William C Cockerham. Handbook of Social Problems: A Comparative International Perspective. Editor: George Ritzer. Sage Publication. 2004.
At this time in history it is a well-established fact that many health problems have social origins and connections. We know that diseases are not always exclusively biological; rather, their onset and course are often instigated and abetted by living conditions and behavior. Health becomes a social problem when the social aspects of people’s lives cause them to become sick or undermine their capacity for longevity. The key variable in this situation is social class, since people in the upper social strata generally maintain good health until quite late in life. It therefore becomes most important to understand what social factors cause health to deteriorate earlier among those at the bottom of society (Robert and House 2000; Wermuth 2003).
Whereas health itself is a social problem because it is spread unevenly throughout society, the provision of health care can be a similar problem when costs and lack of availability act as barriers to medical treatment. This situation is reviewed for the United States, as it is the only major country without some form of national health insurance providing universal health care coverage to its population. However, the focus of the chapter is on the unequal social distribution of health in societies generally, since this condition precedes problems in obtaining health care and promotes the differential need for such care. Consequently, it is the primary purpose of this chapter to review current research findings in a global context and identify the major social causes of health and illness.
Health: Agency versus Structure
Health behavior, like other forms of social behavior, is affected by the dialectical relationship between agency and structure. Agency is the ability of actors to choose their behavior, while structure refers to regularities in social interaction (e.g., institutions, roles), systematic social relationships (e.g., status, class), and access to resources that constrain or empower choices. The interplay of agency and structure are particularly obvious with respect to health lifestyles. Health lifestyles are collective patterns of health-related behavior based on choices from options that are available to people according to their life chances (Cockerham 2000a). Life chances are a form of structure in that they are, as Max Weber (1978; Dahrendorf 1979) suggests, the structural probabilities people have in life to obtain satisfaction for their needs, wants, and desires, and are largely determined by their socioeconomic situation. The behaviors that are generated from health lifestyle choices are typically shaped by the person’s life chances and can have either positive or negative consequences for his or her health.
This is not to say that people often deliberately choose behavior that harms their health, but some people do engage in risk behavior that opens the door to that possibility. Negative health lifestyles like smoking, taking drugs, heavy alcohol use, eating high-fat and unbalanced diets, regularly subjecting oneself to highly stressful situations, not getting enough relaxation and rest, not using automobile seat belts, and so on promote health problems through illness or injury. The research literature is clear that these activities can be harmful. Yet people do these things because of addiction, ignorance, thoughtlessness, or denial. When it comes to health lifestyle choices, either positive or negative, people at the top of society typically make the healthiest choices and have the resources to support their decision. Those at the bottom have greater socioeconomic constraints on their choices and may even find there is little choice available. Poor health lifestyles and their adverse outcomes accompany negative social conditions. We see this situation, for example, in the case of smoking and AIDS.
It is common knowledge that smoking tobacco is bad for your health. There is strong evidence linking smoking to the risk of heart disease, atherosclerosis, stroke, lung and other cancers, emphysema and other respiratory diseases, liver disease, and other health problems, thereby making it the lifestyle practice with the largest number of negative consequences for health (Jarvis and Wardle 1999; Rogers and PowellGriner 1991; Ross and Wu 1995). In the United States, smoking causes a man to lose more than 13 years of life on average and a woman 14.5 years (Centers for Disease Control 2002). Some 440,000 people die each year from smoking-related causes.
Although the proportion of smokers in Western countries has substantially decreased as awareness of the effects of smoking on the body became generally known, some people nevertheless choose to smoke—with the decision to smoke or not smoke an exercise of agency. That is, the decision to smoke is a choice. But is that choice independent of structure? The answer is that it is not. Structure intervenes in this decision as distinct differences persist between specific population groups, suggesting that decisions about smoking are not entirely an individual matter. Social structural factors like gender, race, and social class influence these outcomes. For example, men are more likely than women to smoke, but among smokers they are also more likely to quit. As for nonsmokers, white men are more likely to be in this category than black men, black women slightly more likely than white women, the well-educated more likely than the less-educated, and persons in the upper social strata more likely than those in the lower strata (Cockerham 2004). In Great Britain, Andrew Adonis and Stephen Pollard (1997) find that smoking is largely a habit of the poor, as nearly three times as many people in unskilled occupations smoke as do those with professional jobs. A similar situation exists in the United States, where adults with less than a high school education were nearly three times as likely to smoke as those with a bachelor’s or higher degree (Center for Health Statistics 2002).
So there is a social pattern to smoking, which indicates that smoking is not a random, individual decision completely independent of structural influences. As Martin Jarvis and Jane Wardle (1999) observe, smoking, along with drinking and drug use, are individual risk behaviors that involve an element of personal choice. However, smoking and other risk behaviors have not been viewed in a broad social context as much as they have been characterized as situations of individual responsibility. The reasoning goes that if people wish to avoid the negative effects of smoking on their health, they should not smoke; if they choose to smoke, what happens to them physiologically is no one else’s fault but their own. This victim-blaming approach, state Jarvis and Wardle (1999:241), is not helpful, as it fails to account for the underlying reasons why disadvantaged people are drawn to poor health habits like smoking and the nature of the social conditions that reinforce this behavior.
