Scandinavian Common Sense: Policies to Tackle Social Inequalities in Health
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Scandinavian Common Sense: Policies to Tackle Social Inequalities in Health
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| ISBN-13: | 9781771860659 |
|---|---|
| Publisher: | Baraka Books |
| Publication date: | 11/03/2015 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 176 |
| File size: | 6 MB |
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Scandinavian Common Sense
Policies to Tackle Social Inequalities in Health
By Marie-France Raynault, Dominique Côté
Baraka Books
Copyright © 2015 Baraka BooksAll rights reserved.
ISBN: 978-1-77186-065-9
CHAPTER 1
Social Inequalities in Health: a Real and Persistent Problem
The existence of social inequalities in health is now recognized as a very real and world-wide problem. Whitehead and Dahlgren (2006) have defined such inequalities as "systematic differences in health between different socioeconomic groups within a society." As well as factors such as age, sex, genes, and the risks of exposure to an infectious disease, there are also systematic determinants of health. These are socially produced and avoidable.
Obvious links
The links between the social dimension and health are striking. There is generally a correlation between socioeconomic status and life expectancy at all levels of the social hierarchy. In other words, all social classes are affected, even those that are not disadvantaged. This is shown in Figure 1.1, in which socioeconomic status is indicated by professional category.
A difference between average life expectancies can also be observed at the neighbourhood scale. The difference in average life expectancy between the poorest Montreal neighbourhoods, located in the southeast of the island, and the richest, in the west, is striking: six years for men, four years for women.
The phenomenon is universal. Observed health-related differences are not randomly distributed in the population. They vary, following a systematic, recurrent, and predictable pattern, as a function of socioeconomic groups. The World Health Organization (WHO) study on the social determinants of health confirms this: "In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.
This model is global, though its importance varies from country to country. Some countries succeed in reducing these inequalities. In doing so, as a general rule, society as a whole benefits, for though the health of an individual varies as a function of socioeconomic status, the average health of all the inhabitants of a developed country varies not as a function of average income but of inequalities. The more the gap between rich and poor is reduced, the better the average health of the population. As figure 1.2 illustrates, this is particularly true for mental health.
Some hypotheses on causality of poverty and illness
In recent years, several researchers have been investigating the biological mechanisms by which poverty leads to poor health. Though still fairly young, this is a promising field; researchers have uncovered interesting lines of enquiry and formulated hypotheses that merit investigation. It is generally acknowledged that poor health can drag a person down to an unenviable socioeconomic situation (though social mechanisms such as disability insurance and health insurance can largely attenuate this decline.) It is also acknowledged that, inversely, poverty can affect health. To better understand the relationship between poverty and poor health, we present here some of the physio-pathologic mechanisms discussed in the recent scientific literature.
Depression and mental health
Numerous studies have established a link between depression and poverty. The physiological mechanisms involved depend mainly on excessive secretion of stress hormones.
Chronic stress, such as that provoked by a prolonged state of poverty, leads to high levels of cortisol. These high levels block the action of the receptors in the brain whose function is to respond to the flux of neurotransmitters activated by the perceived need to react to stress or danger. The response normally ordered by the brain in reaction to a threat, problem, or any troubling situation is to fight or fly, after which the level of cortisol comes back to normal. But when cortisol levels remain high, brain chemistry is impaired. In short, high levels of stress hormones inhibit action, and a prolonged state of inhibition encourages the development of a state of depression.
Depression and a diverse range of mental health problems are more prevalent among the socially or economically disadvantaged. Poverty also impacts mental health through impairing physical health and childhood development. "Mental health problems are not randomly distributed in society, and if the epidemiological data indicate that one person in four is likely to suffer a mental health problem during his or her lifetime, it is not just any 'one person in four'." Inequalities in mental health reflect existing divisions in society: divisions of class, sex, age, and ethnic origin. Inequalities exist not only in the distribution of mental health problems, but also in the social factors that cause these problems and in those that facilitate recovery. Access to resources and services that help prevent or treat these problems also depends on socioeconomic inequalities. Noteworthy among other possible causal mechanisms of mental illness are social exclusion, isolation, and privation, which are both causes and consequences of such illness.
