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SOSC 1930 Chapter Full: Health and Equity HREQ 1930 - Fall (COMPLETE FALL TERM).docx

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York University
Social Science
SOSC 1930
Yuka Nakamura

th September 16 The Question of Equity in Health Inequality and Inequity are different concepts - Inequality implies disparities in status, opportunity, treatment, etc. o For Example, as people age – both males and females – their health tends to deteriorate, and it would be unreasonable to expect individuals of all ages to have equal health o We consider differences to categorize people  Doctor’s great health and their knowledge of health give them a special status. Not the fact that they merely study, and that is why they are prestigious.  It comes down to the nature of their work, as they promote what is needed and respected - Health is more fundamental than income o Income is an aspect of life, income is nothing without health. In a sense, income is a reward for hard work. - There are natural inequalities in health that may not be considered unfair; ex as people age, their health tends to deteriorate and it would be unreasonable to expect individuals of all ages to have equal health - Achieving complete equality of outcomes in health, therefore, may not be a possible or desirable policy objective Extreme: - BRIC nations (Britain, Russia, India, China) where there is disparity of wealth. As they have more billionaires than other countries. Money is in the possession of few people, however, people are treated based on wealth - OTHER HAND: Canada gives everyone equal opportunity, thus everyone gets a fair chance to inspire everyone equally. Midpoint: - USA: Fees vary a lot based on the funding of each institution (EG. University/College) ** (In) equity incorporates an assessment of fairness - An ethical principle. It is normative - References social justice and human rights - Unnecessary, avoidable, unfair and unjust o Infant Mortality  Every country keeps track of its infant mortality - Grounded in principles of distributive justice in relation to resources and other processes that address the question of fairness Achieving complete equality of outcomes in health, therefore, may not be a possible or desirable policy objective • Health issues are not individual, they are dealt in groups o Eg. Old people are naturally going to be more sick than young people  Some conditions are inevitable • Eg. Old Age • Prescription Drugs o As we are now told by our society to not endure pain, rather use medicine to reduce pain EQUALITY OF HEALTH IS NOT POSSIBLE - “Equity is, thus, the most relevant concept for determining health policies, rather than equality per se.” - But what is equitable is not free of debate - Equity in health could be interpreted as consisting of equality in outcomes among groups or individuals who are similar from a genetic/age/sex perspective - Yet, this is not a sufficient requirement for achieving health equity in a given society, because it can allow large disparities in health outcomes between different groups - Directed to providing equal opportunity to be healthy regardless of social group membership - Here, we see that equality remains an important concept - Unjust social structures are often at the basis of health inequities - Health inequities systematically put populations that are already socially disadvantaged… at further disadvantage with respect to their health. Social structure just means the way in our society is organized. The Question of Equity in Health II - Recall: Less tolerant of inequalities in health than in a variety of other inequalities (say income). - We understand that health to be a special good with both intrinsic and instrumental value (vs. exclusively instrumental value of income - Income in equality is necessary and acceptable (Income is a reward, motivating factor) - Allow for income equality for a variety of reasons - Health has an intrinsic value - Health directly impacts (enables or obstructs) life chances - “Health is among the most important conditions of human life and… capabilities…” (Sen, 23) - “without health nothing is of any use not money nor anything else” - Eg. Untouchables; Man has lots of money, but is quadrapoledic - In the recent study by the World Bank… ill health and its consequences emerged from interviews with over 60,000 poor persons as the primary reason for impoverishment (Evans 2001) - Bad health will limit you - Equity tied to notion of fairness - Cant intervene to make everyone have the same starting position - ....health is a critical building block, or capability to a better and more meaningful life and ill health a huge threat to social and economic well-being o Social aspect of well-being - Here we want to note, to be taken up later in the course, that health itself is a complex nothing (see for instance, Daniels et all, 1999) - This complexity will have some influence on how we address the issue of equity - The moment you join the community, the community makes demands on you - Absence of good health is a denial of equality of opportunity (Anand, 18) - Equity is tied to fairness which