Social Inequality Essay health

Question
Describe the social gradient in health
Introduction
This essay will critically assess the social gradient in health and will consequently theoretically and
empirically illustrate the relationship between low socio-economic status and relative health
inequality with respect to access and outcome. After establishing this relationship, the case study
of Irelands two-tier health system will be examined to highlight the social gradient of health and will
demonstrate that such inequalities with respect to access and out come are not distinct to
conventional neo-liberal regimes that adopt a market orientated approach to the provision of
healthcare. The social-gradient pertaining to health inequality is in part directly attributable to an
inability for those in a lower socio-economic status to access healthcare services due to monitory
constraints. However, the second more subtle aspect to the social-gradient arguably also emanates
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indirectly from societal problems and class inequality artificially created by the capitalist system. "
Higher levels of economic inequality result in poorer health for everyone, but especially for those on
the lowest incomes. (TASC,2011) Consequently it is for that reason that this level of inequality is a
pernicious byproduct of the capitalist system. As such inequality has been created by the system, it
may also be rectified. "TASC argues that we have the means and opportunity to achieve a more
equal and thus healthier society.(TASC,2011)

Theoretical analysis of the social-gradient

To begin this section, its appropriate here to consider the stark words from a
report commissioned by the World Health Organisation.
Inequalities

in health arise because of inequalities in society in the conditions in

which people are born, grow, live, work and age. [These] do not arise by
chance, and they cannot be attributed simply to genetic makeup, bad
unhealthy behaviours, or difficulties in access to medical care,

Social Inequality Essay health

important though these factors may be. (W.H.O.p26,2008) This is indeed

an important point as it recognises that a considerable dimension in
health inequality is causally determined by social and economic
conditions within a society. Therefore one must consider how the sociopsychological cultural, and socio-economic status interact to create the
social-gradient and produce health inequalities for disadvantaged groups
in particular. it will be then necessary to analyse preventable behaviours
or lifestyle choices which are harmful to an individuals health and wellbeing but also external constraints imposed by social and economic
conditions.
The broken society and fractured economy discussed in Wilkinson and
Picketts groundbreaking research The Spirit Level have much relevance
to the present discussion on the social gradient of health. Before
presenting the empirical and statistical evidence, its worth highlighting
that there is arguably a strong abstract conceptual underpinning of the
relationship between low socio-economic status and health inequality
from Marxs theory of alienation and to a certain extent Durkheims
concept of anomie. Where as Marx describes the the capitalist systems
alienating process which leads to pervasive individualism that culminates
in individuals becoming estranged from themselves and each other. Lee
and Newby provide a definition that illustrates the process that plays an
important role in creating the more subtle aspect of the social-gradient
pertaining to health. Alienation refers to the process, endemic to capitalism, whereby the
products of human
labour become expropriated from and appear as opposed alien to those
who produce them. Workers, indeed not only become alienated from the products of their labour,
but from
the labour process itself, from each other and ultimately from themselves. (Lee and
Newby,2000)
Consequently this has a negative impact on the socio-

psychological well-bing of the individual. Anomie describes the negative

effects on the individual as a result of low-regulation within a society.
The process is aptly elaborated by Lege 2009. Anomie refers to the structural

level and describes a weakening of regulative and integrative

social forces that either results
from rapid social change or is structurally immanent.. (Ledge, 2009) At the individual level its
amounts to a feeling of powerlessness and a lack of control in their lives. This offers an interesting
insight into the complex societal processes at work that cause an individual to be more susceptible
in turning to potentially health-damaging practices as a coping mechanism to aliviate stress. To
provide a more holistic and robust theoretical analysis, one may draw a new connection with
contemporary social control theories such as Labelling and interactionism. In particular Herchis
social-control analysis implicitly reflects a strong influence from Durkheim and Marx. As Herchi
similarly attributes ineffective socialisation and having a negative bond with three seminally
important institutions: the family, peers and the education system as being a decisive determinant in
predicting low self-efficacy. This may cause an individual to fall into the poverty-trap or cycle of
deprivation and may mean that their physical and mental health would be adversely effected.

