Wonky vertebrae and exclamation marks
Visualisations for an important day in my public health journey
Tomorrow is International Scoliosis Awareness Day. If you know me well, you have likely grown frustrated at the enthusiasm with which I commemorate this occasion (it is, after all, arbitrary, and relates to a condition that causes me little trouble). But this year, it falls on the same day as a different personal milestone: my first dose of a COVID-19 vaccine.
Today, through a combination of anecdotes, tentative data viz, and a series of coincidences, I will examine these two events through a health equity lens. By the time I finish rambling, I hope you’ll understand why I have never believed more in our collective right to quality care.
I: Treatment access
I was nine when I was diagnosed with a spinal curvature worthy of medical attention — I showed the classic signs of lopsided photos, leg length differences, and other little things you don’t notice until someone else tells you about them. Scoliosis, this big, scary word from the Greek skolios (“bent” or “crooked”), meant nothing more to me than checkups for a few years. Then, one summer after a growth spurt, it got worse, and a doctor recommended spinal fusion surgery, or the insertion of rods and screws near my vertebrae in a procedure that could take eight hours. I was lucky enough to escape the operating table, having been prescribed a brace and physio instead, and it’s been a few years since I thought seriously about my wonky spine.
When I applied to university two summers ago, I said this in my personal statement:
My experience in seeking treatment for this condition and the [sic] discovery of disparities in access to healthcare have inspired me to pursue studies in public health. While the Chinese clinic where I was treated provides high-quality physical therapy, conditions are not as optimal in places like Egypt and Kenya, where many patients cannot get adequate treatment.
I don’t know if I ever wanted to study my current degree for the reasons I specified — I just knew I didn’t have the STEM abilities I needed for medicine, disliked economics enough to avoid courses with social science focuses, and found this field interesting and diverse. Nevertheless, in vying for a place at UCL, I had declared my intent. Now that I’m here, feeling like I’ll graduate tomorrow, I realised that I haven’t worked on these disparities at all.
The literature on scoliosis treatment access is sparse. One study focused on operative outcomes in adolescents treated for the condition across low- and high-resource settings, finding that greater curve magnitude and more complications were observed in low-access countries such as Ghana, Egypt, and Pakistan. Authors attributed this difference to unequal uptake of orthopaedic care. Other investigations focused on demographic and socioeconomic disparities within nations such as the U.S., revealing that privately insured individuals were more likely to receive surgical treatment and that Caucasian patients were more likely to be admitted to larger hospitals, whose mortality rates were also lower.
Here’s the problem: it’s hard to measure the availability of scoliosis specialist care. The World Health Organisation collects data on the number of medical doctors and specialist medical practitioners in each country, but both categorisations are too broad. After locating no comprehensive international register of scoliosis treatment centres (I shouldn’t have been surprised), I looked through the websites of professional associations such as the Scoliosis Research Society (SRS). The latter’s “Find a Specialist” feature contained the closest approximation I could find of a complete quantitative dataset.
Using these international search results, I determined how many SRS-registered scoliosis specialists there were per million population in 54 countries. Then, I combined these statistics with each country’s 2019 GDP per capita (USD) using R’s ggplot2 package to create the chart below.
Some clear insights emerge. Luxembourg, the country with the highest GDP in the chart, also has the greatest availability of registered specialists serving its relatively tiny population. Populous nations such as Indonesia, India, and China, on the other hand, don’t have as many.
Many problems with this data exist. For one, the SRS cannot capture all the specialists in each country listed (and lists no specialists for the other 150-odd countries of the world). And confounding variables of this association between GDP and specialists may include Internet access, English language knowledge, and scoliosis prevalence in each country. Then again, I thought I had to start somewhere.
II: Vaccine equity
After one unsuccessful attempt waiting in line at a London GP clinic a few Saturdays ago, I recently received an SMS message (one of my most anticipated ever) telling me to book an appointment at a vaccination centre near me. In the meantime, only ~0.2% of the world’s share of vaccines has been administered in low-income countries.