references a fair distribution of equality of opportunity (Daniels et al, 1999) - Recall: This is generally believed to be unfair/unjust if it is avoidable and unnecessary - Principals to talk about equity; notions of fairness, avoidability, unnecessariness, equality of opportunity - Used to measure or take up the question of equity - No content - Principals are universal but the content is local - “Those differentials arising from determinants where individuals have less choice in lifestyle, work conditions, or access to health care and other public services are more likely to be considered avoidable and unfair and thus inequities (Evans, 2001) o Put differently, when does a health inequality become a health inequity - “To answer the question of what constitutes health inequities… it is necessary to move beyond information about health status to an understanding of the underlying social processes and their fairness.” (Evans, 2001) - Because of the emphasis on the processes that bring about certain outcomes, rather than on the outcomes themselves, such an approach is called “procedural.” (Evans, 2001) - We are invited to examine a society’s social arrangements, its basic structure (political, social, and economic institutions), in order to measure its level of fairness in terms of promoting equal opportunity for good health (Evans, 2001) - Kind of education you receive can have a really strong impact on your health o Education you receive will influence the type of career you will have o The career you have will influence the type of career you live o Whether you have access to resources or not - If the education system is unjust, if it doesn’t equip us with the ability to learn o Your life will be affected as well in a negative way rd September 23 Public Health, Ethics and Equity p. 63­ 92 - Life and Death patterned to social class - Middle Income groups in a more unequal society will have worse health than comparable or even poorer groups in a society with greater equality 4.2 Social Determinants of Health: Some Basic Findings - Five Central Findings o Income / Health Gradients – not result of fixed or determinate laws of economic development, however influenced by policy choices o Income / Health Gradients not result of deprivation of poor groups, but operates across whole socio-economic spectrum within societies o Steepness of income / health gradient affected by inequality in societies o Relative income or socioeconomic status more important than level of income o Social and psychosocial pathways Cross-National evidence on health inequalities - US richest nation, however poor health indicators - Costa Rica strong health indicators Individual SES and health - Determining factor in steepness of the gradient appears to be extent of income inequality in a society - High income inequality for middle income groups may have lower health status - Income inequality determines health status Relative Income and Health - Hypotheses: Income inequality has its effect on health inequalities only above some threshold level of inequality, a threshold cross in the US and more unequal countries, but not met in more egalitarian countries - Not resources, but degree of relative deprivation (Not the goods needed for survival, but lack of sources of self-respect that are deemed essential for full participation in society) - US – areas of high income inequality had an excess of death compared to areas of low inequality that was equivalent to all deaths due to heart disease - US – higher income inequality showed slower rates of life-expectancy improvement Pathways linking social inequalities to health inequalities - Differential investment in human capital is strong predictor of health across nations - Income inequality erodes social cohesion, which in turn reflected in significantly lower participation in political activity Health Inequalities and Inequities - Age, gender, race and ethnic differences in health status exist that are independent of socio-economic differences, raising distinct questions about equity or justice - Health inequalities persist even in societies that provide the poor with access to all of the determinants of health Justice as Fairness and Health Inequalities Justice when no one is ill - Rawl’s strategy was to show that a social contract that was designed to be fair to free and equal people would not only justify the choice of those equal basic liberties but would also justify the choice of principles guaranteeing equal opportunity and limiting inequalities to those that work to make the worst of groups fare as well o Assumed contractors fully functional over a normal life span Extending Rawl’s Theory - This extension of Rawls’s theory expands the notion of opportunity beyond just access to jobs and offices, since participation in other aspects of a plan of life also are affected by departures from normal functioning. Rawls endorses the overall approach in PL Justifying Inequality in Rawl’s Theory - It is irrational for contractors to insist on equality if doing so would make them worse off. Specifically, he argues that contractors would choose his Difference Principle, which permits inequalities