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Chapter 3 SOCIAL INEQUALITIES, SOCIAL JUSTICE AND HEALTH

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Title: Chapter 3 SOCIAL INEQUALITIES, SOCIAL JUSTICE AND HEALTH


1
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
2
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

3
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.

4
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).

5
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.

6
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

7
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

8
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).

9
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.

10
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.

11
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.

12
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.

13
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.

14
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

15
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.

16
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.

17
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.

18
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.

19
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

20
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).

21
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.

22
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.

23
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.

24
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

25
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.

26
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.

27
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.

28
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).

29
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.

30
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).

31
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).

32
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.

33
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).

34
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).

35
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.

36
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.

37
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.

38
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.

39
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.

40
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.

41
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

42
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
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