The social factors identified by Jarvis and Wardle (1999) that induce people to smoke are adverse socioeconomic conditions, deprivation, and stressful circumstances. “This illustrates what might be proposed as a general law of Western society,” conclude Jarvis and Wardle, “namely, that any marker of disadvantage that can be envisaged, whether personal, material or cultural, is likely to have an independent association with cigarette smoking” (p. 242). Growing up in a household where one or both parents smoke, having a smoking partner, and socializing with smokers regularly are other reasons that invoke smoking in a social context. These situations are also more likely toward the bottom of the social scale. Of course, some affluent people likewise smoke and the reasons for doing so may be different than those listed above—although stress is a likely culprit for everybody. Smoking among the affluent does not change the fact that this behavior is unusual at the higher levels of society and that the smoking habit is concentrated among lower strata groups, especially the lower class.
Another health problem that would seem to be largely a matter of agency or choice is HIV/AIDS. AIDS destroys a person’s immune system against infection, causing that individual to become sick and often die from a variety of cancers and viruses, or pneumonia. AIDS is a virus itself—the human immunodeficiency virus (HIV)—that is primarily transmitted through sexual intercourse or intravenous drug use (by sharing contaminated needles). Blood transfusions or infection of prenatal infants by their infected mothers are other methods of transmission. With the exception of infants and unsuspecting blood transfusion recipients, choice with regard to sexual risks and IV drug use that would allow a virus into the blood stream is a factor in the transmission of AIDS. After all, why would someone choose to risk exposure to AIDS if they could avoid it by taking precautions (using condoms) or staying away from the social networks and sex partners where AIDS is prevalent? Except for people in a position of powerlessness in a sexual or IV drug-using relationship, it would seem that some choice is involved. But, as I discuss, structural conditions operate as well.
In the beginning of the AIDS epidemic, in the mid-1980s, infected persons were principally homosexual white males in the West and heterosexual couples in Africa, where the illness originated and is believed to have passed to humans through the blood of infected chimpanzees killed for food. However, in the United States, where AIDS mortality is now declining, the magnitude of the epidemic shifted to African Americans and Hispanics. In 1985, there were more than twice as many AIDS cases reported among non-Hispanic white men as among non-Hispanic black men; by 1997, blacks surpassed whites in the total number of new cases annually and had the highest overall rates per capita of any racial group. The most recent figures for mid-2000 for males show non-Hispanic blacks maintaining the highest rate of 117 cases per 100,000 resident population, followed by Hispanics at 48.8, American Indians/Native Alaskans at 16.7, non-Hispanic whites at 15.1, and Asians/Pacific Islanders at 8.2. The rates for females are 48.0 cases per 100,000 for non-Hispanic blacks, 13.4 for Hispanics, 7.6 for American Indians/Native Alaskans, 2.2 for non-Hispanic whites, and 1.9 for Asians/Pacific Islanders. AIDS now stalks the African American community as it does no other, with the somewhat distant exception of Hispanics.
The shift in AIDS cases and mortality from non-Hispanic whites to African Americans and also to Hispanic males points to a pattern that is associated more with socioeconomic than biological factors, as each of these two racial minority groups contains a large proportion of the poor in American society. Some 46.4 percent of all blacks and 51.3 percent of all Hispanics in the United States are poor or near poor, compared with 22.2 percent of the non-Hispanic white population (National Center for Health Statistics 2002). A major reason blacks have the highest rates of AIDS and other sexually transmitted diseases is the “intraracial network effect” (Laumann and Youm 2001). Blacks are highly segregated from the other racial/ethnic groups in American society, and the high number of sexual contacts between an infected black core and its periphery of yet uninfected black sexual partners tends to contain the infections within the black population. Entrenched poverty, joblessness, low incomes, minimal access to health care, and a reluctance to seek treatment for sexually transmitted diseases because of the social stigma attached to them are other major factors.
Even though life expectancy has improved for people in all social classes in the United States and most other countries during the twentieth century, the examples of smoking and AIDS illustrate the penalty for being socially and economically disadvantaged: higher morbidity and mortality in virtually every society. Mortality for the lower classes remains proportionately greater than that of higher social strata, and this gap refuses to disappear. While the last century witnessed a worldwide epidemiological transition from acute to chronic diseases as the major causes of mortality, there was not a corresponding social transition. Whereas communicable diseases killed off the poor in much greater numbers than the affluent in past historical periods, chronic diseases like heart disease and cancer now continue the same pattern. In fact, mortality from both acute and chronic diseases is now greater among the poor than the nonpoor—although members of all social classes eventually die from something. The affluent just stay healthier longer, and this fact demonstrates the strong relationship between social class position and health.
