Chapter 3 SOCIAL INEQUALITIES, SOCIAL JUSTICE AND HEALTH

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Chapter 3 SOCIAL INEQUALITIES, SOCIAL JUSTICE
AND HEALTH
D.F.Marks, M.Murray, B.Evans, C.Willig,
C.Woodall C.M. Sykes (2005) Health
Psychology Theory, Research Practice (2nd
edition). London Sage. Starred authors feature
in video-clips
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SOCIAL INEQUALITIES, SOCIAL JUSTICE AND HEALTH

• Introduction
• Social inequality and health
• Explanations for social inequalities and health
• Reducing inequalities
• Stigma
• Social justice and health
• Summary

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INTRODUCTION

• Since the 17th century, the link between income
  and health has been established.
• In France in the 1820s Villerme found a
  relationship between wealth and health across
  Parisian neighbourhoods.
• Engels in England in 1845 wrote about the
  appalling living conditions of working people in
  Manchester.
• In the 1980s, the Black Report showed that a
  class gradient existed in the UK, such that
  unskilled manual workers consistently had poorer
  health status than those classified as
  professionals.
• Health differences are very robust and resistant
  to intervention as they have existed for 100s of
  years.

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The Condition of the Working Class in England in
1844 (Engels, 1845)

• Engels 1845 book provided a detailed
  description of the appalling living and working
  conditions and the limited healthcare of working
  class residents of Manchester. He wrote
• All of these adverse factors combine to
  undermine the health of the workers. Very few
  strong, well-built, healthy people are to be
  found among them Their weakened bodies are in
  no condition to withstand illness and whenever
  infection is abroad they fall victims to it.
  This is proved by the available statistics of
  death rates (pp. 118-119).
• Engels compared the death rates within the city
  and found that they were much higher in the
  poorer districts. Further, he realised the
  importance of early development and noted
  common observation shows how the sufferings of
  childhood are indelibly stamped on the adults
  (p. 115).

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THE HEALTH GRADIENT

• The persistent health differences across classes
  or socioeconomic groups are referred to as the
  health gradient. This graph illustrates the
  gradient with a plot of mortality against social
  position labeled here as A to E
• When mortality is the outcome measure, a more
• apposite term would be mortality or death
  gradient.

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Health inequalities

• Inequalities are considered as reflecting
• A problem within rich countries
• A failure of health care systems
• A technical problem to be addressed by improving
  access to services among those with poorer health
• Lifestyle, behavioural or cultural differences
  between socio-economic or ethnic groups that can
  be solved through health education and promotion
• Possibly also genetic differences between groups

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Health inequalities

• Are universal in both rich and poor countries
• Are the consequence of economic, educational and
  environmental differences
• Are impossible to solve by the health care system
  alone
• Are amenable to reduction by intervention at a
  societal level

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Health gradients are universal

• Health gradients have been studied in rich
  countries for many years where the health of
  poorest of the rich is worse than that of the
  richest of the rich.
• Recent research shows that health gradients also
  exist in poor countries among the poorest of the
  poor (see chapter 2 for more details).

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Explaining the gradients more than simply
lifestyle

• We have to explain not only why the poorest
  members of rich societies have higher rates of
  disease, but also why health follows a social
  gradient. The usual explanation for inequalities
  in health is lifestyle. There are clear
  socioeconomic differences in smoking and other
  unhealthy types of behavior that are risk factors
  for coronary artery disease. Yet controlling for
  these factors had little effect on the
  socioeconomic differences in coronary heart
  disease in the study by Diez Roux et al.
  Something in addition to smoking, physical
  activity, hypertension, diabetes, low-density
  lipoprotein cholesterol, high-density lipoprotein
  cholesterol, and body-mass index must be
  responsible for the differences in the incidence
  of heart disease.

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SOCIAL INEQUALITY AND HEALTH

• The health gradient is illustrative of the
  reliable inequalities that exist between people
  of different socioeconomic status (SES)
• Those in the lower social classes tend to have
  lower life expectancies and are at higher risk of
  ill health.
• These inequalities exist throughout the lifespan
  for both men and women.

