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SOCIAL EXPENDITURE UPDATE
Social spending is falling in some countries, but in many others it remains at historically high levels Insights from the OECD Social Expenditure database (SOCX), November 2014 |
Directorate for
Employment, Labour
and Social Affairs
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New OECD data show that in recent years Canada, Estonia, Germany, Greece, Hungary, Iceland, Ireland and the
United Kingdom have experienced substantial declines in social spending as a percent of GDP, but in most
countries social spending remains at historically high levels. Public spending in some emerging economies is
below the OECD average, lowest in India and Indonesia but highest in Brazil where – as in OECD countries –
pensions and health expenditure are important areas of social spending. New SOCX data also shows that income-
testing in social protection systems is much more prevalent in Anglophone and non-European OECD countries than
in continental Europe. Finally, when considering the role of private social benefits and the impact of tax systems,
social spending levels become more similar across OECD countries, and while France remains the biggest social
spender, the United States moves up the rankings to second place.
http://www.oecd.org/els/soc/OECD2014-Social-Expenditure-Update-Nov2014-8pages.pdf
http://www.oecd.org/els/soc/OECD2014-Social-Expenditure-Update-Nov2014-8pages.pdf
Mass Imprisonment and Public Health
When public health authorities talk about an epidemic, they are referring to a disease that can spread rapidly throughout a population, like the flu or tuberculosis.
But researchers are increasingly finding the term usefulin understanding another destructive, and distinctly American, phenomenon — mass incarceration. This four-decade binge poses one of the greatest public health challenges of modern times, concludes a new reportreleased last week by the Vera Institute of Justice.
For many obvious reasons, people in prison are among the unhealthiest members of society. Most come from impoverished communities where chronic and infectious diseases, drug abuse and other physical and mental stressors are present at much higher rates than in the general population. Health care in those communities also tends to be poor or nonexistent.
The experience of being locked up — which often involves dangerous overcrowding and inconsistent or inadequate health care — exacerbates these problems, or creates new ones. Worse, the criminal justice system has to absorb more of the mentally ill and the addicted. The collapse of institutional psychiatric care and the surge of punitive drug laws have sent millions of people to prison, where they rarely if ever get the care they need. Severe mental illness is two to four times as common in prison as on the outside, while more than two-thirds of inmates have a substance abuse problem, compared with about 9 percent of the general public.
Common prison-management tactics can also turn even relatively healthy inmates against themselves. Studies have found that people held in solitary confinement are up to seven times more likely than other inmates to harm themselves or attempt suicide.
The report also highlights the “contagious” health effects of incarceration on the already unstable communities most of the 700,000 inmates released each year will return to. When swaths of young, mostly minority men are put behind bars, families are ripped apart, children grow up fatherless, and poverty and homelessness increase. Today 2.7 million children have a parent in prison, which increases their own risk of incarceration down the road.
If this epidemic is going to be stopped, the report finds, public health and criminal justice systems must communicate effectively with one another. That requires comprehensive electronic health records that can be shared among agencies, increasing the likelihood that those who leave prison with health problems will not fall through the cracks.
Better health outcomes also depend on giving newly released inmates a real chance to find jobs and housing. The report calls for the end of laws that keep punishing people after they have been released from prison, like denying public housing and food stamps to those with drug felony convictions.
Finally, the Affordable Care Act — which provides more coverage for mental illness and substance abuse, and expanded Medicaid for childless adults — is a big step in the right direction.
Like any epidemic, mass incarceration must be tackled at many different levels. It is an opportune time for such an approach, as states around the country are thinking more broadly, pulling back on harsh sentencing laws and focusing more on alternatives to incarceration. But the moment may not last long. Public health professionals should seize a unique opportunity to help guide criminal justice reform while they have the chance.
Fury After Ferguson
The reaction to the failure of the grand jury to indict in the shooting of an unarmed black teenager, Michael Brown, by a white police officer, Darren Wilson, touched something deep and ancient and anguished in the black community.
Yes, on one level, the reaction was about the particulars of this case.
It was about whether Wilson’s use of force was appropriate or excessive that summer day when he fired a shot through Brown’s head and ended his life.
It was about whether police officers’ attitudes towards the people they serve are tainted. Why was Wilson’s description of Brown in his testimony so laced with dehumanizing rhetoric, the superhuman predator and subhuman evil, “Hulk Hogan” and the “demon”?
It was about whether the prosecutor performed his role well or woefully inadequately in pursuit of an indictment. Why did he take this course of action? Why didn’t he aggressively question Wilson when Wilson presented testimony before the grand jury? Why did he sound eerily like a defense attorney when announcing the results?
