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1. The Politics of Health Inequities: Contested Terrain (Richard Hofrichter).
PART ONE: SOCIAL FORCES EXACERBATING HEALTH INEQUITIES.
2. A Society in Decline: The Political, Economic, and Social Determinants of Health Inequalities in the United States (Dennis Raphael).
3. Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health (James S. House, David R. Williams).
4. Gender, Health, and Equity: The Intersections (Piroska Östlin, Asha George, Gita Sen).
5. Getting a Grip on the Global Economy: Health Outcomes and the Decoding of Development Discourse (John Gershman, Alec Irwin, Aaron Shakow).
6. The Political Context of Social Inequalities and Health (Vincente Navarro, Leiyu Shi).
7. Income Inequality and Mortality: Importance to Health of Individual Income, Psychosocial Environment, or Material Conditions (John W. Lynch, George Davey Smith, George A. Kaplan, James S. House).
8. Zoning, Equity, and Public Health (Juliana A. Maantay).
9. The Changing Structure of Work in the United States: Implications for Health and Welfare (Sarah Kuhn, John Wooding).
PART TWO: THEORY, IDEOLOGY, AND POLITICS: CRITICAL PERSPECTIVES.
10. Public Health as Social Justice (Dan E. Beauchamp).
11. Social Capital and the Third Way in Public Health (Carles Muntaner, John W. Lynch, George Davey Smith).
12. Measuring Health Inequalities: The Politics of the World Health Report 2000 (Paula A. Braveman).
13. Assessing Equity in Health: Conceptual Criteria (Alexandra Bambas, Juan Antonio Casas).
14. Income Inequality, Social Cohesion, and the Health Status of Populations: The Role of Neo-liberalism (David Coburn).
15. Income Inequality and Health: Expanding the Debate (John W. Lynch).
16. Is Capitalism a Disease? The Crisis in U.S. Public Health (Richard Levins).
17. Theorizing Inequalities in Health: The Place of Lay Knowledge (Jennie Popay, Gareth Williams, Carol Thomas, Anthony Gatrell).
18. The Limitations of Population Health as a Model for a New Public Health (Dennis Raphael, Toba Bryant).
19. Theories for Social Epidemiology in the Twenty-First Century: An Ecosocial Perspective (Nancy Krieger).
PART THREE: STRATEGIES: PERSPECTIVES ON SOCIAL POLICY AND PRACTICE.
20. Toward the Future: Policy and Community Actions to Promote Population Health (Dennis Raphael).
21. Globalization, Trade, and Health: Unpacking the Links and Defining Health Public Policy Options (Ronald Labonte).
22. Socioeconomic Disparities in Health in the United States: An Agenda for Action (Nancy E. Moss).
23. From Science to Policy: Options for Reducing Health Inequalities (Hilary Graham).
24. Addressing Structural Influences on the Health of Urban Populations (Arline T. Geronimus).
25. Swimming Upstream in a Swift Current: Public Health Institutions and Inequality (Rajiv Bhatia).
26. Minnesota’s Call to Action: A Starting Point for Advancing Health Equity Through Social and Economic Change (Gavin Kearney).
27. The Role of Mass Media in Creating Social Capital: A New Direction for Public Health (Lawrence Wallack).
Even though mortality rates overall declined dramatically in the twentieth century and life expectancy increased, the United States nevertheless faces an increasing level of inequity in the health status and mortality of those with less material resources in relation to their social class, particularly in communities of color (Kawachi, Kennedy, and Wilkinson, 1999; Arno and Figueroa, 2000; LaVeist, 2002). For example, African Americans experience excess mortality and morbidity rates substantially higher than those for whites (National Center for Health Statistics, 2000; Williams, 1999). Differences in aggregate health status become inequitable when they are systemic and unjust, a result related to a lack of political power (Whitehead, 1987; Dahlgren and Whitehead, 1991; Evans and others, 2001; see also Chapter Twelve). That is, these patterned, persistent inequities (Beaglehole and Bonita, 1997; Bartley, Blane, and Davey Smith, 1998; Drever and Whitehead, 1977; Institute of Medicine, 2002) are due primarily to failed political struggles and power imbalances, not ad hoc events, individual failure, or the inevitable consequences of modern society. Material conditions such as poverty, inadequate housing, and excessive air pollution, generated by law, public policy, corporate decision making, and sometimes violence, produce and perpetuate health inequities. These conditions often derive from the institutional political and social power conferred by great inequalities of wealth (Callinicos, 2000; Halfon and Hochstein, 2002). Yet most discussions of health, whether in scholarship or the mass media, rarely touch on political conflict. Health is usually about health of the individual, health care, behavior and lifestyles, or developments in medical research. Although equitable access to health care is necessary, it represents only a small part of the requirements necessary for eliminating health inequities (Beaglehole and Bonita, 1997). The United States, for example, is not investing to create the social and economic conditions for health (Arno and Figueroa, 2000). Yet historically, major advances in health status resulted from broad social reforms. These include actions such as the abolition of child labor, shortening of the working day, introduction of social security, reductions in the scale of poverty, improvements in the standard of living, and guaranteeing employment or at least a minimum wage, as well as efforts to improve sanitation, ensure safe food, and provide adequate housing. Improvements in living and working conditions led to reductions in deaths from major infectious diseases. Public health as a discipline arose as an organized response to the negative consequences of industrialization. Later, legislative developments such as the Social Security Act, the Clean Air Act, the Mine Safety Act, and the establishment of the Occupational Safety and Health Administration and Medicare were major steps that improved health for millions of people (Rose, 1992; Porter, 1999).
