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2 Material Conditions, Social Systems and Health
Material Conditions, Social Systems and Health
Many countries have experienced an increase in income inequalities since the
1990s. For example, in the United States the top 1 % of households experienced a
17 % gain in real net worth between 1983 and 1995 whilst the poorest 40%t suffered
an 80 % decline in net worth (Whiteis 2008). There has also been an increase in
income inequalities between countries, widening the income gap between the rich
nations and the poor nations (Deaton 2004). The rich nations are getting richer and
the poor nations are getting poorer. A political economy perspective challenges current capitalist processes including those that foster uneven economic development
(Whiteis 2008). Less than 25 % of the planet’s population live in industrialized
countries but these countries have over 80 % of global Gross National Product
(GNP), which is the total value of goods and services produced in a country. To
exacerbate the inequalities many poor countries are in debt to the rich industrialized
nations and the interest payments alone on this debt amounts to billions of dollars a
month that flows from the poor to the rich countries (Larkin 2008). Positioned
between rich and poor countries are middle-income countries, which can be characterized in various ways. World-systems theory positions middle income countries as
semi-peripheral to the core rich countries, producing raw materials for them and
having a limited industrial capacity. Modernization theories position middle-income
countries as transitioning out of poverty and on a path to converge with the rich
industrialised countries (De Maio 2014).
Mortality rates are particularly high for children in low-income countries. They
are 16 times more likely to die before reaching the age of five than children in high
income countries (World Health Organization 2013: 10). The life expectancy of a
boy born in 2011 in Sierra Leone was 46 years of age, and a girl could expect to live
1 year longer. A boy born in Qatar could expect to live to 83, the longest male life
expectancy in the world, and a Qatari girl could expect to live to 81. This makes
Qatar one of the very few countries where men live longer than women. The best
life expectancy for women is 86 in Japan. For the Anglophone countries of the
United Kingdom, United States, Australia and Canada male life expectancy hovers
around the high 70s and female life expectancy around the low 80s (World Health
The magnitude of the injustice at play can be seen in Fig. 3.1 which shows that
even a relatively small redistribution of wealth internationally could have a dramatic
impact on the life expectancy of the poor and almost no negative health consequences for rich countries. It takes a very large increase in income to obtain even a
small increase in life expectancy in richer countries (Deaton 2007). The flattening
of the curve in Fig. 3.1 at around the $5000 mark is known as the epidemiological
transition, where deaths from infectious diseases are replaced by cancers and heart
disease (Deaton 2007).
The unequal access to resources and unequal exposure to health hazards points
to political processes as a root cause of health inequalities. These political processes
are developed and articulated at both a national level that foster free markets, and
internationally with policies imposing structural adjustment programmes on
Material Conditions and Health Inequalities
Life expectancy at birth 2010, both sexes
GDP per capita, 2010, in price adjusted 2005 US $
Fig. 3.1 Life expectancy and GDP per capita in 2010 (Source (Deaton 2013) (Printed with
Case Study – Zambia and AIDS
Structural adjustment programmes may have a stated goal of helping poor nationstates to cope with their levels of debt in order to secure further loans (Labonté
2008). A range of policies are used to bring about this goal, which may include a
reduction in the level of state spending, a reduction in tariffs on imported goods and
the introduction of user charges for such things as health services (Chopra 2008).
Structural adjustment, as advocated by the World Bank and the International
Monetary Fund (IMF), has been accused of bringing about adverse outcomes for
those countries that have had this imposed upon them.
Ronald Labonté discusses the case of AIDS in Zambia to illustrate the potential
for the devastating consequences of structural adjustment programmes. Labonté
narrates the story of Chileshe, a Zambian woman who is dying from AIDS. A simplistic telling of her tale is that Chileshe caught the disease from her husband who
used to work in a textile plant, but lost his job. He then moved to the capital city on
his own to try to make some income as a street vendor. While working the streets of
the city on his own he traded money for sex. It is through this route that Chileshe
became infected. The supply of anti-retroviral drugs to Zambia through charitable
efforts has been too little and too late for her.
