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Chapter 6

SOC102 Habits of Inequality Chapter 6

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Lorne Tepperman

Habits of Inequality Chapter 6 – Sickness and Stigmatization - Health problems (e.g., widespread sickness, crime, death) are a costly consequence of inequalities - Many factors influence people’s health o Genetic predispositions, which are probably activated by environmental factors o Biological aging (e.g., decline physically, sicken before we die) o Social factors (e.g., workplace dangers, poverty) - There is probably nothing more that Canadians care about more than good health o Largest and most rapidly growing portion of Canada’s gross national product is devoted to health care o Any threat to good universal health care is a serious issue (e.g., long waiting times) o Bad health is easier to prevent than it is to cure  People lose more person-years of healthy life through preventable causes than they do through infectious or degenerative diseases o Public health measures are the best way to guarantee Canadians remain healthy  Three main ways to increase the likelihood of a long, healthy life  Reduce smoking  Improve eating patterns (and thus, reduce obesity)  Promote exercise - Good health requires both a sound mind and a sound body because the mind and body are connected (e.g., an illness in one is likely to harm the other) - Good health requires both good mental health and good physical health - The present-day conception of health is best enunciated by the World Health Organization (WHO) o Health  a state of general well-being, not merely an absence of illness - Canadians are in favour of preventing premature death and suffering o Most know this can be done by stressing good diet, exercise, and the cessation of smoking o Few know this can be done through the reduction of social inequality and the stigma surrounding health problems  We can increase the health and longevity of Canadians by breaking our habits of inequality Social inequality and health - Health has gained interest in the social research community for several reasons o First, with the aging of national populations in the West, health and health care has become an increasing source of concern and expense in all Western societies o Second, people place a great deal of value on good health as a type of well-being and life quality - Health is used as a measure of societal functioning  whether society is working well or not o The overall health of a population tells us how well the government, the economy, the family, and other social institutions are playing their expected role o Health is a more sensitive and secure indicator of well-being than happiness or life satisfaction  People who experience adversity (e.g., harsh or adverse conditions) over an extended period of time tend to lower their goals, so they can be happy (or satisfied) with relatively little  High levels of satisfaction in all populations above the most deprived 20% of humanity  Once the minimum needs for food, shelter, and safety are met, people find similar degrees of happiness in family life, social life, religion, and work  Under conditions of continued adversity, both minds and bodies show signs of stress, decline, and diminished functioning (e.g., mental illness, physical illness)  The human mind is capable of persuading itself to settle for what is available  The human body is less able to continually adjust downward  The mind may often let us lie to ourselves about happiness, but the body is less compromising (e.g., our bodies don’t lie, even when our minds want to)  This is why physical and mental illnesses (e.g., health) are better indicators of societal malfunctioning than happiness and life satisfaction o Health is an easy measure to use  Medical doctors have become so good at measuring health precisely  People’s self-reports of their health are quite accurate o The problem is that many non-social factors influence health, and there is also the interconnection of influences  It is difficult to isolate the unique contribution of social inequality, if our goal is to determine how a reduction of inequality might reduce adverse health outcomes o Another problem is ecological fallacy  EMILE DURKHEIM  Proposed that suicide rates are highly correlated with social integration and social stability o As society becomes less integrated and less stable, the suicide rates go up  Suggested that people whose lives are less socially integrated and less socially stable are more likely than average to commit suicide o E.g., men who are divorced or single are at greater risk of suicide than people (especially women) who are married with children  Criticisms  Durkheim’s method is subject to the ecological fallacy  attributing the characteristics of groups to individuals o People in Group A  low level of social integration and high rate of suicide o People in Group B  high level of social integration and low rate of suicide o It is unjustified to conclude that a low level of integration increases the risk of suicide because we do not know whether the individuals committing suicide in either group are poorly integrated  Other variables may account for the suicide  Only a direct study of individuals can make the link between integration and suicide, but it is hard to carry out because suicide is relatively uncommon - What does it take to prove that social inequality affects health? o The problem of proof involves making all the necessary causal connections at every level of analysis  Need statistics from at least two different periods to measure the change in the variables of interest  Need to show how an increase in societal inequality may have translated into higher numbers of dead, sick, or depressed people  Want to show that the people most directly affected by inequality are the same people whose health goes into the deepest decline o Consider the period 1980 to 2008, a widespread increase in social inequality began with:  Reaganite policies in the US  Thatcherite policies in the UK  Under Premier Mike Harris’s severely anti-welfare and anti-union Conservative government in Ontario  Changing policies  widespread increases in inequality  widespread deregulation of markets and businesses, cuts in social spending, taxes on the wealthy, and export of manufacturing jobs to low-wage foreign countries  took away people’s homes and life savings