A Tale of Two Cities: Around the Globe or Around the Corner?
The authors of one of this week’s articles, Location, Location: Residence, Wealth, And The Quality of Medical Care in Delhi, India, articulate and provide evidence for why the widely held notion that better healthcare outcomes are linked to increased access and availability of care do not seem to hold true for residents of Delhi. The study notes that residents of Delhi have access to some seventy medical providers within walking distance and access to these providers is available regardless of resident income. They also find that the poorest residents tend to utilize more health care without experiencing improved healthcare outcomes.
In 2004, the New York City Department of Health and Mental Hygiene, published a paper on disparities in healthcare among New York City residents. Key findings of the study indicate; poorer people are more likely to report poor overall health, poor health is concentrated in specific neighborhoods, and residents living in certain poor neighborhoods have a life expectancy 8 years shorter than those living in richer neighborhoods.
Delhi is the largest city in India(the 8th largest city in the world) and its residents are among the wealthiest in India. It is home to an estimated 21.5 million people, approximately 8% of those living below the poverty line. The 2007 per capita income was approximately $1,450. New York City, in comparison, is the largest city in the United States and its residents are also among the wealthiest in our country. It is home to an estimated 8.3 million people, approximately 19% live below the poverty line. Income per capita is widely disparate with the richest neighborhoods income per capita of $90,000 while poorer neighborhoods have a per capita income of $22,400.
The authors of the Delhi article postulate that the expertise of a patient’s medical provider is actually more of a determinant of healthcare quality than access to care. And it is quite likely that poor people receive care from less knowledgeable providers. Key findings include the fact that poor people were more likely to visit less competent providers and more often. The rich, were more likely to visit hospitals when they sought public care, and these hospitals are likely to have the most competent providers(university trained medical professionals). The authors of the paper conclude that better educating consumers about their choice in care provider and under what circumstances may help to improve healthcare outcomes. In addition, the government could also allocate more of the public doctors to the poorer neighborhoods to promote equity and decrease social disparities.
The authors of the New York City paper postulate that poor health is generally multi-factorial and can be associated with: access, unhealthy lifestyle choices, and poor living conditions. The paper argues that social conditions have a significant impact on health and efforts to improve disparities must be linked to broader goals of improving economic and living conditions as well as targeting and reducing certain high risk diseases.
In conclusion, determinants of health and improved healthcare outcomes are broad and complex. These determinants affect people from around the globe and around the corner. It is fascinating to realize that we are often not as different as we think. We can actually glean similarities between healthcare issues among populations that would appear to vary greatly at first glance.
 Das J and Hammer J. Health Affairs 26, no. 3(2007):w338-351