Although macro-level forces explain only part of a complex story of social structures, conditions, and events that influence health, they have generally been neglected until recently. Even less well examined is the part that power, politics, ideology, and conflict play in how those forces come to influence health and create inequities. Social conflicts involving inequalities continue to be displaced into the market or specializations within science, evading politics.
This chapter presents a framework for understanding and acting on health inequities. I begin by outlining major social, economic, and political forces that contribute to health inequities, explaining their connection through the concepts of class, race, gender, and social justice. I then consider the way in which contemporary ideologies that organize the social order limit critical thinking, thereby constraining effective action. The last part of the chapter offers suggestions for communicating and organizing more effectively to eliminate health inequities both within and outside of the health professions.
This is an opportune historical moment to examine inequities in health and well-being and to question the definition of health. As social and economic inequality widens dramatically and becomes impossible to ignore, the connection between the vulnerability of people who live on the margins and the importance of working together collectively as a community for the public good has become more salient, if unarticulated. A clearer picture is emerging of the relationship between community-level well-being, resources for basic infrastructure, economic equality, and good health (Institute of Medicine, 2002). Yet in the United States, the federal government continues to target diseases rather than health and redirects resources toward bioterrorism and military preparedness instead of the public health infrastructure (Altman, 2003).
Worldwide, growing social and economic inequality, a basic cause of inequalities in health status, is equally stark (Kim and others, 2000; United Nations Development Program, 1999; Beaglehole and Bonita, 1997; Wilkinson and Marmot, 1998). The richest two hundred people in the world have wealth equivalent to 41 percent of the world's population. About 20 percent of the world's population receives over 80 percent of domestic investment and global trade and income (United Nations Development Program, 1999). According to the World Health Organization, the gap between rich and poor within the industrialized countries, including the United States, is widening (Beaglehole and Bonita, 1997; Labonte, 1998; Wilkinson and Marmot, 1998; Arno and Figueroa, 2000; Callinicos, 2000).
Strikingly, in the United States, income and wealth inequality is greater than in any other industrialized country in the world (Ackerman, 2000; Kawachi, Kennedy, and Wilkinson, 1999; Wolff, 2002), wider than it has been for fifty years and continuing to deteriorate (Wolff, 2002; National Center for Health Statistics, 1998; Reich, 1997; Pappas and others, 1993; Madrick, 2002; Phillips, 2002; Pear, 2002; Krugman, 2002; Miringoff and Miringoff, 1999; Congressional Budget Office, 2001). A survey by the Federal Reserve Board in 2003 indicates a sharp rise in inequality, countering conventional notions about the boom years of the 1990s (Andrews, 2003). The share of wealth received by the wealthiest fifth of the population is greater than at any time since World War II (Wolff, 2002). Almost one-quarter of all children in the United States live in officially defined poverty (Danziger, Danziger, and Stern, 2000). In 2000, nearly one-fourth of the U.S. population earned poverty-level wages (Mishel, Bernstein, and Schmitt, 2001. Household net worth has declined dramatically since 1983 (Wolff, 2000). Tax rates for the wealthiest Americans also continue to decline as their wealth increases (Congressional Budget Office, 2001).
Great social costs arise from these inequities, including threats to economic development, democracy, quality of life, the exclusion of people from full participation in society, and the social well-being of the nation (Kawachi and Kennedy, 2002). Inequality limits people's freedom to develop their capacities and capabilities to the fullest (Sen, 1992). Countries with the most inequality often show signs of social disintegration, violence, and greater poverty (Wilkinson, 1996). Investments in infrastructure such as schools, transportation, and the environment tend to be lower in such societies. Economic growth and productivity gains have not led to better wages or more leisure time.
Serious health consequences result from these inequities, accumulating over the course of a lifetime (Davey Smith and others, 1997). They range from increased and unnecessary excess rates of mortality, morbidity, and psychological stress to reductions in economic productivity (Kuh and others, 2002). Even if people have access to the necessities of life, research shows that that may not be enough to participate fully in society, particularly in relation to things like access to adequate employment, adequate nutrition, modern communications technology, specialized training and skills, or health services (Kawachi and Kennedy, 2002). The most egalitarian countries in the world, not the richest, have the best health status (Wilkinson, 1996; Daniels, Kennedy, and Kawachi, 2000). In the United States, data show that states with greater inequality, such as Texas, Louisiana, Mississippi, New York, and West Virginia, have poorer health status than states with greater equality, such as Wisconsin, Utah, Minnesota, and Iowa (Miringoff, Miringoff, and Opdyke, 2001; see also Kaplan and others, 1996, and Kawachi and Kennedy, 2002).
