Inequality and Health: Implications for Social Work.

Inequality and Health: Implications for Social Work. By the time this article appears, we will have elected a newpresident and a congress. They will have to deal with one of the mostimportant problems facing the nation, namely, the rapid growth inrelative poverty, or inequality. The figures on inequality arestaggering. During the past 20 years, the income received by the top 5percent of families increased by 64 percent, while that received by thebottom fifth fell by 5 percent (Collins, Hartman, & Sklar, 1999). In1998 the top 1 percent of the population had a greater net worth thanthe bottom 90 percent (Wolff, 2000). These trends have profound implications. In recent yearsresearchers from around the world have focused on the socialdeterminants of health Social determinants of health are the economic and social conditions under which people live which determine their health. Virtually all major diseases are primarily determined by specific exposures to these conditions. (Wilkinson & Marmot marmot,ground-living rodent of the genus Marmota, of the squirrel family, closely related to the ground squirrel, prairie dog, and chipmunk. Marmots are found in Eurasia and North America; the best-known North American marmot is the woodchuck, M. , 2000). It seemsincreasingly clear that the health of populations is influencedprimarily by social factors (Tarlov, 1996). Perhaps the most importantof these factors is the distribution of income (Tarlov, 1999). The issueis not poverty, in the sense of material deprivation, but inequality. AsWilkinson and Marmot (2000) note: People further down the social ladder usually run at least twicethe risk of serious illness and premature death Premature Death occurs when a living thing dies of a cause other than old age. A premature death can be the result of injury, illness, violence, suicide, poor nutrition (often stemming from low income), starvation, dehydration, or other factors. of those near the top.Between the top and bottom, health standards show a continuous socialgradient, so even junior office staff tend to suffer much more diseaseand earlier death than more senior staff [italics added] The social gradient exacts "a heavy social cost in terms ofdiminished labor productivity, social exclusion social exclusionNounSociol the failure of society to provide certain people with those rights normally available to its members, such as employment, health care, education, etc. , rising incidence ofcrime, and the erosion of civil society" (Kawachi, Kennedy, &Wilkinson, 1999a, p. xi). This suggests that the United States United States,officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. will facea wide range of physical and behavioral health Behavioral health was first used in the 1980's to name the combination of the fields mental health and substance abuse. As an example, an organization serving both mental health and substance abuse clients might refer to its practice as behavioral health or problems. This columnsummarizes the literature on inequality and health and considers itsimplications for social work. THE DECLINE OF INFECTIOUS DISEASE Infectious diseaseA pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. For much of human history, infectious diseases, such as smallpox,influenza, and tuberculosis, were the major cause of mortality andmorbidity (Tarlov, 1996). Around 1800 death rates from infectiousdisease began to fall and life expectancy Life Expectancy1. The age until which a person is expected to live.2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables. increased. In the UnitedStates between 1900 and 1973, the overall rate of mortality fell bynearly 70 percent, largely because of the decline in infectious diseases(McKinlay & McKinlay, 1977). During the same period, life expectancyincreased from 49 years to 71 years (Sagan, 1987). What explains this change? Historically, infectious diseases wererooted in material deprivation, and their decline was closely linkedwith economic growth and "higher standards of living" (Tarlov,1996, p. 79; Wilkinson, 1994). Yet, something else also may have been atwork. The decline in infectious disease was not the result of decliningrates of infection but to increasing rates of survival among infectedindividuals (Sagan, 1987). The increase in survival rates, in turn, mayhave been linked with the transition from premodern pre��mod��ern?adj.Existing or coming before a modern period or time: the feudal system of premodern Japan.to modern societies. People in premodern societies faced unrelenting poverty and livedin "continual dread of catastrophe" (Sagan, 1987, pp. 23-24).Stress of this kind can have a wide range of negative effects on thebody, particularly the immune system immune systemCells, cell products, organs, and structures of the body involved in the detection and destruction of foreign invaders, such as bacteria, viruses, and cancer cells. Immunity is based on the system's ability to launch a defense against such invaders. . The constant stress of premoderntimes may have been "an unrecognized factor in explaining thedecreased resistance of premodern populations to infection anddeath" (Sagan, p. 40). Conversely, economic growth, by alleviatingmaterial deprivation, may have