Social Class and Health
Regardless of the country a person lives in, class position is a major determinant of health and life expectancy (Braveman and Tarimo 2002; Cockerham 2004; Lahelma 2000; Link and Phelan 2000; Mirowsky, Ross, and Reynolds 2000; Mulatu and Schooler 2002; Robert and House 2000). This finding holds true for all but a few diseases and throughout the life span, although differences narrow somewhat at the oldest ages (Beckett 2000; Robert and House 1994; Winkleby et al. 1992). Typically, class membership is determined by a person’s socioeconomic status as measured by his or her income, occupation, and education. Income, in relation to health, reflects differences in spending power, housing, diet, and access to medical care; occupation represents status, job responsibility, physical activity, and health risks associated with work; and education indicates a person’s skills for acquiring positive social, psychological, and economic resources (Winkelby et al. 1992).
Education is the strongest single socioeconomic predictor of a person’s level of health, although income and occupation are important. Well-educated people are usually the best informed about health matters and most cognizant of the need to live in a healthy manner and obtain professional health services when needed. The well-educated, in contrast to the less-educated, are more likely to have fulfilling, subjectively rewarding jobs, higher incomes, less economic hardship, and a stronger sense of control over their lives and their health (Ross and Wu 1995). They are also more likely to live a healthy lifestyle by exercising, abstaining from smoking, eating nutritious food, and consuming only moderate amounts of alcohol (Cockerham, Rütten, and Abel 1997). The relationship between education and health is strongest in adulthood, as the less-educated have increasingly more sickness and disability and die sooner than the well-educated (Arber 1993; House et al. 1994). While there may be some convergence between health and class in old age, surviving cohorts of lower-class elderly are significantly smaller than their middleand upper-class counterparts.
The relationship between class and health not only consists of the advantages of higher socioeconomic status in guiding health behavior and acquiring medical care, but also the disadvantages associated with the health effects of poverty, racism, chronic and acute stressors, lack of social support, unhealthy living conditions, rundown neighborhoods, poor sanitation, enhanced likelihood of exposure to environmental pollution, lessened access to health care, and greater prevalence of crime, violence, AIDS, heart disease, schizophrenia, and various other physical and mental illnesses. To be poor by definition is to have less of the good things—including health—produced by society.
Race and Gender
Race. The powerful role of class in shaping health is illustrated by the number of studies showing that class generally overrides race and gender in determining health status. This is seen in research in the United States showing that differences in health and life expectancy between races are largely explained by socioeconomic factors (Braithwaite and Taylor 1992; Krieger et al. 1993; Lillie-Blanton and LaVeist 1996; Robert and House 2000; Rogers et al. 1996; Schoenbaum and Waidmann 1997; Williams and Collins 1995). A major reason for this outcome, as noted, is that African Americans and Hispanics are generally overrepresented in the lower class and the lower class has the worst health regardless of race. This is especially true in studies of the health of African Americans, who have the worst overall health profile of any racial/ethnic group in the United States. Being poor means having significantly less opportunity to be healthy, but the biological aspects of race are not terribly important in this context unless social factors like prejudice and discrimination intervene to link race with poverty and lock individuals into the lower class.
This is not to claim that race is entirely meaningless when it comes to disease, as genetic research shows a few notable differences. For example, a gene variation usually absent in whites and Hispanics but found in African Americans increases the risk of developing a rare type of abnormal cardiac rhythm or heartbeat that can be fatal (Splawski et al. 2002). Sickle cell anemia is also more prevalent among people of African origin. Swedes, conversely, are prone to develop an iron metabolism disorder (hemochromatosis) that is absent or rare in Chinese and Indians. However, overall racial differences in health are largely displayed along class lines.
Gender. As for gender, class differences in health are markedly noticeable for men and at least moderately so for women (McDonough et al. 1999; Nettleton 1995; Robert and House 2000). Men generally experience health, illness, and mortality according to their class position (Marmot 1996; Marmot, Shipley, and Rose 1984). We know that socioeconomic disadvantages also harm women’s health, but the strength of the social class gradient in relation to that of men has not been as conclusive, although there is evidence it exists (McDonough, Walters, and Strohschein 2002). Most of the research on class and gender has focused on men rather than women, so less is known about the situation for women. However, Peggy McDonough et al. (1999) found in the United States that the link between social class and mortality is similar for both men and women, and research in North America and Western Europe shows the same pattern (Arber 1989; Pappas et al. 1993; Wilkinson 1996). In Britain, recent research, for example, shows significantly greater morbidity among both men and women who are the most socially disadvantaged (Cooper 2002).
Additionally, the health experiences of women differ from those of men in that women are usually sick more often but live longer—some five to seven years longer on average (Arber and Thomas 2001). Some researchers challenge this assessment and argue that the health of men and women is more similar than assumed, but varies at different ages and in relation to different afflictions (Walters, McDonough, and Strohschein 2002). Nevertheless, the conventional view still holds that women do indeed experience more ill health compared to men and the situation requires considerably more investigation if this conclusion is to be changed. Socioeconomic inequalities in women’s health are also more pronounced if they additionally have to cope with lower wages and less job opportunities than men, and being a single parent and sole provider for a household (Annandale 1998; Lahelma, Arber, et al. 2002; McDonough et al. 2002; Moss 2002; Nettleton 1995). Inequality in women’s health is even more pronounced in South Asian countries like Bangladesh and Nepal, where men live longer than women. The social devaluation of women, along with nutritional deprivation and lessened access to medical care, has helped curtail the natural longevity of women in these countries (Braveman and Tarimo 2002; Cockerham 2004).