To reduce social inequalities in mental health, public policy should, of course, involve direct investment in mental and physical health. But, as well, we have to grapple with economic disadvantage and, above all, with job status. Furthermore, it is essential that investments be made to increase social capital and support individuals.
Cardiovascular disease
Poverty during childhood affects physical health not only when children are young but also when they become adults. A growing body of scientific data on the life course demonstrates that the health status observed at any time is markedly determined by the cumulative effect of preceding circumstances. The study of the life course and accumulated vulnerabilities, which some authors consider fundamental to understanding the origins of social inequalities in health, supports the thesis that such inequalities stem from the conditions of the first years of development.
A relationship can thus be observed between poverty in infancy and cardiovascular disease in adulthood, even taking account of socioeconomic status in adulthood. Atherosclerosis, the slow and progressive formation of plaques in the arteries, can begin in childhood. This condition is strongly associated with poor nutrition which, in turn, is more common in underprivileged neighbourhoods. Moreover, excess weight and obesity are associated with poverty and food insufficiency, that is, the uncertain or limited availability of nutritious foods. These conditions are important risk factors for cardiovascular disease. Unfortunately, they are observed more and more often in children, and at increasingly younger ages. In Great Britain, poverty has been linked to obesity in children as young as five years old.
The endocrine and immune systems
Over time, the stress engendered by chronic poverty raises the production of stress hormones such as cortisol to unhealthy levels, and does so repeatedly, almost constantly. An elevated level of stress hormones harms the mechanisms by which the organism defends itself in the short and the long term from diseases. We know, for example, that an elevated level of cortisol reduces the number of lymphocytes (immune system cells) in the blood. Globally, excessive production of stress hormones such as adrenaline, noradrenaline, and cortisol (produced by the adrenal glands) affects the functional capacity of immune cells. This, in turn, reduces the capacity to resist the infections and other diseases against which the immune system normally fights.
The human brain reacts to acute stress, traditionally a threat to survival, by adaptive 'fight or flight' physiological responses triggered by massive secretions into the blood of stress hormones which, once the stress has passed, quickly drop back to their initial level. Poverty, however, with its daily frustrations and omnipresent insecurity, induces a state of chronic stress.
These physiological effects of stress are felt even by children. As Dr. Louise Séguin explains: "Children as well as parents experience poverty. The stress experienced by the child is reflected by an elevated level of cortisol which affects the child's immune system, physiological functioning, brain, and development." Moreover, numerous studies confirm the finding that poor children have higher rates of poor health than children in general. Poor mothers more frequently report that their children have average or poor health, or have been hospitalized. They also report a larger number of health problems, including problems associated with the immune system, even in infants. At the age of two, poor children are more likely to suffer several health problems at the same time, an indication that their immune system may be weakened by long-term stress. We also know that chronic as compared to short-term poverty has greater impact on the health of children.
Cognitive development
Socioeconomic status does not only affect health directly. It also, though indirectly, affects cognitive development. During infancy the brain develops by mechanisms, such as blood irrigation and the formation of neural connections, whose normal operation depends on an optimal physiological state. In children of poor families, elevated levels of stress hormones inhibit both synaptic connections between neurons and blood supply to the brain. The following extract from a Financial Times interview with Dr. Jack Shonkoff, a specialist in childhood development, summarizes the problem well. "Many children growing up in very poor families with low social status experience unhealthy levels of stress hormones, which impair their neural development. That effect is on top of any damage caused by inadequate nutrition and exposure to environmental toxins."
The last UNICEF report on childhood poverty (2012) also makes this association between disadvantage in childhood and health in adulthood, while also painting a global portrait of the repercussions of childhood poverty on a society as a whole.
[F]ailure to protect children from poverty is one of the most costly mistakes a society can make. The heaviest cost of all is borne by the children themselves. But their nations must also pay a very significant price – in reduced skills and productivity, in lower levels of health and educational achievement, in increased likelihood of unemployment and welfare dependence, in the higher costs of judicial and social protection systems, and in the loss of social cohesion.