stimulated an "increased sense ofpsychological well-being psychological well-beingResearch A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions ," increasing resistance to infection andreducing rates of mortality (Sagan, p. 126). INEQUALITY AND HEALTH As infectious diseases waned, chronic diseases, such as heartdisease, cancer, and diabetes, increased; these diseases currently"account for 75 per cent of the deaths in the United States"(Tarlov, 1996, p. 79). Although economic growth played a central role inreducing infectious disease, it has had a more limited effect on chronicdisease. Wilkinson (1996) estimated that the effects of economic growthbegin to diminish as per capita income Noun 1. per capita income - the total national income divided by the number of people in the nationincome - the financial gain (earned or unearned) accruing over a given period of time approaches $5,000. At this point,"relative" poverty, or inequality, replaces materialdeprivation as a central determinant of population health. What is relative poverty? Why is it so important? Relative povertyrefers to inequality, or poverty in relation to the "mainstreamcommunity" (Barker, 1999, p. 407). Several studies have found arelationship between relative poverty and health in the United Statesand elsewhere (Kawachi et al., 1999a; Kennedy, Kawachi &Prothrow-Stith, 1996). For example, in a study of "inequality inincome and mortality in the United States," Kaplan et al. (1996)found "a significant correlation...between the percentage of totalhousehold income received by the less well off 50% in each state"and mortality, violent crime, and disability (p. 999). Lynch et al.(1998), in a study of metropolitan areas, also found a correlationbetween income inequality and mortality. Perhaps the most detailed information on inequality and health, orthe social gradient, comes from the Whitehall studies of British civilservants (Marmot, 1994). The first Whitehall study, which included onlymen, found that rates of mortality and morbidity were distributed bysocial rank. The death rate for individuals in the lowest occupationalgrades (clerical and manual workers) was more than three times that ofindividuals in the highest grades (senior administrators). Traditionalrisk factors, such as blood pressure, smoking, and cholesterol,explained less than half this difference. Absolute poverty seemed to have little to do with thesedifferences. The participants in this study all belonged to the middleor upper class, worked in white-collar settings, and enjoyed jobsecurity (Marmot, 1994). Relative poverty, however, was a factor. Atevery level, individuals in higher job grades had lower rates ofmortality and morbidity than individuals below them (Marmot). Thisrelationship even held among smokers. After controlling for"pack-years... tar content," and other factors, administratorswho smoked 20 cigarettes a day were less likely to die from lung cancer lung cancer,cancer that originates in the tissues of the lungs. Lung cancer is the leading cause of cancer death in the United States in both men and women. Like other cancers, lung cancer occurs after repeated insults to the genetic material of the cell. than clerical and manual workers who smoked 20 a day (Marmot, p. 206)."Thus, people who own houses and have two cars are healthier thanthose who rent houses and have one car... and people in the highestincome group are healthier than those only slightly less well-off"(Wilkinson, 1994, p. 70). Some researchers have argued that the relationship betweeninequality and health is more apparent than real (Gravelle, 1998;Fiscella & Franks, 1997). Perhaps the strongest argument against"the relative income hypothesis" is that the"association" between inequality and health is really areflection of "the relationship" between "individualincome" and health (Kawachi et al., 1999b, p. 85). Kawachi et al.(1999b) and others have vigorously responded to this challenge, andrecent scholarship tends to support their assertion that the relationbetween inequality and health is real (Wolfson, Kaplan, Lynch, Ross,& Backlund, 1999). Although the relation between inequality and health seems wellestablished, one recent study does raise questions about the precisenature of this relationship. In an examination of Canada and the UnitedStates The United States and Canada share a unique legal relationship. U.S. law looks northward with a mixture of optimism and cooperation, viewing Canada as an integral part of U.S. economic and environmental policy. , Ross et al. (2000) found a strong association between incomeinequality and mortality in the United States (and North America North America,third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. "as a whole"), but not in Canada, at either the provincial"or metropolitan area level" (p. 902). Although the reason forthis is unclear, one factor may be that, in Canada, health care andother resources are "publicly funded and universallyavailable," whereas in the United States, they are distributedthrough the market (Ross et al., 2000, p. 902). Consequently, in Canada,"income, in both a relative and absolute sense' has lesseffect on an individual's "life chances and, in turn,'health chances"' than it does in the United States (Rosset al., 2000, p. 902). EXPLAINING