Inequalities in Health - Essay Example

Health Inequalities Introduction Growing social inequalities in health in the UK and other states, coupled with increasing disparities in wealth and income, have forced many researchers to rethink the role of social class as a primary determinant of health. Social and economic circumstances have been associated though not as heavily as these days, with health inequalities for many decades. Socio-economic status strongly influences people’s physical and mental health, their use of health care, and mortality rates. Many recently published works on socio-economic determinants of health inequalities clearly demonstrate that these exist in the UK and elsewhere in the world, even in the richest societies (Krieger et al. 1997). Within countries the inequalities can be seen throughout the whole social spectrum, suggesting “…there is not simply a threshold of absolute deprivation below which people are sicker, but a linear relationship between socio-economic circumstances and health even among the betteroff” (Macintyre 1994, p.54). Large inequalities in health between the most and least socially advantaged populations in the UK have been reported in every major report on public health (Black et al. 1980). Presence of huge health inequalities not only within but also between countries is another evidence that socio-economic status seriously influences public health. Thus, life expectancy at birth in wealthier Japan is more than 80 years while in incomparably poorer Sierra Leone it is only 34 years – a difference which is shocking to say the least (Marmot 2005). Social Class and Health Inequalities The definitions of ‘health’ fall into three major groups: Cultural: health is a standard of physical and mental well being appropriate to a particular society. Normative: health as an fixed level, or an ideal physical and mental state Functional: health is a state of being necessary to perform certain physical and mental activities (Townsend, Davidson & Whitehead 1990) However, none of the existing definitions or groups fully reflects the essence of this highly complex and multilateral concept. One common definition of health is the following: “health is positive concept that emphasises social and personal resources, as well as physical capabilities. It involves the capacity of individuals – and their perceptions of their ability – to function and to cope with their social and physical environment, as well as with specific illnesses and with life in general” (WHO, 1984). The broadness of this definition implies that the factors influencing health are multiple and complex. Other popular definitions and models of health highlight the same feature of this concept. Thus, Dahlgren and Whitehead (1991) in one the most widely used models of health identify the following levels of individual health: The first-layer factors including age, gender and genetic inheritance; The second-layer factors including behavioural patterns (physical activity, smoking, dieting); The third-layer factors including social position, economic resources and the material environment; The fourth-layer factors including the wider or underlying determinants, consisting of social and community networks, work environment, housing and living conditions, education and transport. And finally, the fifth-layer factors including the economic, cultural, political and environmental conditions in the society in general (p.41-42). In 2006, a group of U.S. researchers conducted an interesting qualitative study in order to find out which definition of health better reflects the opinion of health care professionals. The study involved 73 practitioners most of whom viewed health as the interrelatedness of physical, mental, and spiritual factors. However, none of the participants adopted a single model or definition of health described in the literature: they freely combined elements from several definitions and models (Julliard, Klimenko & Jacob 2006). Therefore, attempts to identify such definition or model of health that would fully reflect the variety of determinants and aspects associated with this concept are doomed to failure. What is really important is that both the theorists and practitioners agree on the fact health represents a complex amalgam of factors perfectly summarised in one of the most popular definitions of health provided by the World Health Organisation: “Health is a state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity” (Wright et al. 1998, p.1312). The models and definitions of health found in the literature suggest that health depends on two major groups of factors: internal biological factors and external environmental factors. Although these two groups of determinants are very important the traditional medicine and health care deal almost exclusively with the biological factors. For example, modern practitioners can offer many options to address the physiological symptoms of tuberculosis, but dealing with the environmental factors such as malnutrition is outside the scope of traditional medicine, although every practitioner would readily recognize malnutrition as the major determinant of this disease. Extreme variety and complexity of the environmental determinants of health as compared with the biological factors may be one of the reasons for lack of serious studies exploring their relationship to health. For example, level of education is reported to correlate with mortality rates among adult population (Blane, White & Morris 1996). However, studying this influence is not a simple taks because is involves several mechanisms. Firstly, the cultural and material background of parents is a strongly predictor of a child’s