But this personal tale can be set within the context of changes in public policy
imposed upon Zambia by the rich industrialised countries. Zambia was a country in
debt, and in order to secure further loans it was required to conform to the neoliberal
policies that the World Bank and the IMF favoured. In the 1990s it reduced barriers
to the importation of textiles. The local manufacturing of clothing, which was run
Unequal Societies and Health
by the state, could not compete with the influx of textiles and clothing and the clothing and textile mills starting closing with the loss of many thousands of jobs.
Workers, like Chileshe’s husband, were now required to dramatically disrupt their
lives in order to make a living.
In addition to opening up the country to imports, Zambia placed fewer restrictions on financial markets. This meant that the profits made by foreign-owned firms
could be more easily taken out of the country so as to avoid tax. The loss of tax
revenue means the government has less to spend on public services, including health
services. The loss of jobs, the lowering of wages in the public sector to reduce state
spending, the imposition of user charges for health services and other elements of
these neoliberal reforms occurred as the AIDS pandemic took hold. Chileshe and
her husband were casualties of these policy changes, a story that, according to
Labonté, has been repeated in variant forms in many southern African countries.
Through these stories we can see mechanisms by which the health disparities
between rich countries and poor countries can be made worse.
Unequal Societies and Health
Although many “diseases of poor countries are indeed diseases that are caused by
poverty” (Deaton 2007: 1) there are examples of poor countries or poor states in
particular countries that have relatively good health outcomes. Commonly cited
examples are Kerala state in India, Sri Lanka, Costa Rica and Cuba. Various explanations as to why some poor countries can have better health outcomes than others
have been put forward. Access to the basic requirements to sustain life are clearly
important, and so adequate nutrition, access to clean water and appropriate sanitation are what we could call the proximal determinants of health. But research has
shown that there are other important aspects of social organization that impact upon
health and could explain some of the differences in health outcomes. It has been
demonstrated that levels of corruption in countries has an impact on health outcomes. Corruption can affect health in a number of ways, from providing obstacles
to accessing health services for those who cannot afford to bribe their way to access,
through to corruption hindering the development of health facilities as funds are
diverted away from their construction (Hanf et al. 2013). It has also been shown that
higher levels of education received by women improves child mortality rates. Higher
levels of education can bring about health benefits in multiple ways, such as leading
to the adoption of more preventive methods including hygienic food preparation, or
recognizing the severity of illnesses in children and seeking out good health care
(Hanf et al. 2013).
Not only is absolute income linked to health outcomes, but so too are relative
income differences within populations. Even in wealthy countries higher levels of
income inequality lead to poorer health outcomes at a population level. We see this
in Fig. 3.2, a graph that looks at the Gini coefficients of different countries. The Gini
coefficient is a measure of inequality, the higher the number on the horizontal axis
Material Conditions and Health Inequalities
Life Expectancy at birth (years)
r = -0.864, p < 0.001
United States of
Gini coefficient (1990-1998)
Fig. 3.2 Income inequality and life expectancy at birth amongst industrialised countries (Source
(De Vogli et al. 2005) (Reprinted with permission))
the higher the income inequality. The graph shows that countries with relatively low
levels of income inequality, such as Japan and Sweden, have longer life expectancies than countries with high levels of income inequality, such as Portugal and the
United States. In general the more egalitarian the distribution of income the higher
the life expectancy (Kawachi et al. 1999).
Once we meet a minimum level of necessary income to ensure that we, as a society, have adequate food, sanitation, education, and environmental quality, then other
factors such as social position become important in determining health outcomes
(Marmot 1999). Various mechanisms have been suggested to explain this. For
instance, the psychosocial stress of being at the bottom end of a rigid social hierarchy has physiological consequences that cause ill-health (Brunner and Marmot
1999). Under conditions of on-going stress the body may release certain chemical
transmitters, or particular parts of the nervous system may be activated, that can
eventually lead to disease. One example of this from workplace studies found that
low levels of control over work, a fast pace of work, and a lack of social support in
a workplace have been associated with coronary heart disease (Karasek and Theorell
1990). That is, the less freedom workers have and the more they are controlled in the
workplace the more likely they are to contract heart disease.