THE SOCIAL GRADIENT Until recently, researchers and policymakers had assumed thatsocioeconomic factors primarily affected the health of people in poverty(Fuchs, 1993). The discovery of a social gradient of health shatteredthis belief. Although most studies have confirmed the existence of thisrelationship, its causes remain unclear ((Lynch et al., 2000). Psychosocial Factors Wilkinson (1997) and others have argued that the relationshipbetween inequality and health is rooted largely in psychosocial factors,including financial strain, job insecurity, low control and monotony atwork, stressful life events and poor social networks, low self-esteem,and fatalism fa��tal��ism?n.1. The doctrine that all events are predetermined by fate and are therefore unalterable.2. Acceptance of the belief that all events are predetermined and inevitable. " (Brunner, 1997, P. 1473). Stress has both direct andindirect effects on health (Wilkinson, 1997). The direct effects are the"physiological" consequences "of chronic mental andemotional stress" (Wilkinson, 1997, p. 592). Stress can disrupt"breathing, blood flow" and immunity and "upset thenormal healing response" (Pert, 1999, pp. 242-243). The indirect,or mediated, effects are behavioral risks, such as smoking, overeating,and alcohol and drug abuse, which individuals often engage in to manageor deaden stress (Wilkinson, 1996). The importance of psychosocial factors is not surprising.Inequality is an "inherently social concept," reflecting"the relationship of an individual to a social group"(Wilkinson, 1996, p. 175). We do not feel poor, or deprived, in theabstract, but in comparison, with others. These evaluations shape ourmoods and feelings about ourselves (Gilbert, 2000). Individuals whobelieve they cannot live up to society's standards often develop asense of shame Noun 1. sense of shame - a motivating awareness of ethical responsibilitysense of dutyconscience, moral sense, scruples, sense of right and wrong - motivation deriving logically from ethical or moral principles that govern a person's thoughts and actions , or self-hatred (Gilligan, 1996). Shame is linked with power and control. To shame someone is toexpose them, to reveal their inner secrets and, in a sense, render thempowerless. Powerlessness, in turn, has well-documented effects on health(Brunner, 1997; Wilkinson, 1996). Researchers have"repeatedly" found that "health and well-being"depend on an individual's ability to influence the"forces" affecting his or her "life" (Syme, 1994, p.85). The importance of psychosocial factors was demonstrated inWhitehall II, a follow-up study of English civil servants (Bosma et al.,1997). Whitehall II included women and examined the effect on health ofpsychosocial factors. Again, workers in lower occupational categorieswere in poorer health than workers in higher categories. Lower-levelworkers also had less control over their jobs and fewer sources ofsocial support (Bosma et al., 1997). This again suggests that lack ofcontrol, or powerlessness, helps explain the relationship betweeninequality and health (Syme, 1994). A recent study by Ross et al. (2000) may provide additionalevidence of the importance of psychosocial factors. As noted earlier, inthe United States, access to health care is based on ability to pay.Although some people with low incomes have access to health care, theydo so only through public assistance or charity, in short, throughprograms that differentiate them from the rest of the population. Thestigma attached to these programs is undoubtedly a source of stress, andpossibly poor health, for the individuals relying on them. On the otherhand, Canada's policy of distributing vital resources on auniversal basis may help explain the lack of relationship betweeninequality and health in Canada. Social Cohesion Social cohesion also seems to affect the health of populations.Social cohesion refers to the degree and level of interaction andcooperation between and among members of a society (Putnam, 2000).Numerous studies have confirmed the importance of social relationships(Kawachi et al., 1999a). The "positive" impact of socialrelationships may "rival in strength the detrimental" effectsof "cigarette smoking, obesity, elevated blood pressure, andphysical inactivity physical inactivityA sedentary state. Cf Physical activity. " (Putnam, 2000, p. 327). Researchers also have explored the links between social capital andhealth (Wilkinson, 1997). Social capital refers to a broad range ofsocial networks, organizations, and supports, including politicalparties, Rotary clubs, soccer leagues, charitable organizations, andcommunity theater groups (Putnam, 2000). Social capital also includespeople's feelings and attitudes about the nature and character oftheir fellow citizens and society. Individuals who are connected tosocial networks and activities are likely to have positive feelingsabout their fellow citizens and society. Social capital seems particularly important in terms of"health and well-being" (Putnam, 2000). Kawachi et al. (1997)examined the relationship among "Social Capital, Income Inequality,and Mortality" in 39 states in the United States. To measure ofsocial capital, they used data on "per capita [Latin, By the heads or polls.] A term used in the Descent and Distribution