And yet the reaction was also about more than Wilson and Brown. It was about faith in fundamental fairness. It was about whether a population of people with an already tenuous relationship with the justice system — a system not established to recognize them, a system used for generations to deny and subjugate them, a system still rife with imbalances toward them — would have their fragile and fraying faith in that system further shredded.
As President Obama put it: “The fact is, in too many parts of this country, a deep distrust exists between law enforcement and communities of color. Some of this is the result of the legacy of racial discrimination in this country.”
He continued, “There are still problems and communities of color aren’t just making these problems up.”
No, they are not. An October analysis by ProPublica of police shootings from 2010 to 2012 found that young black males are 21 times more likely to be shot dead by police officers than their white counterparts.
And yet, people like the former New York City mayor Rudy Giuliani want to blame the victims. On “Meet the Press,” he dodged the issue of white police forces policing black populations, and raised another: intra-racial murder statistics in the black community. After proclaiming that “93 percent of blacks are killed by other blacks,” he asked a fellow panelist, Michael Eric Dyson, a black Georgetown University professor, “why don’t you cut it down so so many white police officers don’t have to be in black areas?”
Classic blame-the-victims deflection and context-free spouting of facts. What Giuliani failed to mention, what most people who pay attention to murder statistics understand, is that murder is for the most part a crime of intimacy. People kill people close to them. Most blacks are killed by other blacks, and most whites are killed by other whites.
In fact, it is so intimate that one study has found that people likely to be involved in murder cases can be predicted by their social networks. A Yale study last year examining “police and gun homicide records from 2006 to 2011 for residents living within a six-square-mile area that had some of the highest rates for homicide in Chicago” found that “6% of the population was involved in 70% of the murders, and that nearly all of those in the 6% already had some contact with the criminal justice or public health systems.”
As a co-author of the study put it, the relationship among killers and those killed was like a virus: “It’s not unlike needle sharing or unprotected sex in the spread of H.I.V.”
So, what are we saying to the vast majority that are not involved: that they must accept the unconscionable racial imbalance in the police shooting numbers as some sort of collateral damage in a war on crime? No!
It’s an unfathomable, utterly immoral argument, and let’s not give Giuliani a pass for making it. After all, New York’s obscenely race-biased stop-and-frisk program was introduced under Giuliani, and some of the most notorious police violations of black men in recent history happened on his watch. As The New York Times recounted in a lengthy 2001 profile:
“In the summer of 1997, a police officer brutalized a Haitian immigrant named Abner Louima in a bathroom of a Brooklyn station house. In the winter of 1999, four members of the Police Department’s Street Crime Unit, searching the Bronx streets for a rapist, shot and killed an unarmed African immigrant named Amadou Diallo; they had mistaken his wallet for a gun. And in the winter of 2000, just as Mr. Giuliani was gearing up his candidacy for the United States Senate, an undercover officer shot and killed an unarmed black security guard named Patrick Dorismond after a brief struggle in Midtown; the victim had been offended by the undercover officer’s inquiries about buying some drugs.”
Also, race is not the best lens through which to consider criminality. Concentrated poverty may be a better lens. According to a July Brookings report:
“Poor individuals and families are not evenly distributed across communities or throughout the country. Instead, they tend to live near one another, clustering in certain neighborhoods and regions. This concentration of poverty results in higher crime rates, underperforming public schools, poor housing and health conditions, as well as limited access to private services and job opportunities.”
If we are serious about fighting crime, we must seriously consider the reason— on both an individual and systemic level — these pockets of concentrated poverty developed, are maintained, and have in fact grown and spread.
But this is not about Giuliani and the police aggression apologists. This is about whether black boys and men, as well as the people who love them, must fear both the criminal and the cop.
Sadly, for many, the Ferguson case reaffirmed a most unsettling sense that they are under siege from all sides.
So people took to the streets. Who could really blame them?
Some simply saw protests marred by senseless violence. I saw that, to be sure, and my heart hurt seeing it. But I also saw decades, generations, centuries of pain and frustration erupting once more into view. I saw hearts crying and souls demanding to be heard, to be seen, to be valued.
The Rev. Dr. Martin Luther King Jr. once said, “A riot is the language of the unheard.” King, a great champion of nonviolence, wasn’t advocating rioting, but rather honoring hearing.