Since the time of Rudolf Virchow, a public health pathologist, and sanitary reformer Edwin Chadwick in the nineteenth century, Western researchers and health professionals have understood the importance of the relationship between social class and mortality and morbidity (Hamlin, 1998; Sram and Ashton, 1998; Rosen, 1993; Porter, 1999; Antonovsky, 1967). A growing and significant body of research accumulated since the 1980s documents unequivocally that poverty, poor quality of life, and income inequality are principal causes of morbidity and mortality (Black and others, 1988; Acheson, 1998; Kawachi, Kennedy, and Wilkinson, 1999; Lynch and Kaplan, 1997; Kawachi, 2000; Kaplan and others, 1996; Wilkinson, 1996; Shaw, Dorling, and Davey Smith, 1999). A wealth of data specifically demonstrate the relationship of racism to inequality in health status and the continuing high mortality rates of African Americans and other people of color, including Latinos and Native Americans, compared with other groups (Williams, 2000; Williams and Collins, 2002; Krieger and others, 1993; Waitzman and Smith, 1998; Northridge and Shepard, 1997). Moreover, health effects of socioeconomic status may be related not only to absolute levels of poverty or severe deprivation but also to inequality itself (Marmot and others, 1991). Individuals with relatively high socioeconomic status are less healthy than those with even higher status.
The particular macro-level pathways by which health inequities link to specific exposures are intricate. Establishing how given social contexts interact with multidimensional biological and psychological pathways to cause disease with any quantifiable certainty remains a challenge. These pathways are often tied to the way production and investment decisions, labor market policies, neighborhood and workplace conditions, and racism and sexism connect with individual histories. Essentially, social injustices become embodied in the individual as disease.
The relationships between class and racial inequality and the distribution of disease are gaining increasing attention. Beginning in the early 1990s, many organizations and government agencies initiated intensive action and dedicated resources toward the elimination of health inequities in Canada, Britain, Australia, Sweden, the Netherlands, and, to a lesser extent, the United States. In Britain, the health secretary called for a debate about the National Health Service to "move away from a preoccupation with health service structures towards a concentration on improved health outcomes across the nation" and argued for "the biggest assault our country has ever seen on health disadvantage [to] start to break the link between poverty and ill health" (Department of Health, 2001). The Department of Health established national targets to reduce health inequalities within a larger policy agenda (Bull and Hamer, 2001). In Australia, the Health Inequalities Research Collaborative works with the federal government to enhance the evidence base across many disciplines and link it to the promotion of public policy, programs, and practice development. In Sweden, the National Public Health Committee proposed goals linked to social determinants of health, particularly full employment and reducing poverty (Östlin and Diderichsen, 2000); Diderichsen and others, 2001). In the Netherlands, the Dutch Ministry of Health conducts research designed to reduce socioeconomic inequities in health through comprehensive strategies with long-term goals (Mackenback and Stronks, 2002). Moreover, the World Health Organization (WHO; 2000) lent its support to minimizing health disparities.
In the United States, advances have been limited. In 2000, the U.S. Department of Health and Human Services established national health goals for 2010, including the elimination of health disparities and ways to assess them, although these goals remain largely symbolic and unprioritized. President Clinton signed into law the Minority Health and Health Disparities Research and Education Act of 2000, which established the National Center on Minority Health and Health Disparities at the National Institutes of Health. Although the Office of Minority Health in the Department of Health and Human Services hosted the National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health in 2002 attended by more than two thousand people, little has come of it. It is conceivable that the attention by the federal government to health disparities reflects a desire to reduce expenditures for state-funded health care and not to transform society to eliminate the root causes of health inequities. The influential report The Future of the Public's Health, produced in 2002 by the Institute of Medicine, repeatedly stresses the importance of health inequities as leading to deterioration in population health. What may be done as a result remains to be seen, given the political climate and the reluctance to confront the political and economic interests that cause inequity. In Minnesota, one of the few states to initiate serious action to eliminate health inequities, the Department of Health in the late 1990s established the Minnesota Health Improvement Partnership Action Team on Social Conditions and Health (2001; see also Chapter Twenty-Six). This ongoing initiative seeks to identify action steps to address health disparities and increase analysis of the social conditions that affect health. Nonprofit public-interest organizations, academics in social epidemiology, and grassroots community groups represent some of the main sources that have been articulating bold visions, innovative theoretical perspectives, and strategies for action (see Chapter Nineteen and thepraxisproject. org). Some organizations may be counted as acting on health inequities even if they do not specifically identify their primary work as health-related. As Nancy Krieger (2001b, p.
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