As for health lifestyles, we know that women typically eat healthier diets and smoke and drink less alcohol than men, but exercise far less (Calnan 1987; Cockerham et al. 1997). Smoking and alcohol consumption are more important determinants of health for men than women, but body weight and physical inactivity are more important for women (Denton and Walters 1999). Social class, however, intervenes in this pattern as people in higher social strata, regardless of gender, participate more in leisure-time exercise, eat healthier foods, and smoke and drink less (Blaxter 1990; Reid 1998). While gender is an important lifestyle variable in that women generally seem to take better care of their health than men and live longer as well through a combination of social and biological factors, differences in health and longevity nonetheless exist between women of different social strata.
Class and Health in the United States
As elsewhere in the world, socioeconomic status is one of the strongest and most consistent predictors of health and longevity in the United States. Traditionally, the poor have had the worst health and shortest lives. For example, rates of coronary heart disease—the nation’s leading killer—have declined for all Americans, but the decrease has been greatest for the upper and middle classes (Cockerham 2004). Heart disease is now more concentrated among the poor because of greater obesity, smoking, and stress, along with less leisure-time exercise, poorer diets, and higher levels of blood pressure. Studies of exercise, for instance, show that men with the lowest level of education have the steepest decline in physical activity as adults (Grzywacz and Marks 2001). Other research shows greater stress, inadequate diets and housing, and more alcohol abuse and smoking among the poor in the United States (Link and Phelan 2000; Mirowsky et al. 2000; Ross and Wu 1995). Residents of disadvantaged neighborhoods characterized by danger, crime, incivility, and limitations on outdoor physical activity have also been found to have worse self-reported health and physical functioning and more chronic health problems than people living in more advantaged neighborhoods (Ross and Mirowsky 2001).
Fifty years ago, coronary heart disease was associated with an affluent way of life (i.e., rich diets, smoking, well-paid but stressful jobs). However, as the affluent began to practice healthier lifestyles and routinely seek preventive care in the form of medical checkups and drugs to reduce high blood pressure and harmful low-density lipoprotein cholesterol levels, heart disease was postponed until later in life or avoided altogether. Preventive health care has never been a trait of help-seeking among the lower classes, who typically wait to visit physicians until they feel bad, are less likely to have a regular physician, and are more likely to go to a hospital emergency room when sick (Cockerham 2004).
Historically, the lower class has not received the same quality of medical care available to the classes above it because they lacked the money or health insurance to pay for care in the American fee-forservice system. Disadvantaged patients relied on charity care or teaching hospitals. A considerable portion of the literature in medical sociology in the 1950s and 1960s documented the problems of the poor in obtaining quality medical care. The situation changed in the mid-1960s with the passage of two federally sponsored health insurance programs: Medicare to cover all persons over age 65 and Medicaid for people with low incomes. Medicaid is a welfare program in which the federal government shares the costs of health care services for the poor with the various states. The passage of Medicare and Medicaid legislation over the strong opposition of organized medicine marked a turning point in medical politics as the federal government emerged as a dominant factor in health care delivery.
Medicare and Medicaid not only established the precedent of the federal government’s involvement in health care administration, but the programs also provided needed insurance to cover services for the old and those living in poverty where these services were not covered before. Prior to this time, the upper class visited physicians for care more often than the other social classes, followed by the middle and working classes, with the lower class at the rear. The pattern changed temporarily in the late 1960s, with the upper class seeing doctors the least and the middle class seeing them the most. However, as the lower class began taking advantage of the new health insurance programs, they replaced the middle class as the strata seeing doctors the most. This is appropriate because they have the worst health problems overall, but indications are that they should visit doctors even more often because they still tend to delay in seeking care until their health conditions worsen (Cockerham 2004). Part of the delay stems from the lack of treatment facilities in poor neighborhoods (Robert and House 2000).
Although health care has become more accessible for the poor in the United States, equity has not been achieved. In a free market system lacking national health insurance covering the general population, those persons who are socially disadvantaged are also medically disadvantaged when it comes to obtaining quality care. The United States has a twotrack system of medical care consisting of a private and public track. The public track is a system of welfare medicine supported by public health insurance. The urban poor have traditionally been dependent on public hospitals and clinics, and this situation has not changed. Often these facilities are underfinanced, understaffed, and overcrowded with patients. Few such hospitals and clinics exist in inner-city areas or neighborhoods populated by the poor. The rural poor also have problems of access, as doctors and hospitals may not be available where they live.