o Hard to calculate the effect of increased inequality on people’s health  If poverty were to blame, then the appropriate social intervention would be to grow the economy and improve welfare payments, employment insurance, and job creation programs  If inequality were to blame, then the appropriate social intervention would be to raise taxes on the upper end of the income scale and increase regulation of the means by which the rich get richer (e.g., more regulation of stock and land speculation, more restrictions on the export of jobs and capital) - ADAM WAGSTAFF and EDDY VAN DOORSLAER o Absolute income  poverty (e.g., shortage of dollar bills) o Relative income  inequality o Concluded that data from aggregate-level studies are insufficient to discriminate between competing hypotheses o Concluded that data from individual-level studies provide strong support for the absolute-income hypothesis, no support for the relative-income hypothesis, and little or no support for the income inequality hypothesis  Proposed that absolute poverty causes ill health, rather than relative deprivation - Why is there still a debate about the link between inequality and health? o WAGSTAFF and DOORSLAER’s conclusions were based entirely on US data  US is the most unequal and unregulated of all developed Western societies o Aggregate-level studies have predominated because they are easier and less costly  Largely inconclusive for policy purposes  Consider a Swedish research study  ULF-G. GERDTHAM and MAGNUS JOHANNESON o Random sample from the adult Swedish population o 40,000 individuals followed up for 10-17 years o Mortality decreases as individual income increases [↑ income = ↓ mortality] o Supports WAGSTAFF and DOORSLAER’s conclusion, but leaves open one other possibility,  Poverty is the immediate cause of health problems, but poverty is also a common outcome of inequality  One might argue that inequality causes poor health by means of increasing poverty - The “social inequality causes poor health” argument remains compelling and suggestive - The dominant viewpoint among population health researchers is that “social inequality causes poor health” o The strongest, most comprehensive understanding of how social factors affect health o In the current population health literature, there is repeated validation of “social inequality causes poor health” Where the halls are white - Link between social inequality and health inequality o Whitehall studies  The classic and most famous proof that social inequality causes bad health (and death)  Carried out over the period 1967 to 1988  Examined detailed health information on British civil servants (e.g., employed, well-adjusted adults)  Found that death rates from chronic heart disease were 3X higher among workers in the lower civil service jobs than among workers in the higher civil service jobs  This gradient in health was observed across the entire job spectrum o Every decrease in job grade corresponded with an increase in health risk o Civil servants in the highest grade were more likely to be healthier than civil servants in the lowest grade, and were also more likely to be healthier than civil servants in the grade immediately below o Economic inequality is not only relevant at the lower end of the class hierarchy o Equality has the potential to benefit the entire society  How does lower (relative) income, status, or rank, translate into lower (relative) health? o Material model  material living conditions (e.g., poverty) is the main source of health problems due to inequality o Psychosocial model  social environment can impact health and disease, even under conditions of affluence  Social inequality tends to correlate with social fragmentation, poorer social relations, and a lack of autonomy for people in the lower ranks  Poorer communities  less safe, less beautiful, and less relaxing  increase stress  cause mood disorders that compromise health  Social inequality is related to excess stress  Excess stress is linked to the release of cortisol  Cortisol  a hormone produced by the body as a response to stress  The more times stress causes the release of cortisol, the more the immune system is compromised and the more vulnerable a person becomes to infectious disease o Infectious pathogens are partly responsible for coronary diseases o Therefore, a person with a severely suppressed immune system will be less able to prevent cardiovascular disease  Cortisol levels fluctuate over the day and respond to dangers in the environment o Workers showed no significant difference in cortisol levels upon awakening, regardless of their SES position o Workers in lower employment grades showed higher levels of cortisol within 30 minutes after waking  Differences in job control produce different levels of stress o Lower status job  worker is less able to control the work setting  more stress  higher blood pressure and higher risk of chronic health disease, or to infection that is connected with heart disease  Examined workplace stress on three different dimensions  Effort-reward imbalance  Job strain  Organizational justice  the fairness of decision-making processes and interpersonal relationships in the workplace [↑ unfairness = ↑ risk of heart disease]  All three indicators of stress at work are linked to coronary heart disease  Poor social support, low autonomy in the workplace, depression, anxiety, and hostility are also linked to coronary heart disease  Replicated many times with similar findings reported for many occupations  As the average income increased over time in developed countries, the conditions of life changed but the income-health gradient has not diminished o Only a small number of people can now be classified as living in a state of absolute poverty o Relative deprivation and absolute income affect people’s health  Absolute deprivation (poverty)  direct impact of the material environment on health  Relative deprivation (income inequality)  income is not distributed equally to all members of a society  Influences both high- and low-income groups  Greater negative effect on low-income groups o Low-income groups do not benefit from “an increase in income leads to an increase in health” because of relative deprivation o People who live in areas with high income inequality  Report poor health  Report fewer healthy days on average  Have a higher risk of premature mortality  Lowering the Gini Index of