunized against influenza. • Although there was a strong age-related trend for the elderly to get an influenza immunization, 27% remained unimmunized even among people aged 75 years and over. • Among the state’s racial and ethnic groups, Latinos (46%) and African Americans (47%) over the age of 65 were almost twice as likely to go unimmunized when compared with Asians (27%) and Whites (28%) in the same age group. • Persons with a "medical home" (a regular place to get medical care) were more than twice as likely to get immunized compared to those who did not have a usual source of care. • The more often an individual saw the doctor, the more likely he or she was to get a flu shot, however, large numbers of people with regular access to care were still unimmunized. • Patients covered by Medicare were immunized more often than those who were not covered; in the Medicare-covered group 32.7% were not immunized. • There were no differences found in immunization rates between women and men.

Each year the Great Valley Center produces a report in the five part State of the Great Central Valley series. The data is updated in 5-year increments.

Based on the data, the Great Valley Center recognizes the potential to improve health outcomes throughout the region. Overall, the indicators suggest five strategies:

* Invest in Prevention * Be Strategic With Limited Resources * Model Healthy Lifestyles for Youth * Build Coalitions in Support of a Healthier Environment * Reduce Poverty

Alcohol abuse is known to cause illness, disability, and premature death. It is also a contributing factor in many instances to criminal activity, motor vehicle crashes, and other injuries. Substantial costs resulting from alcohol abuse are incurred in the United States and in California, including the cost of providing medical care for people with alcohol-related illness, treatment and prevention costs, costs to the law enforcement system, costs resulting from alcohol-related motor vehicle crashes and other injuries, and the indirect costs associated with disability, diminished capacity, and premature death from alcohol-related causes.

The purpose of this briefing paper is to review the research that has been done in this area, and to present preliminary estimates of the costs of alcohol abuse in California and its impact on the state. These estimates are based on research that has been conducted by experts at the national level over the years coupled with some specific analyses conducted for California. We also suggest how one could conduct a thorough study to develop more detailed and refined estimates for the state.

THE COST OF ALCOHOL ABUSE IN CALIFORNIA: HIGHLIGHTS

1) The cost of alcohol abuse in California in 2001 totaled $17.8 billion for health service, substance abuse treatment/prevention, lost productivity from premature deaths, and justice system costs (See Appendix Table 11).

2) Nearly 84,000 hospital discharges resulted from alcohol abuse, including 11,388 discharges with alcohol dependence syndrome, 9,314 with alcoholic psychoses, and 8,115 with cirrhosis of the liver. Almost 16,000 Californians were hospitalized for injuries that resulted from alcohol use (Table 3 and page 3).

3) Hospitalization costs amounted to $1.3 billion (Table 6). The mean length of hospitalization in non-federal hospitals was 6.5 days and the mean cost per hospitalization was over $12,000 (Table 5 and page 3).

4) Public programs paid for 64% of hospitalization costs, including 38% paid by Medicare, and 19% paid by MediCal (Table 5 and page 4).

5) Costs of other medical services, including outpatient care, nursing homes, pharmaceuticals, and other health professionals, totaled $1.11 billion (Table 6 and page 4).

6) Health insurance administration costs in California attributed to alcohol abuse amounted to $122 million for 2001 (Table 6 and page 5).

7) More than 13,000 Californians died as a result of alcohol abuse, including 3,600 who died of primary alcohol-caused diagnoses, over 5,100 who died of an alcohol –related diagnosis, and 4,400 who died of an injury attributed to alcohol. These deaths represented lost productivity of nearly $8 billion and over 358,000 life years (Tables 7,8 and page 6).

8) Criminal justice system costs attributed to alcohol were as high as $6.7 billion including $2.1 billion for police protection, $2.1 billion for judicial and legal services, and $2.4 billion for corrections (Table 9 and page 6).

9) In California’s justice system, 25% of total police arrests are for alcohol-specific offenses; approximately 43% of total arrests have been observed to be alcohol-involved (Table 10 and page 6). An estimated 36 percent of state prison and jail inmates were under the influence of alcohol at the time of their convicted offense (Table 9 and page 7).

10) The alcoholic beverage industry paid excise taxes, license fees, and fines totaling $350 million in 2001. In addition to $41 million in license fees and fines, this included $130 million excise taxes on beer sales, $19 million on wine sales, and $138 million on the sale of spirits (Page 8).

11)Seen as an additional cost for the price of a drink, health care and justice system costs add 18 cents not paid by the drinker. Offsetting beverage industry payments (through excise taxes, license fees, and fines) are less than one cent (Page 13).