provide that they work to make the worst off groups in society as well off as possible - Two points will help avoid misunderstanding of the Difference Principle and its justification o Requires maximal flow in the direction of helping worst off groups  Chain connectedness o Difference Principle: produce less health inequality than any proposed principles that allow inequalities  Flattening health gradient benefits all groups o Rawl says primary social goods are needs of citizens: liberty, powers, opportunities, income, wealth, social bases of self-respect o Without self-respect, difficult for individuals to use their capabilities How conformance with Rawls’s principles promotes population health and reduces health disparities - The Rawlsian ideal of democratic equality also involves conformity with a principle guaranteeing fair equality of opportunity - Discriminatory barriers prohibited, also requires robust measures aimed at mitigating the effects of socio-economic inequalities and other social contingencies on opportunity - Equal opportunity principle requires extensive public health, medical and social support services aimed at promoting normal functioning for all o Aims at improving population health and reduction of health inequalities - Difference principle places restrictions on inequalities in income and wealth - In short, Rawls’s principles of justice regulate the distribution of the key social determinants of health, including the social bases of self-respect. There is nothing about the theory, or Daniels’s extension of it, that should make us focus narrowly on medical services. Properly understood, justice as fairness tells us what justice requires in the distribution of all socially controllable determinants of health. The problem with residual gradients - Reducing health inequalities should not requires steps that threaten our health Can contractors trade health for other goods? - One of Rawls’s central arguments for singling out a principle protecting equal basic liberties and giving it (lexical) priority over his other principles of justice is his claim that once people achieve some threshold level of material well-being, they would not trade away the fundamental importance of liberty for other goods o Rawls does suggest that since fair equality of opportunity is given priority over the Difference Principle, that within the index, we can assume opportunity has a heavier weighting Can legislators trade health for other goods? An objection to our approach and a remark about generalizability - Redundancy connected to Rawls theory to address questions about fair distribution of the social determinants of health shows the theory is generalizable in fruitful ways Rawls versus Alternatives - Fair Equality of Opportunity and differences principles o View certain social and natural contingencies as morally arbitrary and seek principles of justice to nullify their effect  Alternative: Owed compensation for any equality of opportunity - Rawl’s principles provide for our needs - Sen argues that Rawl’s theory operating wrong space but agrees with theory o Sen aware concerns about equality with regard to positive freedom must be integrated with considerations of liberty and equality, though he does not say much about how that is to be done o If we take cases where we can agree on, we will talk about disease and disability o If focusing on Sen capabilities needed for democratic citizenship, then convergence of rawls and sen is quite apparent o Both talk about democratic equality, capabilities needed for free equal citizenship Challenging Inequities in Health from  Ethics to Action - Health of disadvantaged groups sensitive to economic, social and political trends - Men who live in US live 16 years longer than men in poorest countries Rawl’s theory – central themes revolve around how people construct society, concepts of fairness and equality People behind veil of ignorance does not know what social contract they belong to A person who does not know what privileges he or she will be born with (or without ) is, in Rawls' view, more likely to construct a society that does not arbitrarily assign privilege based on characteristics that should have no bearing on what people get. Rawls believes that a society cannot be just without fairness and equality and believes this veil of ignorance both reveals the biases of current society and can help to prevent biases in establishing future social arrangements. October 7 th Public Health, Ethics and Equity. Pg. 37­ 62 - Concern not with economic performance, but health status of which economic and social performance - Two ways for some social inequalities in health may not be caused by the effect of determining social forces on health o Selection (Health determining social position) o Common antecedent determining both health and social position - Social Gradients in relation to health, talking about smokers having a higher gradient of getting cancer than people without Is Such a Social Gradient Inevitable? - Widely recognized that poor have worse health than rich - Gradient result of inequalities in society, inevitable - Counters o Break link between income