Social control theories together with the above mentioned concepts

effectively illustrate how those in low socio-economic groups have a
greater propensity to have unhealthy lifestyles and engage in harmful

Social Inequality Essay health

practices such as smoking, excessive alcohol intake and abuse of illegal

substances.
Despite considerable economic progress made by the industrialised
world and an accompanied rise in average incomes, health inequalities
have persisted as life-expectancy and general health are observed to be
comparatively better for higher socio-economic groups. Its therefore
appropriate to quote Wilkinson and Pickett in describing the negative
impact of materialism on the individual. It is a remarkable paradox that
at the pinnacle of human material and technological achievement, we
are anxiety ridden, prone to depression, worried about how others see
us, driven to consume and little or no community life, lacking social
contact and emotional we all need, we seek comfort in overeating or
consumerism or are pray to excessive alcohol, psychoactive medicines,
and illicit-drugs.(Wilkinson,Pickett p1,2009) Indeed some of these most
pertinent social problems form a key component of the social gradient as
these health related issues disproportionately effect lower socioeconomic groups. Therefore in support of this assertion, one can refer to
Maslow hierarchy of needs in where individuals struggle to meet their
basic physical needs as a consequence they fail to access quality
healthcare services in a timely manner and maintain a generally healthy
lifestyle due to insufficient economic resources but also as a result of
more complex cultural and socio-psychological factors produced by
society.
Considering the Evidence of the social gradient
Its now well established that while relative health inequalities persist as
a result of poverty, mortality rates are now more likely to be causally
determined by the more latent social gradient of health in Western
soscieties. Additionally it appears the changing determinants have also
been accompanied in a change in trajectory of the social gradient over
time. Firstly as the literature points out infectious diseases such as TB
are no longer prevalent in western societies but rather diseases of
affluence such as degenerative cardiovascular disease and cancers are a
more predictable source of mortality rates. What is interesting however,
is the change in the social gradient as the distribution of these diseases
amongst the population has reversed overtime from the rich to the poor.
This trend is identified clearly by Wilkinson and Pickett. Its that diseases
that used to be called the diseases of affluence are now diseases that
effect the poor in affluent societies.(Wilkinson,Pickett,p10,2009) Indeed
this trend began to reverse from the 1950s meaning that such health
problems are now more endemic amongst the poor. These trends in some
respects are not surprising given the rate of economic growth and how
society is structured. A point recognised by an acclaimed French

Social Inequality Essay health

economist, Thomas Pickety, whos enlightening study into the

relationship between inequality and economic growth provides much
clarity on the issue. The principle finding of the study is that the rate of
return on capital has consistently exceeded the economic growth. This
has profound implications for lower-socio-economic groups as the trickledown hypothesis or a multiplier effect doesnt appear to operating in the
traditional way as predicted by neo-liberal economists. Therefore it
appears that the social economic benefits associated with further
innovation and capital accumulation seem to be subject to diminishing
marginal returns. As a consequence its meant that less well off
individuals have not continued to benefited from the increased economic
prosperity and arguably the converse is the case as as health problems
associated with the social gradient are becoming more apparent. To
illustrate this point more effectively its worth considering the research of
Mormot 2007. In Glasgow, UK, life
expectancy of men in one of the most deprived areas was
54 years, compared with 82 years in the most affluent areas,
Thus the poorest men in Glasgow have lower lifeexpectancy than the
Indian average. Men with the lowest
life expectancy in the USA (19972001)5
had lower lifeexpectancy than the Pakistan average.(Mormot,2007)
Therefore the social-gradient doesnt merely refer to the stark contrast in
the standard of health between rich and poor but rather its a trajectory
denoting the variation in health outcomes for different socio-economic
groups. Generally this implies that the relative position of an individual in
relation to their social status in part determines their quality of life. and
standard of health. Therefore according to the status syndrome, whats
important isnt differences between countries but rather status and
income inequality within a country. Typically individuals that have a
relatively higher social-status have comparatively better health
outcomes.A recent innovative study from Cutler & Leras-Muney 2010
investigates the causes behind the social determinants of health
inequality and thus illustrate the latter point succinctly.. Among older
adults in Britain and the United States, a move from the top education or
income tercile tothe bottom tercile is associated with an increase of at
least fifteen percentage points in thelikelihood of reporting fair or poor
health. (Cutler,Leras-Muney,p1, 2010) As identified by these scholars
the social gradient is observable in rich and poor societies. For example
a study conducted by Smith & Goldman 2007 demonstrate that a similar

