Editorial: Iatrogenic poverty-猫眼课题宝

社论：医源性贫困

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发表时间：

2003

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作者：

B. Meessen;Zhenzhong Zhang;W. Damme;N. Devadasan;B. Criel;G. Bloom

关键词贫困、医源性、灾难性医疗支出、医疗保险、社会救助、亚洲、转型贫困和疾病交织在一起。贫穷导致健康不佳，这是有据可查的事实。在每个社会中，穷人的发病率和死亡率都较高（Wagstaff，2002年）。健康状况较低的决定因素包括营养、环境、教育、生活方式和获得保健的机会。对于疾病本身如何导致发展中国家的贫困，人们知之甚少。有两个主要途径。第一种是通过家庭收入来源的死亡或残疾。这减少了未来的创收，并可能危及家庭消费，在家庭耗尽其财富后，它可能会减少投资于子女教育的能力。第二种是通过治疗本身，或者更确切地说是通过治疗的成本。事件链如下：当有人福尔斯生病时，这个家庭面临着几种不同的成本（提供照顾、交通、治疗的机会成本），并采取不同的策略来科普这些成本。有时成本是有限的，家庭可以通过短期调整来缓冲这些成本（如消费预防性储蓄、寻求正规支持网络的帮助、暂时减少其他商品的消费）。然而，有时候，成本已经达到或增加到这些应对机制不再足够的水平。然后，家庭采取出售或抵押其生产性资产的风险更大的战略（恩索尔和Bich San 1996;布卢姆和卢卡斯2000;梅森和克里尔2003）。一些家庭从金融冲击中恢复过来，但另一些家庭没有（Wilkes et al. 1997）。下一次，当他们不得不面对疾病、庄稼歉收或其他问题时，他们可能会陷入贫困。Chambers（1983）称这一过程为贫困棘轮，医源性贫困穷人很清楚这种循环。调查发现，他们认为疾病是他们最大的烦恼之一（Milimo等，2002）。经济学家和贫困分析专家提出了这个问题。世界卫生组织、世界银行和国际劳工组织正试图把它提到议程的更高位置，称之为灾难性的医疗保健支出。但这个问题仍然很少被政治、科学，尤其是医学界所认识。医生们接受的培训是从健康状况的角度来评估他们的干预措施的结果，现在是时候从福利的角度来考虑他们了。让我们看看卫生部门之外的世界。在过去的二十年里，人类发生了什么重大变化？这本杂志的普通读者可能会认同全球化。但对于17亿人来说，这一重大变化有另一个名字：过渡。从计划经济向市场经济的转变涉及到中国、东南亚大部分地区、东欧和前苏联的加盟共和国。这种转变对这些国家的公民意味着什么？一些国家的经济增长，但也重塑了应享权利的格局（Sen 1981）。教育、就业、收入和福利服务过去被认为是理所当然的，而今天，它们是由市场力量和提供贝内的政治承诺共同决定的。人们可以根据托内的技能和劳动力市场的需求找到工作和赚取收入。教育和医疗不再是全民的，而是受到支付能力的限制。大多数政府由于预算有限、过度相信市场力量或其他优先事项而无法为其卫生部门提供充足的资金。因此，许多公共医疗保健设施被淘汰或通过向病人收费来创收。与此同时，许多国家的农村家庭有了新的机会来管理或出售他们的土地和其他生产性资产。市场化确实无处不在。今天，柬埔寨或中国的农民比以往任何时候都更有能力将自己支付医疗费用的能力与支付意愿相匹配。信贷和土地市场，即高利贷

keywords poverty, iatrogenesis, catastrophic health care expenditure, health insurance, socialassistance, Asia, transitionPoverty and illness are intertwined. It is a well-documentedfact that poverty leads to ill-health. In every society,morbidity and mortality are higher among the poor(Wagstaff 2002). Determinants of lower health statusinclude nutrition, environment, education, lifestyle andaccess to health care. Less is known about how illness itselfcan lead to poverty in developing countries. There are twomajor pathways. The ﬁrst is through the death or disabilityof a household income earner. This reduces future incomegeneration and may jeopardize household consumption.After a household has depleted its wealth it may have lesscapacity to invest in the education of their children. Thistransmits poverty to the next generation.The second is through the treatment itself, or moreexactly its cost. The chain of events is as follows: whensomeone falls ill, the household faces several different costs(opportunity cost of care giving, transportation, treat-ment), and to cope with them, it follows diverse strategies.Sometimes the costs are limited, and the household is ableto buffer them by making a short-term adjustment (such asconsuming precautionary saving, calling on assistance frominformal support networks, temporarily reducing its con-sumption of other goods). Yet, sometimes, the costs are at,or increase to, a level where these coping mechanisms arenot sufﬁcient anymore. The household then adopts theriskier strategies of selling or mortgaging its productiveassets (Ensor & Bich San 1996; Bloom & Lucas 2000;Meessen & Criel 2003). Some households recover from theﬁnancial shock, but others do not (Wilkes et al. 1997). Thenext time when they have to deal with an illness, a cropfailure or another problem, they may be tipped intopoverty. Chambers (1983) has called this process a povertyratchet.Iatrogenic povertyPoor people are well aware of that cycle. Surveys havefound that they identify sickness as one of their greatestworries (Milimo et al. 2002). Economists and experts inpoverty analysis have raised the issue. The WHO, theWorld Bank and the ILO are trying to put it higher on theagenda by referring to it as catastrophic health careexpenditure. But the issue is still little recognized by thepolitical, scientiﬁc and, most of all, the medical commu-nities. Doctors are trained to assess the outcome of theirinterventions in terms of health status, it is high time toconsider them in terms of welfare.Let us have a look at the world outside the health sector.What has been the major change for humanity these lasttwo decades? The average reader of this journal mightidentify globalization. But for 1.7 billion people, the majorchange has another name: transition. The transition from aplanned economy to a market economy has concernedChina, most of South East Asia, Eastern Europe and theRepublics of the former Soviet Union. What has thistransition meant for the citizens of these countries?Economic growth in some countries, but also a reshapingof the pattern of entitlements (Sen 1981). While education,jobs, income and welfare services used to be taken forgranted, today they are determined by a combination ofmarket forces and political commitment to provide bene-ﬁts. One can ﬁnd a job and earn an income according toone’s skills and the demand in the labour market. Access toeducation and health care are no longer universal, but areinﬂuenced by the ability to pay.Most governments fail to fund their health sectoradequately because of limited budgets, excessive faith inmarket forces or other priorities. Consequently, manypublic health care facilities are run down or they generaterevenue by charging patients. At the same time, ruralhouseholds in many countries have a new opportunity tomortgage or sell their land and other productive assets.Marketization is indeed ubiquitous. Today, more thanever, the Cambodian or Chinese farmer is able tomatch his ability to pay for health care with his willing-ness to pay. Credit and land markets, i.e. usurious

Editorial: Iatrogenic poverty

社论：医源性贫困

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