Social Inequality And Its Effects On Health

Health is known to be an abstract idea which is problematic to define (Earle, et al., 2007) . Health is not an object with a clear identity (Warwick-Booth, et al., 2012). The meaning of health is constructed through language and interactions, therefore the way in which we chose to talk about and define health has huge consequences for the way it’s dealt with. This of course means that health is not stable or static but varies across time, location, age, educational trajectory and (sub)cultures (Warwick-Booth, et al., 2012). In this way, many different ideas about health co-exist and are of equal value. Perhaps the most widely accepted definition, particularly in areas using a western-style healthcare system, is that of the World Health Organization (WHO) (Warwick-Booth, et al., 2012). Here, health is defined as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity’ (David, 2019). The WHO definition has been praised for being a broader, all-encompassing interpretation that is more positive than the medical, narrow minded view, as it moves away from the negative idea that being healthy is simply ‘not being ill’ (Warwick-Booth, et al., 2012). However, it can be critiqued for several reasons (Ibid) which further demonstrates the difficulty in defining health in a ‘perfect way’. For example, some say it is unattainable and idealistic (Ibid). According to Blaxter, it is simultaneously ‘possible to have bad health in one way and good health in another’ (Blaxter, 1990) with some experiencing bad health despite the absence of disease. WHO also fails to consider other aspects of health such as sexual, emotional and spiritual health (Ewles & Simnett, 2003), which are equally important to many and, in some cultures, have greater emphasis than the biomedical and physiological ideas of disease and health.

Others would define health in a more functional way with emphasis placed upon the ability to cope and adapt (Warwick-Booth, et al., 2012). This is a more humanist view suggesting that health is at the foundation for achievement and is the key to unlocking your full potential (Seedhouse, 2001). This view on health implies the importance of resilience but it is entirely contextual with different communities having different ideas about what functionality even means. As explained above, it is almost impossible to find a definition that suits everyone.

Social inequality is more widely understood and much easier to define than health. Social inequality is ‘the existence of unequal opportunities and rewards for different social groups within a society’ (Moffit, 2003-2019). It is the result of a hierarchical society based on factor such as race, gender or class, and is characterized by a pattern of uneven distribution of rights, resources, punishments, wealth and opportunities (Crossman, 2019) that negatively affects an already marginalised group within a society.

But how do social inequality and health interact? It is well known that those who live in poorer societies live shorter lives; in the same way that poverty and poor health go hand-in-hand, so too does social inequality (Inequality.org, n.d.). There is a huge amount of evidence to support the notion that the higher the level of social inequality within a community, the worse the health outcomes are, not only for a marginalised group but also for the rich (Ibid). Researchers argue that inequality reduces social unity which in turn increases fear and stress, two major elements that contribute to poor health outcomes (Ibid). The Gini coefficient is a measure of inequality and when plotted against life expectancy we can see that people live longer in more equitable countries (Ibid) (Figure 1). Social inequalities, mean marginalised groups are more vulnerable to disease and have reduced health outcomes in general. It could therefore be said that social inequality is as major a cause of poor health as biomedical aspects of life, highlighted by Farmer saying ‘social forces and processes come to be embodied as biological events’ (1999, p. 14).

Social inequalities can be distributed along racial lines in such a way that the health outcomes of the marginalised are affected. A society that has a hierarchy based upon race means that subconsciously there will be a bias. Khiara Bridges’ book details how a physician’s own personal beliefs may contribute to health disparities between racial groups (Bridges, 2011). The author’s main argument is of ‘physician racism’ (Ibid. p.110) and how the same level of care is not given to black and white patients, either subconsciously or consciously. In 2011, the infant mortality rate for black babies was ‘2.5 times higher than for white babies’ and the rate of black women dying from pregnancy related issues was ‘more than 3 times higher than for white women’ (Ibid, p.107). This clearly indicates that worldwide, the treatment and care of white women and babies pre- and post-pregnancy is far better than for black women and infants. The medical explanations for maternal mortality are often pregnancy issues that stem from obesity, high blood pressure and diabetes, which themselves are not inherently racially influenced diagnosis; but these conditions affect black women at disproportionally higher rates and are racially distributed suggesting that they are the result of other socio-economic racial disadvantaging factors such as poverty, race-related stress, access to health care and the treatment they receive (Ibid). Black women have historically been perceived as being unaffected by labor due to their pelvic strength and obstetric hardiness (Ibid, p.117) therefore physicians believed it was easier for them to give birth hence the higher rates of labor related problems. Clearly the poor treatment and care black women receive by doctors is based upon disadvantaging stereotypes. In Khiara Bridges’ book she cites Hoberman (Ibid, p.129) who notes ‘socially conditioned to regard all women as promiscuous, ‘gyneacologists would almost automatically diagnose a black woman with symptoms of endometritis as having pelvic inflammatory disease’ as a consequence of her sexual behaviour’ (Hoberman, 2005). Bridges’ makes it clear that the treatment of patients in this situation is entirely a race issue, not one of class, as poorer white women are treated better than rich black women (Bridges, 2011). Access to health care is one of the leading factors that lead to poor health outcomes. In many instances, this is not an issue of class or poverty but of racism causing unequal opportunities. The Institute of Medicine (NGO) cited in Bridges’ book (2011, p.109/110) found that ‘racial and ethnic minorities receive lower-quality health care than white people, even when insurance status, income, age and severity of conditions are comparable’ (Institute of Medicine, 2005).

