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2 Material Conditions, Social Systems and Health

2 Material Conditions, Social Systems and Health

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3.2



Material Conditions, Social Systems and Health



25



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

Organization 2013).

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

nation-states.



26



3



Material Conditions and Health Inequalities



Norway

China



75



United States

Kuwait

Trinidad



65



Kazakhstan Russia

Turkmenistan



55



India



Gabon



Botswana

South

Africa



Equatorial Guinea



45



Life expectancy at birth 2010, both sexes



85



Japan



0



10,000



20,000



30,000



40,000



50,000



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

permission))



3.3



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



3.4



Unequal Societies and Health



27



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.



3.4



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



28



Material Conditions and Health Inequalities



82



3



80



Japan



Sweden



Switzerland



79



Spain



78



Canada



Norway

Belgium

Finland



Australia



Luxembourg



Italy



France

Greece

Netherlands



New Zealand

Singapore



United Kingdom



Germany



77



Life Expectancy at birth (years)



81



r = -0.864, p < 0.001



Denmark



76



United States of

Portugal America



.25



.3



.35



.4



.45



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



3.4



Unequal Societies and Health



29



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

2001).

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



30



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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

anomie.

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

outcomes.



3.5



3.5



Life Course



31



Life Course



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

health status.

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.

2014).

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



32



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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.



3.6



Conclusion



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



References



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need to move beyond the immediate environment to identify the broader social,

political and environmental processes to understand these patterns.



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Chapter 4



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



4.1



Introduction



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.



© Springer International Publishing Switzerland 2016

K. Dew et al., Social, Political and Cultural Dimensions of Health,

DOI 10.1007/978-3-319-31508-9_4



35



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2 Material Conditions, Social Systems and Health

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