The psychosocial argument has been given credence from a famous research
programme studying the stress effects of hierarchy, known as the Whitehall study
(Brunner and Marmot 1999). This programme studied 17,000 British civil servants.
It found that there was a relationship between the employment grade in the civil
Unequal Societies and Health
service and health-related psychosocial factors. These factors included low control
over work, a lack of variety in work, and a lack of social contact. The researchers
found that there were metabolic changes associated with a person’s position in the
workplace hierarchy, including changes in blood glucose levels and blood-clotting
mechanisms. Long-term exposure to psychosocial stresses in the workplace, like a
lack of control over the pace of work, may lead to increased risk of conditions such
as heart disease and diabetes. Although these studies have been limited to workplaces, the mechanisms affecting health could apply to the general population.
Psychological stress can lie in rigid hierarchies, but also rapid social change, marginal social status and traumatic social events such as bereavement (Krieger 2001).
These traumatic events can directly impact the functioning of the cardiovascular,
immune and metabolic systems in negative ways and so can be pathogenic (Krieger
There is also an argument that unequal societies could lead to a loss of social
capital (Kawachi and Berkman 2000). Terms such as social capital and social cohesion have been deployed to explain why some communities fare better than others
in terms of health outcomes even though they might have similar socio-economic
measures. An influential study by Kawachi and colleagues comparing different
states in the United States found that higher levels of social capital were associated
with lower mortality rates (Kawachi et al. 1997). The focus of social capital
approaches is on the support networks available in social settings that provide
greater resilience to disease for some people. Included in social capital are such
things as trust between members of a community, the intensity of the social networks that people have, the sharing that occurs and the willingness to aid others in
the community. How these impact upon health is debated. One possible mechanism
is that where there is more community activity or civic participation, positive attitudes and norms can influence health behaviors, such as moderating alcohol consumption or promoting physical activity (Nieminen et al. 2013). Higher levels of
social capital have also been associated with high self-ratings of health. From this it
has been suggested that higher levels of social participation enhance a sense of wellbeing, which can be positive for feelings of self-esteem and mental health (Nieminen
et al. 2013).
This aligns with the thinking of Émile Durkheim, who argued that in societies
where there was a lack of regulation and social cohesion there would be more
chance of the inhabitants of that society developing anomie. In Suicide, published in
1897, Durkheim characterised anomie as a pathological mental state of the individual. The individual is not sufficiently regulated by society, and due to this lack of
regulation suffers from the illness of infinite aspiration. That is, the desires of the
individual are infinite and cannot be satisfied as the lack of regulation in society
means there is a lack of restraint. This type of anomie is accompanied by weariness,
disillusionment, anger, and in extreme cases can lead to the individual committing
suicide or homicide (Downes and Rock 2003). Particular ways of organizing society
could promote anomie. For Durkheim modern society was one that had high levels
of anomie due to a lack of constraining forces. In pre-modern society (a society
Durkheim characterised as being based on a form of social cohesion that he called
Material Conditions and Health Inequalities
mechanical solidarity) people were more constrained by tradition, religion and the
networks of interaction between people was less complicated. But in modern society social cohesion was based on what Durkheim called organic solidarity, where
the division of labour was intensified and interactions between people in urbanised
and industrialised settings were more complex (Taylor and Ashworth 1987). The
constraining or regulating nature of interactions were not so intense in modern society, promoting the possibility of anomie. Other factors related to social organization
could also promote anomie, such as too much competition and class conflict. Where
there was no social equality there would be no social solidarity, and therefore greater
Lack of social participation has been linked to poor health outcomes. Australian
research has found that people on lower incomes and with lower levels of education
are less likely to participate in the community (Baum et al. 2000). The participation
that this research looked at took many forms, including participation in volunteer
groups, sports groups, and church activities. The research suggested that there was
an accumulation of social disadvantage here. That is, low income went hand-inhand with low education, and these were associated with poor health, and all of
these were associated with lower levels of participation in the community. The
researchers suggest that reducing social inequity would be the most effective way to
overcome social exclusion (Baum et al. 2000).