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SOCIAL INEQUALITY AND HEALTH

• Health inequalities can be viewed from an
  ecological perspective or systems theory
  approach.
• This approach presents developmental influences
  as four nested systems -
• Microsystems
• Mesosystems
• Exosystems
• Macrosystems
• These systems are reflected in the onion or
  rainbow framework of Dahlgren and Whitehead.

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SCIENTIFIC EXPLANATIONS FOR SOCIAL INEQUALITIES
IN HEALTH

• There are several scientific explanations for
  social inequalities in health
• Psychosocial
• Neo-material
• Statistical artifact
• Health selection
• Mechanisms are likely to be complex, multileveled
  and change over time.

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Psychosocial explanations

• Micro-level (social status)Income inequality
  results in invidious processes of social
  comparison that enforce social hierarchies
  causing chronic stress leading to poorer health
  outcomes for those at the bottom
• Macro-level (social cohesion) Income inequality
  erodes social bonds that allow people to work
  together, decreases social resources, and results
  in low trust and civic participation, greater
  crime, and other unhealthy conditions.

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Neo-material explanations

• Micro-leve(individual incme) Income inequality
  means fewer economic resources among the poorest,
  resulting in lessened
• ability to avoid risks, cure injury or disease,
  and/or prevent illness
• Macro-level (social disinvestment) Income
  inequality results in less investment in social
  and environmental conditions (safe housing, good
  schools, etc.) necessary for promoting health
  among the poorest

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Statistical artefact explanations

• The poorest in any society are usually the
  sickest.
• A society with high levels of income inequality
  has high numbers of poor and consequently will
  have more people who are sick.
• There is little empirical support for his
  explanation.

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Health selection explanations

• People are not sick because they are poor.
  Rather, poor health lowers ones income and
  limits ones earning potential.
• There is little empirical support for his
  explanation.

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LAY EXPLANATIONS FOR SOCIAL INEQUALITIES IN HEALTH

• Lay explanations of social inequalities in health
  include peoples immediate social and physical
  environment.
• Inequalities found in terms of class, race and
  gender are linked with issues of social and
  material exploitation such as institutional
  racism, gender discrimination, corporate
  globalization, degradation of the environment,
  destruction of the public sector, etc.

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EXPLANATIONS FOR SOCIAL INEQUALITIES IN HEALTH

• The persons living/working environments are also
  significant determinants of health.
• There is a growing interest in the role of social
  capital in explaining the social variations in
  health.
• Social capital refers to the degree of civic
  engagement, levels of interpersonal trust and
• norms of reciprocity within the society.

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REDUCING INEQUALITIES

• Tackling inequalities in health should involve
  different levels of intervention (Whitehead,
  1995)
• Strengthening individuals
• Strengthening communities
• Improving access to essential facilities and
  services
• Encouraging macro-economic and cultural change

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HEALTH AND PLACE

• Although the evidence linking ill-health and
  poverty is clearly established there is also
  evidence of regional or area variations. This
  has given rise to a growing program of research
  on health and place that has explored how major
  structural changes, such as those itemized above,
  lead to ill-health.
• Taylor et al. (1997) have described the features
  of healthy and unhealthy environments
• Across multiple environments, unhealthy
  environments are those that threaten safety, that
  undermine the creation of social ties, and that
  are conflictual, abusive or violent. A healthy
  environment, in contrast, provides safety,
  opportunities for social integration, and the
  ability to predict and/or control aspects of that
  environment. (Taylor et al., 1997, p. 411).

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NEIGHBOURHOODS

• Diex Roux et al. (2001) investigated how a
  persons local neighbourhood can act as an
  independent predictor of health using data from
  the Atherosclerosis Risk in Communities Study
  (ARIC Investigators, 1989). Diez Roux
  investigated the relationship between
  neighbourhood characteristics and the incidence
  of coronary heart disease among residents of four
  localities in the US. A summary score for the
  socioeconomic environment of each neighbourhood
  included information about wealth and income,
  education, and occupation.
• During a median of 9.1 years of follow-up, 615
  coronary events occurred in 13,009 participants.
  Residents of disadvantaged neighbourhoods (those
  with lower summary scores) had a higher risk of
  disease than residents of advantaged
  neighbourhoods, even after controlling for
  personal income, education and occupation. These
  findings show that, even after controlling for
  personal income, education, and occupation,
  living in a disadvantaged neighborhood is
  associated with an increased incidence of
  coronary heart disease.