The problems of access, high costs, and the availability of quality care are compounded by the large percentage of Americans without health insurance. In 2001, some 18.1 percent of the population between the ages of 18 and 64 years did not have health insurance coverage. This includes 40.1 percent of all Hispanics in this age group, followed by 22.8 percent of all non-Hispanic blacks and 13.5 percent of all non-Hispanic whites. Only about half (49.7%) of all Hispanics have private health insurance compared with 61.9 percent of blacks and 80 percent of whites. People without health insurance are typically the near-poor, whose annual family income is less than $25,000, which is often too much money to allow them to qualify for Medicaid, or, in the case of some Hispanics, they are illegal migrants. Nevertheless, they live in very disadvantaged circumstances and obtaining medical care is difficult. Health in the United States remains one of the nation’s most important social problems.
Class and Health in Great Britain
Class differences in mortality have been observed in Britain since the first Registrar-General’s Occupational Analysis of 1851 and have continued into the twenty-first century. A negative gradient in mortality by social class—the lower the class, the higher the mortality—has been evident from the beginning. This gradient has persisted even though life expectancy for all classes has continued to improve through the years. The social class-mortality gradient exists for infants, as well as children and adults. It reflects not only differences in mortality but in injury and morbidity as well (Reid 1998). Earlier in the twentieth century, heart disease was an exception to the general pattern in that the affluent were much more prone to heart disease and other circulatory disorders than manual workers. By 1971, as in the United States, the situation had reversed itself, with heart ailments far greater among those at the bottom of society (Coleman and Salt 1992). Consequently, the epidemiological transition in Britain from acute to chronic diseases as the major causes of mortality did not alleviate the health circumstances of the poor. Heart disease shifted more strongly into their ranks than ever before.
Why? Again the answer is differences in living conditions and class-based health lifestyles like alcohol use, smoking, diet, and exercise—especially leisure-time exercise unaccompanied by the stress and strain of manual labor and deadlines, quotas, demands, and schedules for physical outputs mandated by others. More judicious use of physician services, particularly preventive care by the affluent, were also important. Britain, however, is of special interest in studies of class and health because the country established equity in health care delivery. Since 1948, Britain has had a national health service providing the lower classes with medical care similar to that of people higher on the social scale. The British government employs the majority of physicians and other health workers and owns most of the nation’s health care facilities. Services are essentially free to those who use them, and the care provided is generally paid for out of government tax revenues.
A major assumption was that the provision of quality care to all classes would improve levels of health throughout society, as poverty would no longer be a barrier for someone requiring professional medical treatment. Health did improve for all social classes. However, in 1980, the British public was surprised by the government-sponsored Black Report, which disclosed that the lower class still had significantly worse health, disability, and life expectancy than the classes above them. Prior to this time, it had widely been thought that British society was becoming more egalitarian and longevity more equal among the different classes. But the Black Report showed this was clearly not the situation. The report blamed class differences in health on socioeconomic conditions, such as poor living quarters, overcrowding, work accidents, exposure to dampness and cold, and unhealthy lifestyle practices, such as smoking, drinking, and poor nutrition.
Current studies in Britain show that—despite the continued upward trend in life expectancy—the highest strata not only live longer than the lowest, but the gap is widening (Annandale 1998; Reid 1998; Shaw, Dorling, and Smith 1999). That is, the upper class has even greater longevity than it did in the recent past, despite improvement for all classes. A government report shows, for example, that differences in longevity for the two highest classes in relation to the two lowest increased from 3.7 years in 1977-81 to 4.7 years in 1987-91 for males and from 2.1 years to 3.4 years for females during the same period (Drever and Whitehead 1997). From the early to the mid-1980s, males in the two highest classes had gained an additional 1.0 year of life expectancy over men in the two lowest classes, while upper strata women had added an additional 1.3 years. And this had taken place in a country providing equitable health care to all.
Other research shows that the gap in levels of morbidity also widened between the employed and unemployed during the same period, with the unemployed showing increasingly greater amounts of sickness (Lahelma et al. 2000). In addition to a shorter life expectancy, the lower classes still have higher infant mortality, more chronic disability, more absence from work due to illness, and higher ratios of risk behavior like obesity, lack of exercise, and smoking.
Class and Health in Canada, Australia, and Western Europe
The link between class and health in Western society is a universal finding. Studies conducted in Canada, Australia, and Western Europe—all in countries with national health insurance coverage—confirm the pattern noted in Britain and the United States. Canadian studies show that lower socioeconomic groups have the worst health and shortest life spans (Frohlich and Mustard 1996; Humphries and Doorslaer 2000; McDonough et al. 2002), and Australian research shows the same pattern (Lupton 2000). The same situation exists in Western Europe generally (Kunst et al. 1998), including not only Britain (Adonis and Pollard 1998; Arber 1993; Arber and Thomas 2000; Borooah 1999; Chandola 2000; Marmot 1996; Reid 1998; Wilkinson 1996), as previously discussed, but also Britain and Finland (Lahelma et al. 2000; Lahelma, Arber, et al. 2002), France (Orfali 2000), France and Spain (Lostao et al. 2001), Spain (Regidor et al. 2002), Germany (Knesebeck and Siegrist 2000; Mielck et al. 2000), Italy (Piperno and DiOrio 1990), and even the highly egalitarian Nordic countries of Denmark, Norway, Sweden, and Finland (Hemström 1999, 2000; Lahelma 2000; Lahelma, Kivela, et al. 2002; Sundquist and Johansson 1997).