Another feature of inequalities is differential access to health resources. It has
been clearly demonstrated that there are different health outcomes for people with
the same condition. For example, blue collar workers in Finland have lower rates of
coronary bypass operations than their white collar colleagues even though the mortality rate for coronary heart disease is twice as high in the blue collar workers
(Keskimaki et al. 1997). The indigenous Māori population in New Zealand also
have lower rates of bypass grafts than the settlers who have much lower rates of
coronary heart disease mortality (Robson 2008). This sort of discrepancy has been
named the inverse care law (Tudor Hart 2000). This law stipulates that the availability of medical care varies inversely with the need for medical care in the population (Tudor Hart 2000). In the examples noted, blue collar workers in Finland and
Māori in New Zealand have higher levels of need for medical interventions than
other groups in society with lower levels of need but are less likely to get those
interventions. This law means that the poor, who suffer a higher burden of illness,
use fewer health care and medical resources than those who are more advantaged.
On a world scale the picture of the inverse care law is dramatic, where health care
resources are intensively concentrated in wealthy countries and sparse in poor countries (Dorling 2007). A major barrier to access to health care services in poorer
countries is the ‘brain drain’, where doctors and other health professionals trained
in poorer countries, such as South Africa, are recruited by richer countries, such as
Canada (De Maio 2014).
A clear link has been demonstrated between measures of social class of income,
education and occupation and health inequalities. A link has also been shown
between psychosocial stress, rigid hierarchies, levels of social cohesion and health
Given the discussion to date it is unsurprising that health inequalities for different
social groups can be mapped to the different trajectories that individuals have over
their life time. Researchers have argued that past experiences impact on current
Pudrovska and colleagues outline three mechanisms to explain the impact of
earlier experiences on current health status, a critical period model, an accumulation
of risks model and a pathway model (Pudrovska et al. 2014).
The critical period model posits that experiences in early life have permanent
effects on biological systems or behaviors. For example, higher cortisol levels produced as a result of stress from low socio-economic conditions leads to metabolic
differences in later life, with health consequences such as obesity. Support for this
model comes from research that indicates that disadvantage in early life has a stronger adverse health effect than disadvantage in later life periods (Pudrovska et al.
The accumulation of risks model posits that exposures to hazards has a compounding effect on later life. As opposed to the critical period model this model
suggests that disadvantages accumulate or are additive, so that a period of economic
disadvantage in adulthood has its own negative effects that are added on to any economic disadvantage in childhood. Chronic strain can lead to stress proliferation
(Pearlin et al. 2005). Sustained stress through such things as constant economic
hardship or constant discrimination also has a more deleterious impact on health
than periods of hardship broken by periods of relief from hardship (Pearlin et al.
2005). Pearlin and colleagues suggest that the long term experience of discrimination can lead to a “vigilant anticipation” in relation to the next occurrence, acting as
a further stressor (Pearlin et al. 2005: 209).
Finally the pathway model suggests that opportunities and constraints are shaped
by early life circumstances, for example, physical activity as an adult is linked to the
family environment (Pudrovska et al. 2014). This model focuses on the mechanism
by which family socio-economic circumstances have their impact in later life. For
example, in families with privileged economic circumstances the healthy management of diet and physical activity may be emphasized in the upbringing of their
children. This may vary in times and places. With a strongly entrenched gendered
division of labour, girls may be more strongly socialised into health matters than
boys as they are deemed responsible for such activities in their future families. The
effect may be different on men and women. Research has indicated that childhood
disadvantage adversely affects women more than men, providing some support for
this kind of pathway mechanism (Pudrovska et al. 2014).
Life course analyses can consider the distal structural causes of current health
status, rather than focus on current health behaviors and exposures. Parental education, income and occupation are important variables in understanding the health
circumstances of their children, even in adulthood. Parental social circumstances
are associated with the educational attainment of their children, who then may be
Material Conditions and Health Inequalities
funnelled into particular jobs and neighbourhoods as a consequence (Pearlin et al.