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Marmot (2001)

• Walk the slums of Dhaka, in Bangladesh, or
  Accra, in Ghana, and it is not difficult to see
  how the urban environment of poor countries could
  be responsible for bad health. Walk north from
  Manhattan's museum district to Harlem, or east
  from London's financial district to its old East
  End, and you will be struck by the contrast
  between rich and poor, existing cheek by jowl. It
  is less immediately obvious why there should be
  health differences between rich and poor areas of
  the same city. It is even less obvious, from
  casual inspection of the physical environment,
  why life expectancy for young black men in Harlem
  should be less than in Bangladesh.

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ETHNICITY CORRELATES WITH PLACE

• Ethnic variations in health within rich
  countries are very large. For example, white men
  in the 10 "healthiest" counties in the US have a
  life expectancy above 76.4 years while black men
  in the 10 least healthy counties have a life
  expectancy of 61 years in Philadelphia, 60 in
  Baltimore and New York, and 57.9 in the District
  of Columbia. The main determinants of the excess
  deaths among Harlem men are circulatory disease,
  homicide, and HIV infection.
• The study by Diez Roux et al (2001) suggests
  that socioeconomic characteristics of
  communities, in addition to individual
  characteristics such as income, education, and
  occupation, are related to the incidence of
  coronary events.

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Three theoretical approaches to the study of
health and place

• Hazard exposure Physical and biological risk
  factors are spatially distributed. This approach
  posits a direct pathway between hazard exposure
  and health risk
• Social relationships Space and place shapes the
  character of social relationships and in turn
  psychosocial and behavioural risk factors
• Sense of place and subjective meanings This
  approach considers the shared social meanings
  people have of their community.
• Source Curtis Rees Jones, 1998

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Explaining inequalities

• The studies reviewed above suggest that
  behavioural, material and local circumstances
  vary with SES. It is impossible to decide with
  the presently available information how much each
  of these causes is contributing to the gradients
  in illnesses and deaths. Understanding the
  material, behavioural and locality-based causes
  and the interactions between the three is a
  priority for further research.

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STIGMA and DISABILITY

• Stigma refers to unfavourable reactions towards
  people when they are perceived to possess
  attributes that are denigrated.
• It has detrimental effects to a persons sense of
  identity and can act as a form of social
  oppression through rationing of resources,
  services, research funding/efforts and care to
  these individuals/groups.

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STIGMA AND DISABILITY

• Stigmatisation can be found in all cultures
  throughout history.
• Multidisciplinary research is needed to further
  explore how stigma is related to health,
  disability and social justice.
• Current debates about abortion of impaired
  fetuses and legislation of euthanasia revolve
  around the pervasive devaluation of people with
  disabilities, and the negative assumptions about
  their lower quality of life.

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QUALITY OF LIFE, ABORTION AND DISABILITY

• Disability rights organisations argue that
  abortion decisions should not be made on the
  grounds that disabled people have a lower Quality
  of Life (QOL). This has an anti-eugenetist
  dimension.
• The rationales for screening and termination
  include assumptions that people with disabilities
  are more costly to society, that the lives of
  children with disabilities are harmful to their
  families and that some impairments involve a
  level of suffering and misery that makes them not
  worth living.
• The way professionals describe test results and
  the influence of the advice they give is also a
  concern. The advice given, while often subtle,
  most frequently encourages termination in
  response to potential impairment results and most
  testing takes place within a plan-to-abort
  context (Rinck Calkins, 1996).

