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LETTER |
Steven H. Woolf, MD, MPH is with the Departments of Family Medicine, Epidemiology and Community Health at Virginia Commonwealth University, Fairfax. Robert E. Johnson, PhD is with the Departments of Biostatistics and Family Medicine at Virginia Commonwealth University, Fairfax.
Correspondence: Requests for Reprints should be sent to Steven H. Woolf, MD, MPH, Virginia Commonwealth University, Department of Epidemiology and Community Health, 3712 Charles Stewart Drive, Fairfax, Virginia 22033 (e-mail: swoolf{at}vcu.edu).
We agree with Muennig that income disparities, among other potential factors, might dampen the effectiveness of medical treatments. This point is precisely the subtext of our article.1 However, whether a greater effect of medical advances on mortality might have been realized had circumstances in 1991–2000 been more equitable bears little on how one measures the effect that actually did occur. To borrow Muennig’s example—that medical advances might have increased life expectancy by 2.5 years had the Gini coefficient been zero—does not change the reality that life expectancy increased by only 1.5 years.2
Perhaps Muennig intends a more subtle point: that advances in medical technology may be bound up in efforts to resolve disparities and cannot be treated independently. We acknowledge this concern and raised it ourselves.1 To the extent that such confounding occurs, we agree that our calculations would overestimate the ratio in lives saved between correcting disparities and improving medical technology.
For example, suppose that our calculations found that 2 lives per 100 are saved by technological advances and that 10 lives per 100 would be saved by correcting disparities (a ratio of 5:1 similar to that reported in our article). If 6 of the 10 lives that could be saved by correcting disparities relied on technologies that never came into existence—the resources for their development having been diverted to the disparities issue—the effort to correct disparities would save only 4 lives (a ratio of 2:1).
We doubt, however, that confounding between the 2 endeavors is this extensive. As we discussed in our article1 and elsewhere,3,4 correcting disparities in health outcomes probably has far more to do with socioeconomic conditions and barriers to access and insurance than with offering African Americans new drugs and devices. Elsewhere we demonstrate that adverse health events and deaths would be averted in much greater numbers by ensuring that all eligible patients receive recommended treatment, even with older agents, than by providing newer agents to those with current access.5
Our article discusses other potential threats to the precision of our calculations. For example, our calculations assumed that the correction of disparities would be absolute and would occur immediately. Moreover, our analysis focused only on race. Given the fundamental influence of socioeconomic conditions on disparities,6 we are now working to quantify the health improvements that would occur by resolving gaps in income, education, and other social determinants of health.
References
1. Woolf SH, Johnson RE, Fryer GE Jr, Rust G, Satcher D. The health impact of resolving racial disparities: an analysis of US mortality data. Am J Public Health. 2004;94:2078–81.
2. Freid VM, Prager K, MacKay AP, Xia H. Chart-book on Trends in the Health of Americans. Health, United States, 2003. Hyattsville, MD: National Center for Health Statistics, 2003.
3. Woolf SH. Society’s choice: the tradeoff between efficacy and equity and the lives at stake. Am J Prev Med.2004;27:49–56.[Medline]
4. Satcher D, Fryer GE Jr, McCann J, Troutman A, Woolf SH, Rust G. What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. Health Aff (Millwood). 2005;24:459–464.
5. Woolf SH, Johnson RE. The breakeven point: when medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med. In press.
6. Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why both matter. Health Aff (Millwood). 2005;24:343–352.
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