The Nordic countries represent a unique case because they are relatively similar in terms of history, culture, language, geographical location, economies, and social structure (Lahelma, Kivela, et al. 2002). They all have high standards of living and extensive state welfare systems providing universal benefits for health, education, and social security for young and old. Moreover, there is an emphasis on gender equality, full employment, and a relatively even distribution of income. Yet even in these countries, Lahelma, Kivela, and their colleagues (2002), along with other scholars (Hemström 1999, 2000), find persistent socioeconomic inequities in levels of health among women as well as men. Germany represents another special situation in that the country was formerly divided between a capitalist West and communist East. Despite the fact that both parts of Germany experienced different political, economic, and social systems for 45 years (1945-1990), upper socioeconomic groups in East Germany as well as in West Germany have better health compared with people below them on the social ladder (Mielck et al. 2000).
Explanations of the Class-Health Relationship
It is obvious from the prior discussion that health is a social problem largely because of class inequities and the living conditions associated with these inequities. Health, like class, is stratified from top to bottom along socioeconomic lines. Major explanations for this relationship include the following.
The Social Gradient in Mortality
A British project providing strong evidence of class differences in mortality is the Whitehall Studies conducted by Michael Marmot and his colleagues. Some 17,000 male civil government employees, classified according to their job, were interviewed about their health practices in the late 1960s. These men were between 40 and 64 years of age at the time. In the first study, Marmot et al. (1984) examined the mortality rates for these men and found that regardless of the cause of death, those with the highest occupational rank had the lowest mortality and the percentages increased the lower the job position. What was particularly interesting was that the highest status men (senior administrators) had lower mortality than the next highest (professional/executives) and so on down the line until the bottom of the status hierarchy was reached, where mortality was the highest. Marmot (1996) was surprised that the pattern of class differences in deaths among the civil servants paralleled society as a whole, since the jobs were all stable, provided pensions, and presumably were free of occupational hazards. The difference between the top and bottom grades of the civil service was in fact three times greater than the top and bottom social classes in national mortality data.
Marmot et al. (1991) conducted a second study to recheck their results and found that, as in the first study, each group had worse health and higher mortality than the one just above it in the status hierarchy. As Marmot (1996) later stated: “In the higher grades of the civil service there is no poverty, yet those who are near the top have worse health than those at the top and the gradient continues all the way down” (p. 48). These findings led to the formulation of a social gradient theory of mortality. This theory holds that the highest social strata (the upper class) lives longer than the next highest (the upper middle class), which lives longer than the next highest (the lower middle class), and so on down the social ladder—forming a gradient from high to low. The exact reasons for this gradient are not yet known, but some studies suggest that the gradient results from class differences in self-esteem and stress (Evans, Barer, and Marmor 1994), income inequality (Wilkinson 1996), deprivation over the life course (Power and Hertzman 1997), or health lifestyles and social support (Cockerham, Hattori, and Yamori 2000), or some combination thereof.
While there are questions whether the social gradient theory can also be used to explain health differences between rich and poor countries or geographical areas within countries, the theory holds up relatively well with respect to class differences. That is, the social gradient exists as depicted. Moreover, the research upon which it is based suggests that medical care alone cannot counter the adverse effects of lower-class position on health. The Whitehall studies demonstrate that the lower a person is on the social scale, the less healthy that person is likely to be and the sooner he or she can expect to die. Conversely, the higher one is on the social ladder, the better are one’s prospects for health and longevity than those of people in the class below.
Another influential explanation emerging from research in Britain is Richard Wilkinson’s (1992, 1996) relative income theory. Wilkinson focuses on the health of whole societies, rather than individuals, because when it comes to practical politics and public policies, he maintains that it is the health of whole societies that is most important. He suggests that relative position in a social hierarchy can be determined by relative income, and that the psychosocial effects of the different social positions in a society have health consequences. Stress, poor social networks, low self-esteem, depression, anxiety, insecurity, and loss of a sense of control are reduced and social cohesion is enhanced—when income levels are more equal. Consequently, Wilkinson claims that relative levels of income within a society therefore have more significant effects on health and mortality than the society’s absolute level of wealth. That is, what matters the most in determining health and mortality is not how wealthy a society is overall, but how evenly wealth is distributed among its members. Countries with the longest life expectancy may not have the most wealth; instead, the best health and greatest longevity is found in those nations with the smallest differences in income levels and smallest proportion of the total population living in poverty. This is seen in countries like the United States, for example, that have wide disparities in income and lower life expectancies than countries like Sweden, where income is more evenly distributed and life expectancy is higher.