inequality below the threshold of 0.3 would help prevent 1.5 million adult deaths per year in the US - Link between income inequality and health inequality o Income inequality causes health inequality due to a disinvestment in human capital  States that are less egalitarian in their income distributions spend less on social programs  People with high incomes want lower taxes and less government investment in public services for the poor (e.g., health education, preventative care)  Poorer but more equal countries have better health outcomes for the mass population  Distribute resources more fairly by taxing the rich and redistributing resources to the poor o Inequalities in access to resources  Not everyone has the same access to information and beneficial goods, services, and information  A person with more resources is better able to maintain a healthy lifestyle and better able to get the best medical treatment available  The resources that are associated with a high SES are flexible  They can be used in many different ways under different situations  They are unequally distributed in a society - Understanding socio-economic inequality is key to understanding health inequality o At the individual level, flexible resources shape individual health behaviours  Income inequality influences behaviours that can be damaging to or protective of health  Unequal distribution of protective behavioural factors (e.g., access to health care) can be explained in part by the unequal access to material factors, which cause risks to individual health o At the community level, a high SES people are more likely to live in a high neighbourhood  Crime, noise, violence, pollution, and traffic are minimized  Near health-care facilities, excellent schools, clean and safe playgrounds, and high-quality grocery stores  Income inequality can lead to poorer eating patterns among the poor, which can lead to poorer health - Role of social capital and trust as a primary determinant o Social capital  strength of the connections people feel to one another o Income or class inequality increases the risks to health by decreasing social cohesion  Increases the risk of social conflict (e.g., isolation, loneliness, criminal victimization)  Results in less social support (e.g., less financial and social aid, less emotional and spiritual support, less health care information and access, more high-risk behaviours)  Reduces the level of trust among people in the society  Leads to feelings of vulnerability and isolation  Harms health by causing stress and depression  Stress and depression are often gateways to health-compromising behaviours o Inequality impedes the formation of new social capital  High social capital in communities advocates individual and community health o More social inequality, combined with high levels of distrust, also decreases people’s confidence that public money will be spent to improve health - Researchers calculated how many people social inequality kills o Reviewed earlier studies on the effects of six social factors, all based on large national surveys o More people die from being absolutely or relatively poor than from accidents or lung cancer combined  291,000 deaths per year due to poverty and income inequality in the US  119,000 deaths per year due to accidents in the US  156,000 deaths per year due to lung cancer in the US - The health impact of income inequality is not offset by positive societal factors The cuckoo’s nest: Mental health and addiction - San Clemente Palace is a five-star hotel and resort on an island in Venice o The island was a site of a hospital for pilgrims returning from the Middle East during the Crusades (900 years ago)  converted into a convent  used as a quarantine station during the Black Death  Europe’s first mental institution for women until 1992 o There is no allusion to the hotel’s association with mental illness, which is potentially stigmatizing - According to Health Canada, mental disorder  any condition characterized by alterations in thinking, mood, or behaviour (or some combination thereof) associated with significant distress and impaired functioning over an extended period of time - Mental disorder and mental illness are used interchangeably o Mental illness  clinical diagnoses that require medical or psychiatric treatment o Mental disorder  more numerous and wide ranging, but far from trivial o Mental illnesses and disorders pose serious limits to people’s ability to carry out their daily lives and interrupt the normal functioning of families, schools, workplaces, and other social institutions - The causes of mental disorder and mental illness are poorly understood o DSM-IV published by the APA is the professionally accepted classification for mental illnesses  Describes the most common categories of mental illnesses (e.g., anxiety disorders, mood disorders, psychosis, dementia, eating disorders, personality disorders) o Experts agree that most mental illnesses arise from an interaction of genetic (or biological), psychological, and social (or environmental factors)  Major social disruptions (e.g., war, natural disasters) can trigger the development of mental illness  Through stress, the breakdown of social order, and the trigger or release of antisocial tendencies  Individualistic nature and fast pace of life in industrial societies erode traditional sources of social stability (e.g., family, religion) can increase the risks of mental illness  Social inequality contributes to the development of mental illnesses  Through the creation of stress and blame - Mental illness is the leading cause of disability in Canada o Mental disorders have a combined lifetime prevalence rate of 20%  1 in 5 (6 million Canadians) will suffer from a mental disorder at some point during their lifetime - Co-morbidity  the presence of one mental disorder predisposes an individual to another one o This complicates prevention, diagnosis, and treatment o In the US, 45% of people who experienced any mental illness within the past 12 months suffered from more than one disorder during that time - Mental illness affects all types of people o No social class or social group is free of mental illness o Not everyone is equally at risk for mental illness  Social causation  mental illness found among poor people are due to the stresses of poverty  Depression is more common among poor peo
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