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This chapter presents an overview of what we currently know about social inequalities in the experience of dying. A review of existing evidence for social variation in premature mortality, cause, and place of death, is followed by consideration of how access to end of life care services may differ with social position. It concludes with a discussion of how policies and funding can and should influence inequalities in end of life experiences, highlighting areas for future research and advocacy.

In pandemic planning, much attention has been paid to justice in the distribution of scarce health care resources: vaccines, anti-virals, and access to advanced modes of treatment such as ventilator support. This chapter examines critically the extent to which some proposals fail to take existing injustice into account. It considers the justice of pandemic planning, arguing that in order to be just, pandemic planning requires attention to basic health care infrastructure for everyone. Without, for example, access to basic primary care, people will be less likely to present for treatment and pandemic disease may not be identified at a time when spread is more readily preventable.

This chapter describes who uses palliative care and reviews the factors affecting access to palliative care. It is difficult to estimate what the appropriate level of palliative care provision in a population should be. However, such provision varies considerably between countries and many patients across the world have little or no access to palliative care due to lack of service provision. Even within nations with good palliative care provision there is considerable local variation. Patients differ in their access to palliative care on the basis of diagnosis, age, socio-economic status, ethnic background and the presence of a family carer. Some of the factors underlying these differences are poorly understood and require further research.

Successful adherence is influenced by many factors, including disease type, the complexity of the regimen, patient resources, system-level barriers, the clinician–patient relationship itself, and various cultural beliefs and experiences. Approximately one-fourth of patients fail to follow their prescribed treatment regimens, and the focus of this chapter is on understanding the barriers to adherence, with an eye toward strategies that promote adherence (e.g., simpler regimens, clear explanations, accurate understandings of likely side effects, strong social support networks, fostering patient autonomy and self-efficacy, partnering with patients, ensuring access to care). Multifaceted interventions to improve adherence are most effective.

This chapter discusses a variety of issues that impact access to optimal health care for gay and bisexual men in the United States. Special consideration is given to health insurance coverage and health insurance discrimination among gay and bisexual men. A discussion of domestic partner benefits highlights the role of legally-sanctioned partnerships and access to health insurance. The chapter concludes with specific recommendations for improving the health care environment and communication practices of providers who care for gay and bisexual men, including special populations of gay youth and elderly gay men.

This chapter appraises the evidence, principally from the UK and the USA, to determine in which ways the ‘socially excluded’ — the poor, black, and minority ethnic (BME) groups, asylum seekers and refugees, the homeless, those within the penal system, and drug users — fare with respect to accessing specialist palliative care and related services during advanced disease and at the end of life. It presents suggestions on how those involved in public health policy and the delivery of palliative care and related services can extend care to include these disadvantaged groups.

In Dr. King’s 1966 speech to the Medical Committee for Human Rights, he is quoted as saying “of all the forms of inequity, injustice in healthcare is the most shocking and inhumane.” Dr. King did not view healthcare as a human commodity, but as a fundamental human right. This chapter discusses what Dr. King might say about heathcare today regarding topics such as access, heath disparities, infant and age-adjusted mortality, and physician shortage. Dr. King might say that the Affordable Care Act is the most important legislation to impact the health of the nation and that although progress has been made, much still needs to be done, particularly concerning access to care, health insurance coverage, and representation of minorities in health professions.

This chapter examines the contextual factors related to the occurrence and risk of asthma, health behaviors, access to health care, and the design of effective interventions to reduce the burden of asthma. The latter is exemplified through the discussion of a specific community-based approach to asthma management: the Neighborhood Asthma Coalition.

This chapter deals primarily with the impact of social injustice on children in the United States, emphasizing children's rights in a legal context. It covers the legal status of children in society, the impact of social injustice on children's health, underlying factors and roots of this social injustice, and what needs to be done. The chapter concludes that the well-being of children depends on many investments, such as adequate family income, safe housing neighbors, and caregivers whose own lives are sufficiently supported to be able to invest time in and nurture their children. It also includes boxes on how the United States compares with other developed countries, and saving children's lives in developing countries.

The provision of end-of-life care for people with intellectual disabilities is becoming an issue of increasing concern. This is an ageing population. Comprehensive and up-to-date morbidity and mortality data are lacking, mostly due to methodological problems (including the lack of a data base of people with intellectual disabilities in many countries). However, it is evident that with increased longevity among those with intellectual disabilities there is also a rising incidence of life-limiting illnesses such as cancer or dementia. How are the end-of-life care needs of this group being met? Are they able to access appropriate palliative care services when they need it? This chapter focuses on the challenge facing those with intellectual disabilities in achieving equal access to palliative or end-of-life care services.

This chapter describes Oregon's experiment with cost-effectiveness as part of a grander proposal to overhaul the state's health insurance system. It discusses the plan itself, the debate surrounding it and the consequences of the proposal. The plan included several features: requiring employers to provide health insurance to all permanent employees, funding a high-risk pool for individuals with pre-existing conditions, and expanding the state's Medicaid program to cover additional state residents. In the end, though, formal CEA itself played little role in the actual plan. It proved so controversial and difficult to implement that it was abandoned early on in the process even as the ranked list of medical conditions/treatments was salvaged.