educational attainment. From this perspective the level of education is a marker of socio-economic conditions during childhood. These conditions could determine health in adulthood. Secondly, the level of education is also a strong predictor of occupation and labour market position during adulthood, and these also could be the major influence on adult health. Thirdly, the level of education is directly linked to receptivity to health education messages. The person’s ability to consider them and adopting health-enhancing behaviours while avoiding those which put health at the risk is another major determinant of health in adulthood. Fourthly, personality characteristics such as self-efficacy and/or time-preference influence both the length and success of education and health behaviour. And lastly, impaired health during childhood and adolescence could lead to low educational attainment and poor adult health (Sorlie et al, 1995). Evidently, presence of such multiple causalities makes it extremely difficult to properly analyse and correctly understand how exactly social class influences health. Existing research in the field of environmental influences on health focuses mostly on health as a function of welfare though some recently published works draw attention to other environmental factors as well. The core idea underlying this point of view is that poverty is the only significant socio-economic determinant of poor health. This point of view is easy to accept if take into account the numerous poverty-induced factors such as malnutrition, poor sanitary, lack of medical care and their negative impact on health. However, such perception does not reflect the full picture of social determinants that influence health. Poverty does have the huge potential to damage health of individuals and populations, but it is not fully clear what additional social and/or biological factors are needed to realize this potential. The equation that neglects these factors does not have any chances to provide a complete explanation of the link between poverty and health. Thus, a good illustration to the assertion that poverty alone should not be held responsible for inequalities in health can be found in the statistical data collected by the United Nations organisation. The statistics shows that life the average life expectancy in rich countries does not necessarily exceed life expectancy in poor countries though in many cases such correlation can hardly be denied. For example, in the US, one of the richest countries across the globe with a GNP of more than $34 000, the average life expectancy is a bit less that 78 years, but Cuba and Costa Rica, the poor neighbours of the US with GNPs much less than $10 000, have life expectancies of 76.5 and almost 78 respectively (UNDP 2006). A similar situation can be observed in China and several Indian states: despite poverty, which sometimes reaches extreme levels, the populations of these countries and territories have good health (Marmot 2005). Evidently, the link between poverty and health does exist, but other social processes and circumstances that impact the state of health must be carefully studied too otherwise our knowledge about the issue will be incomplete. Therefore, many researchers prefer to use the term ‘social class’ which implies more aspects than the level of income as in the case of ‘poverty’. One popular definition of social class is the following: “social class is a term used to categorize individuals in a stratified social system; social class characteristics are often related to (but may not be limited to) child-rearing practices, beliefs, values, economic status, prestige and influence, and general life chances” (Cushner et al. 2003, p.320). Although the term ‘social class’ may be politically incorrect, it does encapsulate the whole range of factors that may potentially affect health. A neutral term ‘socio-economic status’, which is used by many to replace the insulting ‘social class’, does not change the fact that “… people typically ‘know their place’ [and] measure themselves against a social standard” (Heller et al. 2004, p.130). The influence of social class on individual’s health was noticed long ago. In 1842, Edwin Chadwick published his famous book “General Report on the Sanitary conditions of the Labouring Population of Great Britain’ which became the first attempt to analyse the mortality rates among several different populations. In particular, Chadwick discovered that the average age at death in Liverpool was 15 for servants and unskilled labourers while gentry and professionals lived 20 years longer on average (Bartley et al. 2000). Clearly, the situation has much improved since those days, but the inequalities in health have remained as well as the system of social classes which nourishes them. The conditions in which people live and work continue to play an important role in spreading, treatment and prevention of communicable as well as non-communicable diseases (Farmer, 1999). Recent figures from the UK clearly demonstrate that members of lower social classes, including children, have more chances to fall victims of pneumonia, infectious diseases, food poisonings, and violence than their counterparts from higher social classes. The incidence of hart disease, cancer, and respiratory disease are also higher among the adults from lower social classes (Bartley, Blane & Smith 1998). As a result, mortality rates among the representatives of lower social classes are significantly higher than among members of higher social classes, as shown in the table below. Table 1. Health inequality in England and Wales, 1931 – 1991: Standardized Mortality Ratios by Registrar-General’s Social Class (GRSC) in men aged 15-64 RGSC 1931 1951 1961 1971 1981* 1991* I Professional 90 86 76 77 66 66 II Managerial 1991 III routine non-manual 94 92 81 81 76 72 100 III Routine non-manual and skilled manual 1991 III skilled manual 97 101 100 104 103 117 IV Semi-skilled manual 102 104 103 114 116 116 V Unskilled manual 111 118 143 137 166 189 *ages 20-64 (Bartley 2004) There is a remarkable consistency in the distribution of mortality between representatives of social classes. Representatives of higher social classes tend to have lower mortality rates than people from the other layers of social hierarchy. Although the distribution shown in the table is not bipolar (higher social classes versus the rest of population) the overall trend is obvious: a statistically significant change in the level of social status is associated with a statistically significant change in health. A comparison between figures representing mortality rates 70 years ago and 10 years ago clearly demonstrates that in terms of absolute figures situation has much improved much since those days. Yet, the disturbing tendency is the increasing mortality gap between social classes as shown on the below chart. Chart 1: The Widening Mortality Gap Between the Social Classes *1979-83 excludes 1981 England and Wales. Men of working age (varies according to year, either aged 15 or 20 to age 64 or 65 (Drever & Whitehead 1997) Evidently, the widening occurs due to faster reduction of mortality rates among member of higher social classes, which is another evidence of the still important role of social class in accounting for inequalities in health. Valuable data that further reinforces the link between social class and health disparities is provided in the epoch-making Black Report. The core idea underlying this document was to review the evidence about health disparities amongst social classes, identify possible causes, and suggest implications for policy and further research in the field. Despite the absolute improvement in health across all the classes, the authors found statistically important correlation between social class and such important aspect of health as life expectancy, infant mortality rates and disparities in the assess to and quality of medical services (Black et al. 1980)). The Black Report suggested four possible explanations for inequalities in health: Artefact: both 'health' and 'social class' are artificial categories constructed to reflect social organisation; Natural and social selection: this explanation relies on the popular opinion that the fittest people have better chances to succeed in society, and classes reflect this degree of selection; Poverty: it leads to poor health, through nutrition, housing and environment. Cultural and behavioural: there are differences in the diet and fitness of different social classes, and in certain habits like smoking (Black et al. 1980). Abundant information collected by the authors during their 3-year research includes enough facts and reliable statistics to properly justify each of these explanations. One of the latest attempts to identify the major socio-economic determinants of health belongs to a group of researchers from University College London. They list ten “…different but interrelated aspects of the social determinants of health (Wilkinson & Marmot 2003, p.9): The social gradient: the need for policies to prevent people from falling into long-term disadvantage; Stress: how the social and psychological environment affects health; Early life: the importance of ensuring a good environment in early childhood Social exclusion: the role of friendship and social cohesion; Work: the problems of unemployment and job insecurity; Unemployment: the impact of work on health; Social support: the dangers of social exclusion; Addiction: the effects of alcohol and other drugs; Food: the need to ensure access to supplies of healthy food for everyone; Transport: the need for healthier transport systems. These factors identified after a thorough analysis of relevant literature help grasp the full picture of social determinants of health. They improve our understanding of how socio-economic factors found at all levels of society affect health of individuals and populations, and once again highlight the huge importance of social class for emergence of health inequalities. Conclusion Social class is a complex concept that encapsulates level of income, cultural and educational background, employment opportunities, and many other aspects. Therefore, any attempt to establish a simple causal relationship between social class and poor health is doomed to failure. However, numerous studies clearly demonstrate that the relationship does exist and that the conditions associated with social class are even more important than medical services for health of the populations Further research in the field of social patterning of health is essential for several reasons. Firstly, only comprehensive understanding of all aspects associated with the relationship between social status and health will provide a valuable insight in the potential for improvement. Secondly, identification of the social groups especially vulnerable to problems associated with poor health would make it possible to improve the quality and effectiveness of governance of appropriate medical services and interventions strategies. Thirdly, complete information about the relationship between health and social circumstances can provide new insights into the nature of some specific diseases. The range of potential research questions associated with this relationship between social class and health inequalities is impressive. 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