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ABORTION AND DISABILITY

• There is a tension between this argument and the
  feminist position that women have a categorical
  right to make decisions about their own bodies
  including the decision to terminate an unwanted
  pregnancy.
• However, the disability movement position is not
  against abortion itself, rather it revolves
  around the bases upon which the decision is made.
  
• Aborting a specific foetus on the basis of a
  devalued attribute is different from aborting any
  foetus on the basis of not wanting to have a
  child at that time (Fine Asch, 1982). The
  disability movement also asserts the rights of
  disabled women to have children.
• This fundamental human right is denied to many
  women, particularly those with cognitive and
  emotional impairments, as the additional support
  and resources that they need to allow them to
  raise a child are often not available.

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Disability and QOL

• A recent review by Gill (2000) challenges this
  assumption. In general, people with disabilities
  have rated their quality of life as good to
  excellent (e.g. Eisenberg Saltz, 1991).
• Where found, lower quality of life ratings may
  have related to more to sociodemographic factors
  (e.g. poverty, exclusion, lack of social support)
  than disability per se (Asch, 1998).
  Consistently, research has failed to show an
  association between diminishing quality of life
  and increasing severity of physical impairment
  (e.g. Viermero Krause, 1998).
• Many factors mediate quality of life but overall
  the research indicates that life satisfaction is
  good for people with disabilities and that they
  derive satisfaction through finding a sense of
  meaning, performing expected social roles,
  enjoying reciprocal relationships and a sense of
  living in a reciprocal social world (Albrecht
  Devlieger, 1999).

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Negative attitudes in health care

• Despite no empirical basis suggesting compromised
  quality of life, healthcare professionals
  consistently and significantly underestimate it
  in people with disabilities.
• Negative attitudes inform decision-making and are
  communicated, directly and indirectly to their
  patients and patients families.
• Negative attitudes about people with disabilities
  include underestimating quality of life,
  underestimating future capabilities (especially
  for children), overestimating depression, viewing
  it a normal and inevitable response (therefore
  not treating it) and underestimating the
  functional ability to commit suicide.
• Health care professionals have to make explicit
  decisions about whether to assist a patient who
  asks for help to die. They also have to make less
  explicit decisions around provision of
  life-sustaining treatment (e.g. whether to
  withhold heart operations for Down Syndrome
  children).

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Assisted dying and disability

• Disability prejudices held by health care
  professionals result in unsupported assumptions
  that the quality of life of people with
  disabilities is diminished
• There are a number of forms of assisted dying
  including a person ending their own life by their
  choice using a tool supplied by someone else,
  someone else ending a persons life with their
  consent, someone else ending a persons life
  without their consent and withholding
  life-sustaining treatment (with or without
  persons consent).
• All of these forms of assisted-dying have been
  applied to people with disabilities. That
  assisted-dying can refer to without the consent
  of the person who dies is particularly worrying.
• It has been suggested that many people with
  disabilities fear that episodes of illness may be
  viewed as an opportunity to allow them
  merciful release (Marks, 1999), and there may
  be some basis
• for this.

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Disability issues of social justice

• The two debates discussed above are about the
  differential value placed on the lives on people
  with versus without disabilities/illnesses. As
  Charmaz, (1999) suggests, people with a chronic
  illness become viewed as worth less which may
  eventually contract into worthless. Stigmatised
  individuals are regarded as flawed, compromised,
  less than fully human (Heatherton et al., 2000)
  and, in the case of people with disabilities,
  worthless and lives not worth living. Being
  judged as not worth living may represent the most
  fundamental claim to injustice and inequality
  (Saxton, 1998).

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SOCIAL JUSTICE AND HEALTH

• A health psychology committed to social justice
  needs to address the needs of the most
  disadvantaged in society.
• Critics of the research into social inequalities
  in health often charge that social inequalities
  are both an inevitable part of life and also are
  necessary for social progress.
• An alternative perspective is to consider not
  simply inequalities per se but inequities in
  health. As Dahlgren and Whitehead (1991) argue,
  health inequalities can be considered as
  inequities when they are avoidable, unnecessary
  and unfair.
• Their approach is derived from the theory of
  justice as fairness developed by the moral
  philosopher John Rawls (1999).