Even long-suffering people will not suffer forever. Patience expires. The heart can be broken only so many times before peace is broken. And the absence of peace doesn’t predicate the presence of violence. It does, however, demand the troubling of the comfortable. When the voice goes unheard, sometimes it must be raised. Sometimes when calls for justice go unmet, feet must meet pavement. Sometimes when you are unseen, you can no longer remain seated. Sometimes you must stand and make a stand.
No one of good character and conscience condones rioting or looting or any destruction of property. Those enterprises aren’t only criminal, they’re fruitless and counterproductive and rob one’s own neighborhood of needed services and facilities and unfairly punish the people who saw fit to follow a dream and an entrepreneurial spirit, and invest in themselves and those communities in the first place.
But people absolutely have a right to their feelings — including anger and frustration. Only the energies must be channeled into productive efforts aimed at delivering the changes desired. That is the hard work. That is where stamina is required. That is where the long game is played.
As the old Negro spiritual proclaims: “Walk together children/Don’t you get weary/Oh, talk together children/Don’t you get weary.”
When is Medical Treatment Overtreatment? Maine Doctors Take New Look
By PATTY WIGHT • NOV 26, 2014
Medical treatment can cure illnesses and save lives. But too much treatment can cause harm, even death.
The Lown Institute in Boston estimates that between 10 and 30 percent of medical treatment in this country is unnecessary and racks up between $2 billion and $800 billion in extra costs. In Maine, some health care providers are changing their approach to ensure that they give patients what they call "right" treatment.
About eight years ago, nurse practitioner Tom Bartol realized that some of the care he was prescribing may not benefit his patients as much as much as he thought. He was researching statins - drugs that are used to lower cholesterol and prevent heart disease.
"And we looked at the data and we saw a 37 percent risk reduction," Bartol says. "That's what all the guidelines are based on - this 37 percent risk reduction."
"And we looked at the data and we saw a 37 percent risk reduction," Bartol says. "That's what all the guidelines are based on - this 37 percent risk reduction."
Sounds pretty good. But then Bartol wondered - what's the baseline risk for heart disease for his patients? Some on statins had a risk of between 3 and 6 percent; and when you consider those numbers, that nearly 40 percent reduction in risk doesn't sound quite as impressive.
"I started questioning the guidelines," Bartol says. "We have a lot of clinical guidelines we're supposed to follow. We sort of follow them like a cookbook. I was following them blindly, as I suppose many people do. They have no idea of the data behind it."
"I started questioning the guidelines," Bartol says. "We have a lot of clinical guidelines we're supposed to follow. We sort of follow them like a cookbook. I was following them blindly, as I suppose many people do. They have no idea of the data behind it."
Shannon Brownlee, a former journalist who wrote a book about medical overtreatment, came to a similar conclusion 15 years ago. She was reporting on tests to detect prostate cancer. Turns out, the test catches a lot of non-lethal cancers that don't need treatment.
"And when men get treated, usually with surgery, half of them get incontinence and impotence," Brownlee says.
Brownlee says part of what drives unnecessary treatment is money: Doctors are paid per procedure or test. "And it's also what we, as patients, have come to expect. Patients think that if their doctor didn't run a lot of tests, their doctor didn't really care about them. They've come to replace technology for real care."
The Problem With Prostate Screening
By RICHARD J. ABLIN
TUCSON — SCIENTIFIC data from clinical trials provides the foundation of medical decision making, from a doctor’s prescription pad to sweeping public health policies. Public trust that the data is accurate and unbiased is the glue that binds our $3 trillion health care system. I worry that this trust, particularly when it comes to American men and their physicians and screening programs for prostate cancer, is now at risk.
In 1970 I discovered the prostate-specific antigen, or PSA, which is now the most widely used tool in prostate screenings. But there has been a growing concern about whether the use of the PSA test has led to overdiagnosis and overtreatment, with millions of unnecessary surgeries, complications and deaths.
Nevertheless, the medical community has roundly embraced the results of a recent study finding that PSA screening reduced prostate cancer deaths by 20 percent. The study, the European Randomized Study of Screening for Prostate Cancer, joined another survey, the so-called Swedish Goteborg study (the results of which provided a basis for the European Randomized Study), which found an astounding 44 percent reduction.
But there’s a big problem with both of these studies: In March the Goteborg study’s authors announced in the British Medical Journal that their data “are not available to outside investigators.”
That the researchers would block access to government- and charity-supported research is bad enough. Even worse, it calls into question why, if the data was strong, the researchers wouldn’t open it up to independent scrutiny.
As it turns out, there are some major concerns about the methodology and results of the studies, first raised last fall in the Journal of the National Cancer Institute by two Australian researchers.
