S207 Week 7 13 February 2007 Inequality  how can we think about health inequalities or health disparities?

how can we think systematically about the production of health disparities? what sorts of interventions make sense, given that theoretical understanding?  macro, institutional/organization level  to what extent can we think about US and global inequalities in the same way? to what extent do we need to think about them differently?  we know a lot about the dimensions of disparity, we have a lot of statistical information.  there’s no sort of settled understanding about how to think about these things. there’s no canon. it’s much more an exercise to think about how/what can a medical sociologist contribute to this discussion. what do health inequalities look like in the US and globally? John: Robert & House talked about things that have negative impact on health. Jonathan: poor people tend to wait longer to access health services. stage of disease at which people present is more severe for those who are poor. debate about whether SES comes first, or whether poor health comes first. one possible explanation is that poor people are sick more, and sick more often. not that low SES causes sickness, but in fact, when you’re sick, you’re unable to earn an income, and thus you’re poorer. Romi: evidence for SES affecting health Beth: race and SES not proxies for each other Beth: disparities more stark than they used to be Robert and House: you can use any measure of SES .. they talk about the relationship between SES and health as being monotonic and nonlinear. when you’re trying to come up with theoretical causal explanations for how social position or social status contributes to health, it’s important to look at what the shape of that relationship looks like. what does it mean for something to be monotonic and nonlinear?  monotonic = for every stepwise increase in one factor, you get an increase in the output. at no point does SES go down while health goes up.  nonlinear = it isn’t a perfect one-to-one relationship (for every $10,000 in income, you get some even increase in health). sometimes the amount in terms of extra benefit for your health will wax and wane, but it’ll always be a benefit.  diminishing returns. when you’re trying to come up with a causal relationship.. the monotonic is important b/c in the debate, some people will argue that maybe we can make it an even playing field by giving everyone even access to health care, or bring everyone up to a certain level, you can reduce health disparities. after a certain threshold, everyone is pretty much going to be the same.  Beth: minimum wage just means you won’t have desperately poor people.

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diminishing returns. for every increase in social attainment or educational status etc., it will not give you the same amount of increase in health.  middle/lower range of income/SES: if you can make a little change there, that’s going to have a much bigger impact on reducing health disparities. for every unit of increased socioeconomic position, you get a very large difference in health benefits. so if that’s the case, the more you can fiddle with the lower half of the SES spectrum, you’ll get an exaggerated effect in terms of health. Robert and House fig. 6-1 (p. 81). each dot is an individual country. this relationship gives you clues as to what’s going on, and as to what’s going to have the greatest impact. Robert and House – idea of different returns of socioeconomic position or race for different times/places. p. 84. “Krieger and colleagues: education does not have the same economic return for blacks as it does for whites, raising the question of whether there might also be differential health returns by race” Martine: Wilkinson article discusses problems associated with comparing SES across countries. relative social position more important indicator Jonathan: poor health in US doesn’t look like poor health in poor countries. sanitation, basic needs attended to in wealthy countries. evidence suggests that tide theory (rising tide lifts all boats) only gets you so far. at this end of the spectrum, one causal relationship might be operating; at middle end and high end, other causal relationships may be operating proposed frameworks/concepts/theories that account for how health outcomes are produced handout:  life expectancy at birth by race  disparity between white and black is fluctuating  between 1960 and 1990, we end up with about the same gap between blacks and whites  six leading causes of death by race  heart disease is #1 for all, cancer #2 for all  homicide, HIV infection, perinatal mortality among blacks (affect younger people)  respiratory disease, pneumonia among whites (affect older people)  even though the things that kill people have changed, the fact some people are dying at higher rate and earlier ages has stayed the same. you could think about the causes of death as the immediate physical/biological reasons people are dying, but the fact this gap has remained constant suggests something else (social factors, social conditions) is operating that is contributing to this persistent gap. social conditions are giving rise to different causes of death, but that gap will more or less persist  you could make the argument that it’s important to intervene of homicide rates and violence.. but when you intervene on homicide, the underlying social conditions that not only given rise to homicide, but other outcomes, will compensate (immediate causes of death can change, but the mortality divide is not going to change. even if you intervene on immediate causes of death, all that means is that you’re touching whatever causal processes occur right before mortality happens. you’re intervening

only on the biological/physical manifestations of underlying social conditions/inequality. those conditions will end up manifesting themselves in other causes of death, thus maintaining the gap.  a social condition can be multiply realized, and has multiple pathways.  Romi: Link and Phelan talk about how targeting only one mechanism, you’ll only affect one small aspect of disease .. but if you try to target SES, you’re able to effect change that is not disease-specific. it is a fundamental cause of disease. Paul Farmer (p. 13)  immediate consequences of poverty and racism  inadequate housing -> exposure to TB  inaccess to health care -> greater severity of disease, progression to active disease, reinfection  poor health, poor nutrition -> progression to active disease  inability to comply/adhere -> reinfection, multiple drug resistance (MDR), greater severity of disease, progression to active disease, exposure to TB  a lot of health policy ends up being at this level.  multiple pathways to health inequality. even if you remove one pathway (e.g., access to health care), many will remain  we still lack a systematic conceptual framework that is broad enough yet precise enough for us to think about what is going on, and where we can intervene  Cindy: I am troubled by his focus on physicians as agents; this is more structural  Krista: I don’t know if his actual work is doing what we’re talking about  most of our health care dollars are going toward more proximal targets  he doesn’t situate his book in this way, but I see it as a response to ongoing conversations. he’s not saying MDs are be-all end-all who need to shoulder burden. it’s that MDs are saying they’re only concerned with providing care to individual patients. isn’t it sociologists’ job to fix systemic issues? Farmer says it’s a conditional no.. huge global disparities will inevitably impinge upon the individual patient in front of you.  in places like Haiti, where there is severe deprivation, level of health care being provided is so dismally low, this is one place/level where we can intervene  Martine: even neoliberal programs aimed at structural causes actually exacerbate the inequalities they’re purportedly out to reduce. structural adjustment programs. neoliberal investment still leaves capitalism and power relations intact  this generation of scholarship has brought up how so much of clinical literature and public health literature is about how to intervene within single arrows. the overriding claim is that we have to take a step backwards, think upstream. what is leading to poor nutrition? problematizing compliance. not taking it as a given. Martine’s point begs the question: is there something upstream from poverty and racism? is there a social structure that is more fundamental? fundamental causes become important in times of social change (anytime society changes, new treatments, something changes in the environment). why is this?  when HIV came onto the scene in the 1980, that was a time of immense social change, medically speaking. their point is not to deny that it’s not worth going after AIDS. it’s not saying that to alleviate the morbidity and mortality due to AIDS is unimportant.