This chapter reviews France's response to its HIV epidemic. France's response to HIV involved many actors including those from government, non-government organizations, clinicians, and social scientists, among others, and produced responses ranging from access to care to the protection of patients' rights. As in other European countries, the availability of HAART has led to a significant reduction in mortality as well as improvement in the health status of all HIV-infected patients. As a result, HIV is considered to have moved from an acute to a chronic disease in France. The fact that most patients have been covered by social security has been a key factor in effective treatment efforts.

There has been a sharp increase in forced displacement in recent decades, particularly of urban refugees who comprise 60% of refugees worldwide. Urban refugees are largely concentrated in the developing world. Non-recognition of their status as refugees in countries of asylum contributes to unique legal, social, and material precarity which engenders a range of protection challenges, including health risks. This chapter provides an operational definition for urban refugees and discuss their unique health risks within the legal and policy contexts they live in, their access to health care, and the challenges experienced by host countries grappling with resource constraints and stretched health-care systems.

This chapter highlights groups that are under-served and otherwise disadvantaged at the end of life. It focuses on people who live in rural or remote areas. Despite some important benefits to living and dying outside metropolitan areas, rural/remote persons are often disadvantaged as they reach the end of life, and in many different ways. Although it is impossible to highlight all global issues, the chapter summarizes relevant current research and emphasizes key aspects of rural/remote inequity for attention. Some comparative points about urban under-served groups are also made, as it would be unfair to categorize all people who live in or near cities as having better end-of-life care chances than rural/remote persons.

This chapter is about secondary level prevention: that is, the restoration of health and alleviation of illness symptoms. It is argued that it is at the level that there is greatest commercial potential for health providers. Gross inequalities in access to health care at a global level are considered in relation to the migration of health workers from low- and middle-income countries to high-income countries. Examples of age-related inequalities and age discrimination considered include the neglect and abuse of older people within healthcare systems and the inadequate attention given to health conditions that affect older people disproportionately. Health care systems are increasingly attuned to the rise in chronic and non-communicable diseases (NCDs) but the imperative to contain costs impedes effective development. It is argued that there is a need for a better understanding of older people's experiences of living with chronic illness and of the importance of age to illness experience.

This book argues that primary care medicine in the United States is in crisis. Drawing on personal experience from the perspective of a solo practitioner of primary care, the book reflects on unfavorable trends in the field that are amenable to repair. It cites examples such as polypharmacy (doctors' propensity to overprescribe) and “poly-doctoring” (the excessive and expensive referral to multiple specialists), as well as the malaise of a malpractice suit facing health care professionals. It also discusses problems in the U.S. health care system, such as lack of access to health care, the staggering price tag of modern technologic medicine, and the growing number of old people. The book blames the sad state of primary care medicine on economists' tenets of maximized efficiency, profit, and productivity. It suggests that American patients deserve ready access to a compassionate, comprehensive, and sustained relationship with their primary care physicians, which this book argues is the backbone of good health care.

Oral diseases are often called a neglected or silent epidemic. They are largely due to social injustice in which private wealth overrides the public’s health. Although oral diseases affect almost everyone, prevention of them and access to dental services have not been high priorities in the United States. This chapter, after defining oral health, describes the neglected epidemic of oral diseases and then discusses the roles that the food and tobacco industries play in contributing to oral disease and poor oral health. Although organized dentistry has done much to improve oral health, it also has limited access to dental care for millions of Americans. The chapter discusses health literacy and social inequality, national issues concerning oral health, state and local issues, school programs, the dental public health infrastructure, and the dental workforce. It discusses what needs to be done. A text box addresses oral health in low- and middle-income countries.

Philosophically speaking, the question “What are the ethical implications of understanding breast cancer?” raises a host of issues, including informed consent, risk assessment, and access to breast cancer care. What we find is that, initially, there are adequate guidelines for informed consent, adequate efforts to develop risk assessment measures, and a decent level of access to breast cancer care in the United States. But things can be improved from an ethical standpoint. Upon reflection, the informed consent process would benefit from a more explicit discussion of uncertainty in breast cancer medicine and the ways breast cancer patients make decisions about their care. Risk assessments would benefit from a more personalized approach. Access to breast cancer care could be improved by continued studies of the diverse forces that limit access to proper breast cancer care.

Older people experience a range of age-related conditions such as arthritis, respiratory disease, circulatory disease, and mental health problems such as depression and dementia. The prevalence of such conditions increases with age as does multiple pathology. One consequence of this age-related increase in morbidity is that older peoples’ ability to remain living independently in the community may be compromised as they experience difficulties with essential activities of daily living. Informal or family care is fundamental to any community care policy for older people and the contribution of the family generally in providing care is well established both qualitatively and quantitatively. Approximately, 12% of adults self-define themselves as ‘informal carers’, whilst 56% of adults expect their family to provide care and support in old age. This chapter examines how health care needs are differentially distributed within the older population and the importance of class (and gender and ethnicity) in the distribution of both longevity and morbidity. Consequently, it examines how the typology of caring about, taking care, care giving and care receiving extends our understanding of the formal and informal care sectors and how these dimensions of caring are linked to the key socio-structural factors of class, gender and ethnicity.

Palliative care physicians enjoy the opportunity to make a special kind of difference in the lives of patients, families, and communities. Through their experiences in the palliative care program at the safety-net hospital, many medical students and residents have learned to their surprise that the dying poor sometimes have access to better care than the dying rich. Today, the dying poor are not only receiving better care—as this story illustrates, they are also playing an important role in helping to illuminate what such care really looks like, and their experiences are helping to improve the care of dying patients in their community and throughout the world.