inequality and health inequality, one could achieve greater equality in health Is the Gradient Important – Inequality Between Social Groups or Among Individuals? - 638 deaths from lung cancer, <5% non-smokers - Eg. One with higher cholesterol will have a higher chance of getting plaque than people with lower - Different ways to raise life expectancy o Increase level of health of the lower half of the civil service o Or gain more knowledge for public health Social Causation or Health Selection (Endogeneity) - Health determine socio-economic position as well as social circumstances affecting health - Health major determinant of life chances - Health selection o Lead to argument that ill health led to lower position in social hierarchy, social exclusion, having a job offered less opportunities for control and imbalance between efforts and rewards, increased risk of unemployment, and job insecurity, living in a deprived neighborhood, having less participation in social networks, eating worse food, indulging in addictive behavior, and breathing in polluted air as well as being sedentary - Plausibility – No guarantee selection operating - First, Longitudinal studies allow a judgment to be made as to which came first; health or social circumstances - Second, changing social class differences over time - Third, dealing with selection is to examine the effect of social circumstances that could not have plausibly been affected by health status of individuals o Sick may lose job more than healthy Country Differences in Health: Social Causes? - Rich countries have better mortality than poor countries - Widening social gradient within countries Social Causation – A Simplified Model Medical Care? Individual Lifestyle? - Combined major coronary risk factors accounted for a quarter of the social gradient in mortality o Smoking, lack of physical activity, obesity, high cholesterol levels and high blood pressure - Two Approaches o Ask why there is a social gradient in smoking – Causes o Ask what else may account for the social gradient in disease other than smoking - Higher incomes – Smoking rates from 40% to <20% - Poorer – Smoking stayed at 70% - Smoking kills you, it’s a choice Issues in Social Causation of Inequalities in Health Poverty or Inequality? - Civil service are stable, low paid jobs. Executive officers are better off but worse health than administrators above them in hierarchy - Whitehall says inequality is important; place in hierarchy appears to predict risk of death and disease - Areas with greater income inequality are likely to have more fragmented social environments Psychosocial or Material Causes of Inequalities - Psychosocial Factors that link social position to health – Social supports/social integration, psychosocial work environment, control/mastery, and hostility. Social Supports/Integration - Lower the position, less participation in social networks outside family, negative degree of social support Psychosocial Work Environment - Two dominant models o Demand / Control Model  Not too much work pressure that causes stress-related illness, but too much psychological demand in the face of low control over circumstances at work. Control / Mastery - Low control characteristic of individuals - Higher the mean level of control, lower the coronary heart disease rates Hostility - Mean hostility of a city and that city’s mortality from coronary heart disease Fundamental causes' of health disparities: A comparative analysis of Canada and the United States - Canadians are in better health than Americans, and good health is more equally distributed across income groups in Canada than in the US - Canada more advanced social policy programs – reduce strength of relationship between economic resources and health - High income educated individuals have range of resources – learn how to protect themselves - that socio-economic status will be more strongly linked to the risk of developing preventable diseases than of unpreventable diseases; ii) that this link will be stronger in countries with greater economic inequality - Canadians more often smokers - Results of the logistic regression clearly support both predictions of fundamental cause theory. In the two countries, lower levels of education and income increased the odds of experiencing a preventable disease over a less-preventable one. In the United States, however, these odds increased to statistically significant levels, whereas in Canada, they did not. - The top 1% of the income earned in the US is equivalent to 90% of the population, America has higher tolerance for inequality Unnatural Causes – In Sickness and In Wealth - US low life expectancy - High rates of disease death in west end - Better wealth = Better health - Lower grade of employment, higher grade of heart disease - Relation between health of people and social circle - Education moves people up life expectancy gradient - Lost job o Blood pressure rose, went to doctor more, took a toll on her mentally and physically - People who have lower tier jobs have more high blood pressure and it doesn’t drop because it’s a high demand job, the lower tier the job, the more demand it has - Most of poor in