it’s another pathway that links the core fundamental causes and the ultimate inequalities in health  Romi: over time, the same strata of people is able to avoid risks  Craig: AIDS started out as disease of affluent white gay men (over time, less so)  importance of resources, broadly construed  the face of AIDS has changed over time  it all hinges on this basic, self-evident concept that resources help you avoid getting sick in the first place, and if you do get sick, they serve to minimize the consequences. resources impact incidence (who actually gets sick) and progression dental care  Beth: people who have access to buy toothpaste, and fluoridated water, and education programs that teach brushing habits.. those people have better oral health outcomes than those who don’t have the knowledge or resources to spend on those things.. so they have quicker progression to active disease. so we see upper-middle class with good oral health, and minority/low-income kids who have disease in their mouth. Lutfey and Freese – diabetes  anytime there’s a new therapy, new knowledge to minimize disease.. who’s going to take advantage of it? those who are more advantageously situated to begin with. compensatory inversion. inequality being maximally maintained over time. this fundamental cause framework helps explain why when we have new knowledge about heart disease or about smoking causing lung cancer, we don’t see everybody taking advantage of that knowledge. helps explain why inequalities are durable and persistent over time.  people at the bottom who would disproportionately gain from new innovations are the same people with the least access to them  Paul Farmer – p. 12 – “the spectacular successes of biomedicine have in many instances further entrenched medical inequalities” 

Wilkinson  when you look within a society, the poor people have the worst health. when you look across societies, societies with greater income inequality (greater bifurcation of income/wealth) have worse health outcomes than countries where income inequalities are less severe. in socialized countries, as a consequence of tax structure, the absolute difference between the rich and poor will be that much less. those countries are characterized by far fewer and far less poor health outcomes.  idea of social cohesion / social capital. a raging debate in the literature. lot of intellectual energy going into thinking about this. what do we mean by social cohesion?  social capital is the capital or the assets/resources that resides in your networks and connections with other people. people interacting with one another, and some resource/asset/value that comes out of those interactions. people in the health field are looking at social networks. book called Heat Wave re: heat wave in Chicago, with unprecedented number of people who died. he did social anatomy of this heat wave, and he found that older folks and those without social connections / who were socially isolated were the ones who died. debate was already going on, but this book contributed to the idea that social networks could actually be healthy.

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is social capital upstream from, at same level as, or downstream from poverty and racism? pathological culture that needs to be fixed. more fundamental structural inequalities that produce distribution of social capital social capital is a theoretical concept for talking about things like social cohesion, the degree to which people associate with others, or belong to associations or go to church.. all these disparities ways to measure the extent of collective identity, collective agency.. aggregate amount of social capital that characterizes a society. Wilkinson is arguing you can characterize a society by the degree to which they invest in social capital. some societies encourage/promote/reward social relationships, social networks.. other societies are politically organized and have prominent discourses that are much more individualistic debate over whether it is absolute levels of deprivation/privilege or whether it is relative Nancy Adler shows people picture of a ladder and asks people where they think they would place themselves. very strong linear relationship to their health status. people’s sense of where they are in a society is highly associated with their health status p. 99 – Table 2. Wilkinson’s take-home message, where he hangs on to social cohesion as a potential explanation, is that within entire countries, when you plot the average income against life expectancy, you get no relationship at all. he’s saying that countries where there’s a higher per capita income are not actually enjoying higher life expectancy (US has relatively poor outcomes in life expectancy, infant mortality, etc.). he latches onto the idea that there must be something that distinguishes societies that have higher income inequality and lower health. why is it that these more equal societies enjoy better health? there are some societies that encourage/promote/are politically structured to encourage social cohesion / collective agency / collective activism, and that is what in part promotes better health people that are already collectively organized can fight for or against whatever cause heat wave example – high social cohesion leads to people checking up on each other Tania: but a lot of people died in heat wave in Europe too. we have to be careful about conflating individual determinism with that of the society. what Wilkinson might say is that in a place like the US, the percentage of people who died might be higher than the percentage who died in Europe. it’s comparing societies/communities against each other, not explaining why an individual in Chicago died whereas someone in Europe did not Martine: Navarro specifically critiques Wilkinson, but it’s not really what Wilkinson is arguing. Navarro is bringing in additional political/power issues. you need to look at who is systematically excluded from or included in the socially cohesive society. this is the Heat Wave argument as well.

globalization are global health disparities of a qualitatively different nature?  Jonathan: patterns have been reproduced since colonialism  John: they’re the same inasmuch that we’re exporting our health care system to the rest of the world

biomedicine is a particular culture and mode of healing that is becoming hegemonic and exported to other countries  first, do people agree with that?  second, is there room for resistance or for something else? is biomedicine an example of globalization? a culture, a political philosophy.. people talk about American way being exported.. what exactly is being exported?