Determinantes sociales de la salud

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La justicia social es una cuestión de vida o muerte.
Afecta al modo en que vive la gente, a la probabilidad de enfermar y al riesgo de morir de forma prematura.
Vemos maravillados como la esperanza de vida y el estado de salud mejoran de forma constante en algunas partes del mundo, mientras nos alarmamos ante el hecho de que eso no ocurra en otros lugares.
La esperanza de vida de una niña que nazca hoy puede ser de 80 años, si nace en determinados países o de 45 años, si nace en otros. Dentro de cada país hay grandes diferencias sanitarias estrechamente ligadas al grado de desfavorecimiento social.
Semejantes diferencias no deberían existir, ni dentro de cada país ni entre los países.
Esas desigualdades y esa inequidad sanitaria, que podría evitarse, son el resultado de la situación en que la población crece, vive, trabaja y envejece, y del tipo de sistemas que se utilizan para combatir la enfermedad. A su vez, las condiciones en que la gente vive y muere están determinadas por fuerzas políticas, sociales y económicas.
Las políticas sociales y económicas tienen efectos determinantes en las posibilidades de que un niño crezca y desarrolle todo su potencial, y tenga una vida próspera, o de que ésta se malogre. Cada vez hay una mayor convergencia entre los países pobres y los ricos con respecto al tipo de problemas de salud que hay que resolver. El desarrollo de una sociedad, ya sea rica o pobre, puede juzgarse por la calidad del estado de salud de la población, por cómo se distribuyen los problemas de salud a lo largo del espectro social y por el grado de protección de que gozan las personas
afectadas por la enfermedad.
En el espíritu de la justicia social, la Organización Mundial de la Salud (OMS) puso en marcha en 2005 la Comisión sobre determinantes sociales de la salud, con el fi n de recabar datos científi cos sobre posibles medidas e intervenciones en favor de la equidad sanitaria y promover un movimiento internacional para alcanzar ese objetivo.
Gracias a la labor de la Comisión, varios países y organizaciones son ahora socios que tratan de formular políticas y programas que abarquen al conjunto de la sociedad y permitan infl uir en los determinantes sociales de la salud y mejorar la equidad sanitaria. Esos países y asociados se hallan en la vanguardia de un movimiento mundial.
La Comisión hace un llamamiento a la OMS y a todos los gobiernos para que tomen la iniciativa en la acción mundial sobre los determinantes sociales de la salud, con el fi n de alcanzar la equidad sanitaria. Es esencial que los gobiernos, la sociedad civil, la OMS y otras organizaciones internacionales se unan para adoptar medidas encaminadas a mejorar la vida de los ciudadanos del mundo. Alcanzar la equidad sanitaria en el lapso de una generación es posible; es lo que hay que hacer y éste es el momento adecuado para hacerlo.


Determinantes Sociales de La Salud

Ver también "Con la Inequidad todos pierden". Articulo de la Nación por el Dr. Horacio Lejarraga.

In Memorian: JH´s Dean for Barbara Starfield

Image via WikipediaMessage from the Dean

Johns Hopkins Bloomberg School of Public Health

Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming-an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area.

Barbara came to Johns Hopkins in 1959 as a fellow in pediatrics at the School of Medicine. She joined our School in 1962 where she earned her MPH in epidemiology. As professor, she went on to lead the Division of Health Policy in the Department of Health Policy and Management from 1975 to 1994. After stepping down as Division head, Barbara remained an active member of the HPM faculty and was founding director of the Primary Care Policy Center. She was named Distinguished University Professor in 1994. Barbara was greatly admired as a teacher, mentor and colleague.

I am sure that I speak for all of us when I say that my deepest sympathies are with Tony Holtzman--Barbara's husband, her four children, her eight grandchildren, as well her many friends and colleagues around the world.

We'll provide information about funeral arrangements and a memorial service when they are available.

Michael J. Klag, MD, MPH

Dean

Johns Hopkins Bloomberg School of Public Health

Web links:

http://es.wikipedia.org/wiki/Barbara_Starfield

http://www.jhsph.edu/faculty/directory/profile/4169/Starfield/Barbara

http://www.biomedcentral.com/info/publishingservices/profiles/100111

http://www.iseqh.org/

http://www.mgfamiliar.net/Starfield_statement.pdf

Related articles

• On the Death of Barbara Starfield (medhumanities.org)
• 'Inequities' vs. 'Disparities': Why words matter (inequalitiesblog.wordpress.com)
• NHS shakeup review leaves big questions unanswered (guardian.co.uk)
• Producing More Primary-Care Doctors (economix.blogs.nytimes.com)
• State Hires Former Medicaid Bureaucrat to Help Lobby Federal Government for a Medicaid Waiver (reason.com)
• File under O, for obvious: Empathetic men are better in bed (theglobeandmail.com)
• Why doctors shouldn't have to choose between medicine and family (kevinmd.com)
• Heat Wave: If It's Not Hot Enough For Ya, It Will Be Soon (ecocentric.blogs.time.com)

Crisis en atencion primaria

The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org.

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation's best trainees — or the chaos and inefficiency of U.S. health care will only worsen.

The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.

But as Treadway's story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.

Redesigning Primary Care In a video roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.

And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.

These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.

Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they're sending is that more money will not be enough to revitalize primary care.

Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.

In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.

Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients' homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, "This is what I was meant to do."

No potential conflict of interest relevant to this article was reported.

Source Information

Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.

Crisis en atencion primaria

The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org.

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation's best trainees — or the chaos and inefficiency of U.S. health care will only worsen.
The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.
But as Treadway's story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.

Redesigning Primary Care In a video roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.

And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.
These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.
Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they're sending is that more money will not be enough to revitalize primary care.
Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.
In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.
Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients' homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, "This is what I was meant to do."
No potential conflict of interest relevant to this article was reported.

Source Information
Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.

Crisis en atencion primaria

The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org.

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation's best trainees — or the chaos and inefficiency of U.S. health care will only worsen.

The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.

But as Treadway's story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.

Redesigning Primary Care In a video roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.

And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.

These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.

Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they're sending is that more money will not be enough to revitalize primary care.

Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.

In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.

Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients' homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, "This is what I was meant to do."

No potential conflict of interest relevant to this article was reported.

Source Information

Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.

El concepto de prevencion

The concept of prevention: a good idea gone astray?

B Starfield1, J Hyde2,3, J Gérvas4,5, I Heath6

1 Johns Hopkins University, Baltimore, MD, USA
2 Victoria Department of Human Services, Melbourne, Australia
3 Monash University, Melbourne, Australia
4 Equipo CESCA, Madrid, Spain
5 Canencia de la Sierra (Madrid), Spain
6 Caversham Group Practice, London, UK

Correspondence to:
Dr B Starfield, Professor of Health Policy, 624 N Broadway, room 452, Johns Hopkins University, Baltimore, MD 21205-1990, USA; bstarfie@jhsph.edu

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of “diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

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