of the estate of one who dies without a will. It means to share and share alike according to the number of individuals. density of membershipin voluntary groups...and level of social trust" from the GeneralSocial Survey of the National Opinion Research Center (Kawachi et al.,1997, p. 1491). The study found an inverse relationship A inverse or negative relationship is a mathematical relationship in which one variable decreases as another increases. For example, there is an inverse relationship between education and unemployment — that is, as education increases, the rate of unemployment betweeninequality and level of social trust and citizen involvement inorganized activity. Low levels of trust and involvement were linked withhigh rates of mortality. The authors concluded that lack of socialcapital could be one way that income inequality influences asociety's rate of mortality (Kawachi et al., 1997). Early Childhood Development Experiences in early childhood also contribute to the socialgradient (Bartley, Power, Blane, Smith, & Shipley, 1994). Frominfancy, environmental, and particularly socioeconomic, factors have aprofound effect on the brain's growth and development (Hertzman,1994). The brain, in turn, "influences" the development of"cardiovascular ... immune," and other systems, as well as the"sensory, cognitive, and social skills necessary to guide theorganism through life" (Cynader, 1994, pp. 155, 163). Thus, the"quality" of early experiences can have a lasting effect on"the individual's social responsivity throughout life"(Cynader, p. 162). The effect of socioeconomic factors is not limited to the brain,however. Hertzman (1994) noted that the stresses associated with birthitself pose a greater threat to "lower-class children" than to"upper-class children" (p. 169). Social rank even protects, or"buffers," upper-class children from the effects of"exposure to lead in the environment" (Hertzman, 1994, p.170). In recent years scholars have developed two different theories ofhow early childhood experience affects later life (Hertzman, 1994). Oneapproach assumes that individuals go through critical biological andsocial periods (Hertzman). Some researchers believe that "thebaby's brain is open to experience of a particular kind only duringnarrow periods of opportunity" (Gopnik, Meltzoff, & Kuhl, 1999,p. 189). Distinct events, particularly in the early stages of life,"will have a strong independent effect in later life"(Hertzman, 1994, p. 173). An alternative approach is the "pathways model," whichstresses the "cumulative effects of life events and the ongoingimportance of the conditions of life" (Hertzman, 1994, p. 174).This approach is based on the finding that health status is affected byan accumulation of events throughout the life span. Although this modeldoes not deny the importance of early experiences, it recognizes that"if appropriate stimulation is missed at a specific time in earlychildhood, the function can be developed through other forms ofstimulation later in life" (Hertzman, p. 177). In either case, inequality plays a crucial role. For example,education during the first 20 years of life may protect against dementiain later life (Hertzman, 1994). Illiterate individuals may be at greaterrisk of dementia and mental decline in later life than individuals witha primary education; individuals with primary education are at greaterrisk than individuals with secondary education. In terms of the pathwaysmodel, "the crucial socioeconomic predictors of longevity" arefactors such as "wealth, family assets, lifetime earnings, andoccupational careers" (Smith, 1996, p. 988). Smith linked therelationship between inequality and health with neglect of, andunderinvestment in, education, health care, and other human resources The fancy word for "people." The human resources department within an organization, years ago known as the "personnel department," manages the administrative aspects of the employees. . IMPLICATIONS FOR SOCIAL WORK The article began by noting the growth of inequality in the UnitedStates. In light of the relationship between inequality and health, wemay predict that the United States will face a wide range of physicaland behavioral problems in the years ahead. Social workers can play aunique role in addressing this issue. The inequality and health literature reveals that health isessentially a biopsychosocial phenomenon, and social work researcherscan add to this literature. In addition, as the largest group of mentalhealth providers, social workers can provide insight into the role ofpsychosocial factors in the relationship between inequality and health.Finally, social justice and advocacy have long been central to socialwork's mission, and in a sense, we are obligated to become involvedin efforts to reverse the trend toward growing inequality. ABOUT THE AUTHOR Stephen H. Gorin, PhD, is professor, Plymouth State College,Plymouth, NH 03624, and executive director, NASW NASW National Association of Science WritersNASW National Association of Social Workers (Washington, DC)NASW National Association of Social WorkersNASW National Association for Social Work (UK)New Hampshire New Hampshire,one of the New England states of the NE United States. 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