America are white - Not having a safety net is killing the brain, hormones are released - African Americans die earlier and have many worse health situations than white counterparts, discrimination - Racial Discrimination can be a stress provider and lead to diseases - Economic Policy is Health Policy o Improve it and we improve health - Wealth equals Health October 21 st Class Notes: Durkheim on Suicide - Recognizes that determining the cause of phenomena is usually a difficult thing - CF-Schofield and Causal vs. Contributory vs. Associational (Vs. Correlational) - Complex social processes o In the case of suicide, what’s the conventional way of accounting for it? - It’s a social problem, not psychological - Observes that even when suicide rates increase within or across nation states, the presumed psychological causes remain in the same proportion - Compares suicide rates of Protestants + Catholics within a specific geographic region o This eliminates contamination of data o Observes that both faiths equally proscribe suicide - Comprised of a variety of denominations - Doubt and uncertainty are then a feature of the community of followers less opposed to the certainty of Catholicism Different Types of Suicide: - Egoistic Suicide – Individualism (Absence or low levels of social integration) - Altruistic Suicide – Over-identification with the group - Anomic Suicide – Absence of regulation - Fatalistic Suicide – Over-regulation (Ex. Forced Marriage) - Needs and Priorities in Women's Health Training: Perspectives from an Internal Medicine Residency Program Background: Few studies have examined residents' perspectives on the adequacy of women's health (WH) training in internal medicine (IM). This study sought residents' opinions regarding comfort level managing 13 core WH topics, their perceived adequacy of training in these areas, and the frequency with which they managed each topic. The association between reported comfort level and perceived adequacy of training and management frequency was also assessed. Methods: A 67-item questionnaire was administered from April to June 2009 to 100 (64%) of the 156 residents from the traditional, primary care, and IM-pediatrics residency programs at a single institution. Descriptive and correlation statistics were used to examine the relationships between self-reported comfort level, perceived adequacy of training opportunities, and frequency managing WH issues. Data was stratified by sex, IM program, and post-graduate year (PGY). Results: The majority of residents reported low comfort levels managing 7 of 13 topics. Over half of residents perceived limited training opportunities for 11 of 13 topics. With the exception of cardiovascular disease in women, greater than 75% of residents reported managing the 13 topics five or more times in the prior 6 months. Correlation analysis suggested a linear relationship between low comfort levels and limited training opportunities, and between low comfort levels and low frequency managing WH topics (r=0.97 and r=0.89, respectively). Stratified analyses by sex, IM program, and PGY showed no significant differences. Conclusions: Key gaps remain in WH training. Our results emphasize the importance of reinforcing WH training with hands-on management opportunities. Understanding institution- specific strengths and weaknesses may help guide the development of targeted initiatives. st Class Notes – October 21 - Feminist – Women who are about what is happening with women, have the same value as men do - Half of students are women, half of workforce - 53% of women for population, 1% of wealth - 20% less pay than men - Women in Canada and UK won right to vote in Canada 1918, US 1920 - Women took over jobs of men in war - Baby boom was second wave - Women spending more time on themselves didn’t have a happy life because they did not leave enough time for family, husband etc. - Early 90s, third wave - Amy Richards helped start the third wave - Women are still paid less than men - Goals of feminism in 60s and 70s was successfully integrating women into the world rather than at home - Men has not integrated at home in the same rate of women entering work force - 7/8 home caregivers are women - Most of unpaid work is done by women - 4.3h of unpaid work – women – 2.5h of unpaid work – men - 1929 – women legally recognized as persons in women - 50% less likely to consider running for office o Fear of raising money o Fear of exposing themselves and their families - Gender gap report - 1 wave – Women were excluded, not recognized as persons nd - 2 wave – Women had certain kind of rights, born out of women getting a taste of power and independence. - 3 wave – Attend to differences, attend to why women keep getting screwed over and some women benefit - Greater chance of getting killed by a terrorist than being married o Chances of happiness are destroyed by an affiliation with feminism - Why is there an image of women to be beautiful – Slender, skinny women - Current Canadian government seems to be focused by an objective of disempowering women, being driven by elimination of unpaid work Conce
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