Social Inequality Essay health

pattern may be identified in Mexico as the poorest and least educated

elderly population report poor health at least 10% more then elderly who
are in a higher socio-economic status. One can argue that important
social variables such as education and income interact with individual
background factors to produce health inequality. While education and
income as identified in these studies are shown to have a positive impact
on an individuals well-being, however, they may not necessarily operate
in an identical way. For instance its difficult to regard these as distinct
independent variables as higher education is typically associated with
increasing ones life chances and better employment opportunities. The
relationship between health and education may also be subject to
reverse causation as possibly good physical and mental health facilitate
the individual to progress in education. While these variables are highly
correlated a study from Cutler & Learas-Muney 2005 assed programs of
mandatory school attendance to a certain age in the last century and
found that the increase in education was positively correlated with an
improvement in general health. To illustrate the salience of education as
an indicator of higher employment prospects, improved standard of living
and general health, its worth drawing on Cutler & Leras-Muney 2010.
More educated individuals in the United States report better health and
face lower mortality risk. They also suffer less anxiety and depression,
endure fewer functional limitations, and face decreased probabilities of
being diagnosed with heart conditions, stroke, hypertension, high
cholesterol, emphysema, diabetes, asthma, or ulcereven after
conditioning on background characteristics such as race, age, and
income.(Cutler,Learas-Muney p11,2010) A similarly robust study was
conducted by Mackenbach 2006 that demonstrate comparable findings
for many EU countries.
The prevalence in the use of harmful substances such as smoking has
received much attention in the literature as its a seemingly avoidable
practice that also bares a high financial cost on the individual. A clear
social-gradient may be identified in smoking rates as those in lower
socio-economic groups are disproportionately more likely to smoke. While
at first glance it may appear that smoking comes down to an
independent individual choice un-effected by the socio-economic system.
however, complex societal and economic process do in fact play an
important role in determining smoking rates amongst low socio-economic
groups. For instance as identified by Kruger & Denney They struggleto
make ends meet; have few opportunities toachieve positive goals;
experience more negative
life events such as unemployment, maritaldisruption, and financial loss;
and must dealwith discrimination, marginality, isolation,
andpowerlessness.(Denney & Kruger, p153,2010) Therefore other