Several studies initially supported Wilkinson’s thesis, including those with data on mortality in U.S. metropolitan areas (Lynch et al. 1998) and states (Kawachi et al. 1997). But the most recent studies do not support his position. One problem is that cash income may bear little relation to material and psychosocial well-being in subsistence agricultural economies, where many goods and services are obtained directly from the environment and barter is common (Ellison 2002). This situation limits the utility of relative income theory to rich countries. But new studies conducted with data from countries with high per capita income have likewise failed to find a significant association between income inequality and health (Gravelle, Wildman, and Sutton 2002; Lynch et al. 2001). Other research determined that the association between income distribution and variations in health is modest if people living in poverty are excluded (Judge, Mulligan, and Benzeval 1998). There is research that also failed to find a greater slope in the social gradient when income and mortality differences in a population widen (Ellison 2002; Power and Hertzman 1997), and there are statistical questions about what income equality actually measures in relation to health (Ellison 2002; Gravelle et al. 2002). The evidence is now mounting that the income inequality thesis does not explain differences in health between countries, with the possible exception of child and infant mortality, nor are its effects the same in all countries (Lynch et al. 2001).
Social Causation/Social Selection
Another approach to explaining health inequality is the social causation/social selection debate. The social causation explanation maintains that the lower class is subjected to greater socioeconomic adversity as a result of a deprived life situation and has to cope with this deprivation with fewer resources. Thus, adversity and the stresses associated with it affects the lower class more severely than it does the classes above it, and their health is more impaired as a result. The social selection explanation holds that there is more illness in the lower class because chronically sick persons tend to “drift” downward in the social structure (the “drift” hypothesis), or conversely, healthy individuals in the lower class tend to be upwardly mobile, thereby leaving behind a “residue” of ill persons (the “residue” hypothesis).
Poor health can limit the upward social mobility of people as they lack the health to improve their situation in life and dwell in a more or less permanent sick role, or poor health can cause them to drift downward in the social structure as they find it difficult to maintain their position in society. However, most ill persons are most likely not especially mobile, either up or down. Essentially, they stay where they are. When the question is whether class position affects health (social causation) or health causes class position (social selection), the strongest evidence is on the side of social causation (Marmot et al. 1991). This evidence suggests that class position contributes more to the onset of poor health than poor health causes class position. But the two explanations are not mutually exclusive in which one explanation is completely wrong and the other totally correct (Annandale 1998; Lahelma 2000; Macintyre 1997). There are undoubtedly situations where sickness locks a person into the lower class or causes downward movement in society. Nevertheless, class position and the health lifestyles and living environment associated with it are the most powerful social factors bringing about poor health.
Health in the Former Socialist and Developing Countries
Thus far this chapter has largely focused on the relationship between health and society in affluent Western countries. This relationship is perhaps most apparent in countries where there are relatively high standards of living and social factors like class position play a particularly obvious role in promoting or harming health. Most of the research literature and theories about the health/society link likewise reflect conditions in industrialized countries (Gilbert and Walker 2002). Elsewhere in the world, health is also a social problem. The concluding part of this chapter briefly reviews the situation in the former socialist countries of Europe and developing countries where health today is especially problematic.
Former Socialist Countries
The socialist regimes of the former Soviet Union and Eastern Europe came crashing down in 1989-91 largely because of economic failures. Much earlier, however, in the mid-1960s, life expectancy had already starting falling in these countries. This rise in mortality is, in fact, one of the major crises of the late twentieth century, second perhaps only to the AIDS epidemic. This is a surprising development and without precedence in modern history, as nowhere else has health worsened so seriously in peacetime among industrialized nations. Ironically, the former socialist countries espoused a communist ideology of socioeconomic inequality that theoretically should have promoted health for all of their citizens. Yet the reverse occurred and life expectancy fell dramatically for men, while longevity for women typically stagnated instead of rising, as it did in the West.
Infectious diseases, environmental pollution, and genetic maladaptations have not been the primary causes of the decrease in life expectancy, nor has poor-quality health care been the main culprit (Cockerham 1997, 1999, 2000b; Hertzman 1995; Marmot 1996). Virtually all sources agree that increases in cardiovascular diseases are responsible for the change in mortality patterns, while alcoholrelated accidents and poisonings are also of major importance (Cockerham 1997, 1999, 2000b; Dmitrieva 2001; Marmot 1996; Tulchinsky and Varavikova 1996). Are social factors responsible? The answer is yes. These factors are stress, health policy, and especially health lifestyles.
Stress has probably been an important contributing variable in this situation, but its exact role has not been determined because of a lack of direct evidence linking cardiovascular mortality in the former socialist states to chronically stressful socioeconomic and psychological conditions. This is not to say that stress is not important; rather, its effects have not been documented. The stress explanation is also undermined by the fact that the Czech Republic reversed its rise in male mortality in the mid-1980s despite sharing the same stressful circumstances with its socialist neighbors.