Media reports of these disparities in global access to COVID-19 vaccines are widespread, and I don’t have any new information to contribute to this crucial discussion. The delayed vaccination of low- and middle-income countries keeps us from achieving herd immunity in reasonable time and harkens back to an era when HIV drugs were rendered unaffordable to patients in the Global South, costing too many lives. Though air travellers predominantly come from wealthy nations, unequal vaccine distribution will severely limit other passengers’ abilities to move between borders if vaccine passports are introduced. Moreover, access is not only limited internationally; doctors have argued that the groups most vulnerable to SARS-CoV-2 infection (i.e. older people, essential workers, people of colour, and those with pre-existing conditions) are also the least likely to get vaccinated because of practical and structural barriers, even in rich countries such as the United States.
Because this issue has been covered so widely (and for good reason), there’s little data to add to existing sources. Instead, in an effort to display the relationship between country wealth and vaccination reach, I played around with ggplot2 again to produce these small multiples (the countries and multi-sized dots are the same as those used above).
Please excuse my use of donut charts, which I now know is a cardinal sin in data viz practice. After agonising over the latter for a while, though, I discovered that my circular plotting of both variables had created a compelling visual pattern in the first row of the grid — do you notice anything resembling punctuation there?
I reasoned that the countries whose small multiples resembled exclamation marks were in the greatest need. Where both GDP per capita and vaccination rates were high, this was obviously not concerning, and there were few cases where high GDPs coincided with abysmal vaccination rates in this chart. Moreover, in countries where proportions vaccinated were high despite low GDPs per capita, we can consider their approach a relative success. Therefore, the most alarming examples here are the countries whose GDPs and vaccination rates are both low.
III: Is it all connected?
The two issues I’ve discussed above seem disparate, but it would make sense for them to be statistically correlated. I produced a straightforward bubble plot to test this:
It looks like it’s rare for countries to have more than one SRS-registered scoliosis specialist per million population, and that GDP (in the presence of possible confounders) is positively associated with both healthcare outcomes. Within these 54 countries, European nations make up the majority of those with more than 40% of their populations vaccinated, and nations in Africa are hardly represented.
These two outcome variables do not relate through only statistical association. I didn’t need to wait in line to get my first vaccine dose — I just did so (unsuccessfully) because I wanted an earlier chance at gaining peace of mind. I knew that my turn would come.
To book tomorrow’s appointment, I needed to be literate in English, have the ability to travel a moderate distance on foot or through alternative means, and be able to give up more than an hour of my time. I needed a stable Internet connection and a good understanding of my local area. I needed to live in a high-income country, with all its associated visa, standardised testing, health, and transport expenses.
I needed all this for a shot that has saved lives. Meanwhile, my parents in Kenya are still waiting for something they deserve much more than I.
And when I was a patient? My diagnosis came easier because an aunt worked in orthopaedics. My family were my fiercest advocates, and they knew how to navigate a complex health system, but we possessed the resources that not everyone has to demand better care. While I was complaining about getting up early to drive to this clinic and that orthotics centre, I forgot that I had the chance to visit those places. When I was taking advantage of my newfound eccentricity and bionic-like figure at school, I was busy not being doubled over in pain because I had those scans in time. As I drew creative inspiration from my experiences during that brief period of worry and trial, I never wondered whether I would survive. There was no question about the standard of treatment I received.
I have been subject to a series of lucky coincidences. It shouldn’t be true that the most persistent young people I know, those who demonstrate the best compliance I’ve ever seen and whose parents rally and push and ask all the questions, have to endure so much to obtain the best procedures because of where they live. And the inverse care law, whereby the most inferior care is given to the most vulnerable populations, will be a death knell for our post-pandemic public health if I’ve ever heard one.
Once I calm down, I’m sure I can do something to fix this.
Thank you for reading.
P.S. In the process of writing this piece, “tomorrow” has become “today”, so my apologies to any future readers confused by my chronological terms :)