Social Inequality Essay health

variables such as neighbourhood. and employment status can negatively

effect stress levels and mental-health. This is supported by Marmot 2004
as high stress amongst lower socio-economic groups is associated with
obesity, smoking, and drinking. While stress certainly does effect higher
socio-economic groups, It does so in different ways as typically those in
a higher socio-economic-status will experience pressure and stress but
will generally have a degree of control over their employment and
personal lives. Drawing on social-control theory discussed ina previous
section, individuals experiencing relative deprivation who struggle to
meet basic physical needs will unsurprisingly be more susceptible to
stress. As a result, the individual reporting a lack of control over their
situation and this culminates in a feeling of fatalism, thus making such
socio-economic-groups more susceptible to participating in unhealthy
practices. This is empirically supported by Blaxster, 1990 find that
groups who are alienated from social and economic life tend not to follow
a healthy lifestyle due to a fatalistic view of their future life prospects.
While later studies have rejected her finding it is still recognised by
Pamper 2010 that belief in the
limited benefits of healthy behavior may obstructaction among low socioeconomic-groups.(Pampel,p355,2010)
Finally social-capital within neighbourhoods is an understudied yet
potentially fruitful concept with much explanatory power in influencing
the social-gradient. Some scholars who attribute significance to socialcapital argue that the relationship between socio-economic-status and
health is mediated through access to material resources within a
neighbourhood. For example an institutional-resources-model states that
the quality, accessibility and availability of institutional resources might
explain the relationship between neigh- bourhood characteristics and
outcomes in children and adolescents.(Vyncke,p3,2013) Therefore the
quantity and quality of services and facilities are thought to be lower in
disadvantaged areas. For example sidewalks in poorer neighbourhoods in
the U.S. are thought to reduce physical exercise amongst young people
This prospective may be supplemented with a relationships model along
with a collective norms and efficacy model. With respect to a
relationships model, qualitative parenting practices have a positive
impact on the health and well-being of child which is important for their
future development. However, family stress and problems at home
disproportionately effect disadvantaged areas. The norms and collective
efficacy model argues that disadvantaged areas make it more likely for
individuals to fall into the poverty trap and a cycle of deprivation which
would adversely effect their health.

Social Inequality Essay health

The Case Study of Ireland

In addition to the evidence provided on other EU countries and the social-gradient,
Irelands two-tier healthcare system contributes immensely to the social-gradient. Late and
Wheelan in their study of Ireland support the evidence presented that a social-gradient is
evident in smoking rates and it is most prevalent amongst low socio-economic groups In
addition to monitory constraints on low socio-economic-groups in purchasing more
expensive but healthy food and also accessing gyms, insufficient economic-resources can
directly impact on ones mental and physical health. As illustrated by work conducted by
the ESRI, lower socio-economic status is positively correlated with problems accessing
and receiving healthcare. Nearly 70% of third level graduates have insurance compared
to 40% of early school leavers, 75% of professionals and managers have insurance
compared to 21% for unskilled manual workers. ( Watson, Williams) The stark inequality
and the social-gradient is tragically demonstrated in Sarah Burkes book on Irelands
Apartheid healthcare system. Burke identifies the case of Susie Long who was a publichealth patient who was receiving cancer treatment. However, due to the stark inequities in
the public system and the long-waiting list, it tragically meant that Susis died before she
was able to receive treatment.

Conclusion
i While studies from Wilkinson ^ Pickett 2009 amongst others have been
subjectively criticised on the basis of their methodology, in particular
focusing on issues like reverse causation, independence of variables, and
the problematic nature of cross-national comparison, It is difficult
however, to refute the observable objective statistics such as mortality
rates and more tangible economic indicators such as effects of income.
Additionally its even more difficult to refute the observable health
inequalities for different socio-economic groups which clearly reflects the
nature of the social-gradient. This essay has theoretically and
empirically described the social-gradient in health. A potentially novel
prospective in conceptualising the social-gradient was outlined by
drawing on Marxs theory of Alienation, Durkheims concept of anomie
along with social-control theories in an attempt to explain why lower
socio-economic groups are prone to seemingly avoidable health
damaging practices such as smoking. Next the evidence for the socialgradient was considered normatively and objectively. Consequently the
relative importance of of cultural and socio-psychological factors along
with socio-economic status were assessed. Finally the case study of
Irelands two-tier health-service was assessed to demonstrate that
economic-resources play a decisive role in accessing healthcare and may
adversely effect general health and mortality rates.
Bibliography

Social Inequality Essay health

D Cutler, A Learas-Muney helaht and social inequality accessed from

http://www.nber.org/papers/w14333.pdf
Vyncke et al. BMC Public Health 2013, 13:65 http://www.biomedcentral.com/14712458/13/65
Rachael Layte, Christopher Wheelan, Explaining Social Class
Inequalities in Smoking:
The Role of Education,
Self-Efficacy, and Deprivation
Michael, Mormot, 2004, status syndrom
Michael Mormot 2006, 2007, blackboard
Tasc health inequality report (Blackboard)