The 2014 Ebola crisis in West Africa resulted in an estimated 28,637 cases with at least 11,315 people having died by the time the WHO declared the outbreak over in 2016 (BBC News, 2016). There were racial dimensions to who was saved, evacuated and given aid, with white westerners being prioritised over black Africans (Benton, 2014). The USA pledged $22 million for beds in a hospital, however, these were only to be used by foreign health workers; which was understood to mean white foreigners, not black health workers (ibid). Clearly the infecting and subsequent deaths of white foreigners was seen as the major tragedy here and not the thousands of deaths of West Africans. Therefore, the way in which aid and healthcare is distributed and the severity of an issue can be dependent on race.

Social inequalities can also be based on gender. Both men and women have stereotypes about their roles in life, their health and the way in which they should be treated. Men have historically been seen as tougher, less emotional than women, therefore getting them to engage in their own health is much more a problem than for women. Men also have a much higher rate of suicide because it is socially unacceptable for them to talk about their emotions (Oliffe, 2010 ).

Gender can also influence the likelihood of diagnosis and the access to support received as a result. Autism is believed to be more prevalent in boys, with current statistics indicating a ratio of 4:1 (Fombonne, 2009). As a result, everything we know about autism comes from studying boys, so the symptoms included in diagnostic tools are male-dominated (Geelhand, et al., 2019). This understanding has huge implications for autistic girls. Female autism is not only misunderstood, but research has shown that early identification is essential for optimizing an individual’s outcome (Geelhand, et al., 2019) and girls tend to be diagnosed less frequently and later in life (Begeer, et al., 2013) which makes it harder for them to access support and ultimately affects their social relationships, day-to-day experiences and mental health. Gender-related expectations could be influencing the symptom severity and likelihood of early diagnosis. Research suggests that shyness is more tolerated (and even expected) in girls; so passivity, compliance and withdrawal may be of greater concern for boys than for girls (ibid). This demonstrates the possibility that a caregiver and physician’s perception of behaviour is influenced by a childs gender (ibid) and so the support they receive differs as a result of stereotypes. Girls are also stereotyped to be more capable of coping with complex emotions, especially for verbally intelligent girls, and are naturally more sociable. Therefore girls that may have ASD-like symptoms in one way, might not be struggling socially in the same way an autistic boy might be and could even have learnt to behave like and mimic their peers in certain situations in order to ‘fit in’ which ultimately masks their ASD (Autism Awareness Australia, n.d.). Girls struggling with undiagnosed autism develop depression, anxiety and self-esteem issues at higher rates than boys in their teenage years (34% for depression and 36% for anxiety) (Mandavilli, 2015) and a small study found that 23% of women hospitalized for anorexia, also met the criteria for autism (Anon., 2017). Some were even being misdiagnosed with ADHD and receiving entirely the wrong support (Arky, n.d.). Being diagnosed late not only leads to mental health issues but girls often miss out on the early support needed for skill building, both socially and academically (ibid).

Social inequalities also include the socio-economic status of individuals. Those of a lower economic status may not be able to afford healthcare insurance in places and so their health problems go untreated. They may also not be able to afford vital prescription medications or at home first aid kits to treat minor injuries that could worsen if left alone. There has been research that indicates a correlation between the quality of housing and hygiene, and health outcomes, with those living in poverty being more susceptible to health problems (Farmer, 1999). Framer argues that there are inequalities in the distribution and outcomes of infectious diseases with research showing that in 1995, most deaths happened in the developing world, but infectious disease was still a major killer in the US poor (ibid). Education is also a major factor that influences socio-economic status. Those that have not benefited from a good education or come from a family where education isn’t valued, are less likely to earn well and therefore live in prosperous areas. They therefore not only live in worse-off areas, but they also may not have received adequate education about nutrition, smoking, drugs and hygiene (ibid). Farmer notes that ‘simply being on welfare and having a history of drug or alcohol abuse were strongly associated with death (ibid, p.4). A lower socio-economic status also goes together with mental health problems and the services that you have access to is entirely a postcode lottery. There are wide disparities in the spending per child in different part of the UK on mental health services (Wilkinson, 2019).

In conclusion, health and an individual’s health outcomes are massively influenced by social inequalities such as gender, race, and socio-economic status. Each of these have impacts on the way in which communities are viewed within a society, the quality of and access to support as well as influencing the biomedical aspects of health.