A policy failure to address chronic diseases is another likely contributing factor, as the Sovietstyle health care delivery system lacked the flexibility administratively and structurally to adjust to health problems that could not be handled by the mass measures successful in controlling infectious ailments (Field 2000). The strongest evidence identifies negative health lifestyles as the primary social determinant of the decline in life expectancy (Adevi et al. 1997; Cockerham 1997, 1999, 2000b; Janeèková 2001; Ostrowska 2001; Steptoe and Wardle 2001). The lifestyle pattern is one of excessive alcohol consumption, heavy smoking, high-fat diets, and lack of health-promoting exercise. Heavy alcohol use is especially noteworthy among Russian men, as adult males compose 25 percent of the population but drink 90 percent of all alcohol consumed.
The social nature of the mortality crisis is underscored by the fact that these lifestyle practices are especially characteristic of middle-age, working-class males. This social group, not surprisingly, is largely responsible for the decline in male longevity. Social class is once again important, yet in the former socialist countries it is the health lifestyles of the working class—not so much the lower class—causing premature deaths from heart disease and alcohol-related incidents. The epicenter of the downturn in life expectancy during the Soviet period and today is Russia, where 2000 figures show Russian males living 58.9 years on average, some 5.1 years less than in 1965. Russian women lived 71.8 years in 2000 compared with 72.1 years in 1965. Only 76.2 percent of Russian men and 91.3 percent of women currently reach the age of 50 years. Elsewhere, in countries like the Czech Republic, Poland, and Hungary, the situation has improved or is improving, but in Russia and many other former socialist states, problems remain.
Inequities in health are even more striking in developing countries characterized by extensive poverty, such as those in South Asia and Africa. Modern medical care is an unaffordable luxury for many urban dwellers and virtually nonexistent in rural areas. In such countries, health policy is usually oriented toward just meeting basic needs, such as treating the sick, rather than prevention or the expansion of specialized services. Whereas levels of health are much worse in some countries than in others, life expectancy in developing nations has generally improved (Gallagher, Stewart, and Stratton 2000; Kuate-Defo and Diallo 2002). Widespread use of immunizations and the effective treatment of diarrhea with oral fluids have saved millions of lives. Nevertheless, the low levels of health and life expectancy are appalling by Western standards. Overall life expectancy in 2000 in Mozambique was 31.3 years, Zambia 33 years, Burundi 33.4 years, Central African Republic 34.1 years, Somalia 35.1 years, and Uganda 35.7 years.
Much of the blame for low life expectancy in Africa south of the Sahara is due to the massive AIDS epidemic. Of the over 23 million people with HIV worldwide, some 95 percent of the total live in developing countries and 70 percent are in sub-Saharan Africa (Gilbert and Walker 2002). In some African countries, 20 percent to 35 percent of the total population is HIV-infected as the virus spreads through society affecting people from all walks of life largely through heterosexual intercourse. For example, about one in eight of all adults between the ages of 15 and 49 years are infected in South Africa. The majority are women, who are especially disadvantaged throughout Africa by poverty, a heavy workload, lack of access to health services, and low social status and decision-making power (Berhane et al. 2001).
AIDS is not the only problem, however, as communicable diseases are more prevalent in developing countries despite the epidemiological transition to chronic illnesses. Africa’s burden of disease is still marked by very high communicable disease morbidity, including high rates of tuberculosis, malaria, and other infectious diseases. As H. van Rensburg and Charles Ngwena (2001) explain: “Africa’s health status, burden of disease, and health care needs are conspicuously shaped by poverty, malnutrition, infectious diseases, armed conflict, drought, famine, inadequate access to primary and secondary education, lack of safe water, sanitation, and a range of socioeconomic factors propelling inequitable distribution of resources” (p. 369). Poverty underlies most of the social conditions promoting poor health (Gilbert and Walker 2002). About half of the entire population of Africa south of the Sahara lives in poverty. In countries like Niger, where over 90 percent of the population lives on $2 a day or less and the government spends three times more on international debt repayment than health and education, prospects for improvement in health care delivery are poor (Rensberg and Ngwena 2001).
Class is still important in determining the health of people in developing societies, as the upper classes live the longest, with the class gradient much steeper and even smaller at the top than in industrialized nations. In both low-income and middleincome countries, including not only African nations but countries in Asia (i.e., Thailand and Indonesia) and Latin America (i.e., Dominican Republic, Venezuela, Brazil, and Mexico), wide gaps in health and health care exist between socioeconomic strata (Braveman and Tarimo 2002). Roberto Castro (2001), for example, documents socioeconomic differences in health problems in Mexico, and Everardo Nuñes (2001) describes health inequities in Brazil, where over 30 percent of the population lives in poverty.
This chapter has shown that inequalities in health exist globally and are based on a number of factors, especially social class but also race and gender. Health becomes a social problem when particular segments of the population are deprived of healthy living conditions and adequate health care. Although people are living longer today than ever before in most countries of the world, there are indications that disparities in health are increasing between social strata on a global basis just as economic inequalities are widening (Braveman and Tarimo 2002). As Lahelma (2001:88) points out, egalitarian policies need to be implemented that aim at improving the health of the most disadvantaged groups, reducing the gaps between other strata, and improving the overall level of health of the population as a whole. This will take time, money, and commitment to the goals. But presently there is little progress in this direction on a worldwide scale, and health remains a major global social problem.