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Justice as fairness

• According to Rawls there are certain underlying
  principles of a just society
• Assure people equal basic liberties including
  guaranteeing the right of political participation
• Provide a robust form of equal opportunity
• Limited inequalities to those that benefit the
  least advantaged
• When these principles are met citizens can be
  confident that they are respected by others and
  can acquire a sense of self-worth.

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Adhering to principles of fairness would address
basic social inequalities in health (Daniels et
al., 2000)

• Assuring people equal basic liberties implies
  that everyone has an equal right to fully
  participate in politics. This will in turn
  contribute to improvements in health since
  according to social capital theory political
  participation is an important social determinant
  of health.
• Providing active measures to promote equal
  opportunities implies the introduction of
  measures to reduce socio-economic inequalities
  and other social obstacles to equal
  opportunities. Such measures would include
  comprehensive childcare and childhood
  interventions to combat any disadvantages of
  family background. They would also include
  comprehensive healthcare for all including
  support services for those with disabilities.
• A just society would allow only those
  inequalities in income and wealth that would
  benefit the least advantaged. This requires
  direct challenge to the contemporary neo-liberal
  philosophy that promotes the maximization of
  profit and increasing the extent of social
  inequality.

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Psychologists and social justice

• Increasingly psychologists have recognized the
  link between poor social conditions, social
  inequalities and physical and mental health. In
  2000 the American Psychological Association
  passed a landmark resolution on Poverty and
  Socioeconomic Status. This resolution called for
  a program of research on the causes and impact of
  poverty, negative attitudes towards people living
  in poverty, strategies to reduce poverty, and the
  evaluation of anti-poverty programs. This
  resolution has been followed by a number of
  initiatives.

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Psychologists and social justice

• Bullock and Lott (2001) developed a research and
  advocacy agenda on issues of economic justice.
  Such an agenda is not just concerned with
  describing the impact of poverty and inequality
  on health and wellbeing but also with advocating
  for social and economic justice.This includes
• Challenging the victim-blaming ideology that is
  often adopted in psychological approaches to the
  study of health and illness.
• Defining health psychology not as an observer of
  social injustice but rather as a resource for
  social change (Murray and Campbell, 2003).
• A more politically engaged health psychology such
  as the one championed by Martin-Baro (1994) who
  challenged psychologists to adopt a preferential
  option for the poor.

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Psychologists and social justice

• Three approaches have been suggested by Fine and
  Barreras (2001)
• Public policy documenting the impact of
  regressive social policies and agitating against
  such policies
• Popular education challenging popular
  victim-blaming beliefs (common-sense) about the
  causes of ill-health
• Community organizing working with marginalized
  communities and agitating for social change.

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Building alliances

• The success of such a strategy requires building
  alliances with social groups most negatively
  impacted by social inequalities. These can range
  from patient-rights groups to trade unions and
  other activist groups (Steinitz and Mishler,
  2001). As Martin-Baro (1994) stressed the
  concern of the social scientist should not be so
  much to explain the world as to transform it (p.
  19). By adopting this approach health psychology
  can begin to move from the sidelines to a more
  central role in the broader movement to promoting
  a healthier society.

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Summary

• 1.Health and illness are conditioned by social
  conditions There is a clear relationship between
  income and health leading to the development of a
  social gradient.
• 2.Psycho-social explanations of these social
  variations include perceived inequality, stress,
  lack of control and less social connection.
• 3.Material explanations of the social gradient in
  health include reduced income and reduced access
  to services.
• 4.Political factors connect both psycho-social
  and material explanations in a broader causal
  chain

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Summary (continued)

• 5.Lay explanations of social inequalities in
  health include peoples immediate social and
  physical environment. Social environment
  includes the character of peoples social
  relationships and their connection with the
  community.
• 6.Stigma is concerned with the disqualification
  of individuals because they have certain socially
  devalued attributes.
• 7. Social justice is concerned with providing
  equal opportunities for all citizens. A health
  psychology committed to social justice needs to
  orient itself to address the needs of the most
  disadvantaged in society