2005). From this perspective the children of the rich are more likely to go into professional and managerial positions and the children of the poor into unskilled jobs.
The health consequences of structural inequalities suggest the need to consider
health conseqeunces across a range of policy domains. Stressful events during pregancy, such as being made unemployed, can impact upon factors like the length of
gestation and low birth weight. Low birth weight in turn is associated with higher
rates of neonatal mortality, and in adults with higher rates of lung disease, heart
disease and diabetes (Scharber 2014). What happens before birth can have life long
effects. Children of parents who have been imprisoned have higher rates of attention
deficit disorder, developmental delays and a range of other conditions (Turney
2014). The consequences of sentencing policies then should be considered not simply in relation to the victim of the crime and the convicted person, but also its wider
impact on families and communities.
There is no doubt that there is a strong association between health and social
inequality. It is not surprising that living in poverty means that you have less access
to basic resources such as food, appropriate housing, heating, education, health services, and so forth. Lacking these resources will affect your health status. Where the
level of inequality is greater the whole population suffers from higher levels of ill
health. Concepts such as social capital have been used to try to explain this. This
suggests that where a society is more unequal, people are less likely to participate in
that society and it will be less cohesive and the lack of social cohesion has a negative
effect on health. Greater inequality will have a greater health impact on the working
class and the poor.
To better understand the relationship between health and material conditions we
need to consider more than biomedical and lifestyle frameworks, but also feminist,
political economy, human rights and ecosocial frameworks (Zierler and Krieger
2008). The example of Chileshe in Zambia provides us with a way of generating
such an understanding. Political and economic forces and a gendered division of
labour are crucial variables in helping us to understand the impact of AIDs in
Zambia. Paul Farmer and colleagues have described how the damming of a river in
Haiti led to groups of people being forced onto poor quality land. Increasing levels
of poverty in that situation led to women forming unfavourable sexual unions with
men, which in turn facilitated the spread of AIDS (Farmer et al. 1993). The drug
economy of the United States and the social and political forces that brought about
that economy can be seen as important variables explaining the increase in AIDS
among poor African and Hispanic American women (Zierler and Krieger 2008).
These examples of AIDs infection illustrate the central role of political and social
organization in the creation of health inequalities. Where we see infectious and
chronic disease having a varying impact on different social groups and classes we
need to move beyond the immediate environment to identify the broader social,
political and environmental processes to understand these patterns.
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Gender and Ethnicity in Health
Abstract There are persistent disparities in health outcomes by ethnicity and gender. This chapter addresses a range of explanations for these disparities including
systemic discrimination, the legacies of colonization and patriarchy, and the influence of medical practitioners’ attitudes on their interactions with patients. A case
study of discrimination in the United States, including a discussion of the Tuskegee
Syphilis Experiment, illustrates its ongoing impact. The chapter concludes that the
complex interactions between ethnicity and gender within a wider system of social
stratification, contribute to discrimination and oppression which manifest in various
forms in health and illness.
Keywords Ethnicity and health • Gender and health • Health inequalities • Social
determinants of health • Systemic racism theory • Patriarchal domination • Aversive
racism • Statistical discrimination
In addition to the social gradient in health discussed in Chap. 3, there are persistent
disparities in health outcomes by ethnicity for just about every diagnosed condition,
and there are differences in sickness experiences and life expectancies by gender.
The following chapter on the health of indigenous communities can usefully be read
in conjunction with this chapter as issues of ethnicity, gender and indigeneity are
firmly entwined. Chapter 12 on sexuality and sexual behavior extends the discussion of gender, identity and health. This chapter focuses on health disparities patterned by gender and ethnicity. Explanations for these disparities include those
noted in the chapter on material conditions and health, such as differences in access
to resources, psycho-social stress and levels of social capital. In this chapter additional explanations discussed include systemic discrimination, patriarchy and interpersonal forms of discrimination.
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K. Dew et al., Social, Political and Cultural Dimensions of Health,