In its report on the situation of young people in Montreal, the city's Direction de santé publique (Department of Public Health) states that all children do not arrive at school with the same advantages and that the school milieu presents several hurdles for the most disadvantaged children. When cognitive development, skills acquisition, and academic learning have been impeded, it becomes more difficult to escape the poverty in which one grew up. After failing in school, young people tend to drop out, become parents prematurely, and reproduce the difficult conditions they have known since their childhood, with all the familiar negative impacts on health. From infancy to adulthood, they encounter situations and circumstances that degrade their health: academic difficulties, poor training during adolescence, jobs with poor working conditions and inadequate income, low-grade housing, and more.
Early intervention is needed to counter the impacts of poverty on cognitive development. In this context, the index of school readiness is a valuable tool. It is used to assess a child's degree of preparedness even before the child starts going to school. The index measures a child's development in five domains: cognitive and linguistic development; communication skills and general knowledge; social competence; affective maturity; and physical health and well-being.
Montreal's Direction de santé publique has conducted a survey to measure school readiness on its territory, and to determine what is needed to ensure that all children are ready for schooling. The results showed that the proportion of vulnerable children (that is, those assessed as deficient in at least one domain) rose from 28 percent in neighbourhoods with a 10 percent poverty rate to 40 percent in those with a 52 percent poverty rate.
Illnesses associated with atmospheric pollution
It has been clearly shown that low socioeconomic status is associated with greater exposure to pollution and its trail of health problems. It suffices to think of the poor air quality in working-class neighbourhoods that are near highways or industrial zones. Such neighbourhoods, moreover, are often far from parks and open green spaces where vegetation helps purify the air. Numerous studies have shown that as air pollution increases, so too does the frequency of hospitalizations for respiratory problems. A Montreal study has shown that people who live near roads with heavy traffic are at increased risk of being hospitalized for respiratory problems; and 1,500 premature deaths per year in Montreal are attributable to atmospheric pollution.
The fine particles in the air that cause certain health problems can enter the body not only through respiratory pathways but also through blood vessels, and hence the hypothesis that fine particles (less than 2.5 µm in diameter) are inhaled, pass through the tissues of the respiratory system to penetrate into blood vessels, and thus encourage the development of atherosclerosis (plaques that block arteries and may cause cardiovascular diseases such as strokes, infarctions, and angina). One of the many studies supporting this hypothesis compared data from 51 American cities. When all other risk factors for mortality had been taken into account, life expectancy dropped by 0.6 years for each incremental increase in fine particle concentration of ten micrograms per cubic meter of air. This effect was largely attributable to cardiovascular failure. And since pollution levels between cities can vary by as much as 20 µg/m3, life expectancy varies even more ...
Upstream: the social determinants of health
The negative repercussions of poverty on health mentioned above give only a sampling of the effects of poverty on the health and well-being of individuals. There are, in fact, many other such effects. These include, to name a few, diabetes, cancer, infectious diseases, nicotine addiction, respiratory diseases, intrauterine retardation, and accidental injury of children. The prevalence of these health problems is higher amongst disadvantaged people.
Upstream of the physiological mechanisms triggered by poverty are what are known as the social determinants of health. This term refers to poor living conditions imposed by poverty, which also constitute risk factors, such as unhealthy housing, lack of education, poor working conditions, limited access to quality food, and weak social support. As well as such directly operating living conditions, the social determinants also include more global realities such as, for example, government policies (access to education, universality of healthcare, family benefits, access to housing, etc.), ethnic discrimination, and the economic situation. The diagram below (figure 1.3), prepared by the WHO Commission on Social Determinants, clearly illustrates the different types of determinants and the steps in the process by which they produce social inequalities in health. This diagram highlights the avoidable nature of these inequalities, and shows the consequences of political and economic choices.
Several dimensions, approaches, and models intersect in analyses of the causes of social inequalities in health. Psychosocial, behavioural or cultural models, the life-course approach, the materialist model — all refer to different aspects of the phenomenon, which can play a role to varying degrees, according to the situation. Several elements are at work in situations of poverty. These include increased exposure to health risks such as stress (psychosocial model); the adoption of harmful behaviours because of their predominance in the social environment (behavioural and cultural models); an accumulation of circumstances during the course of life that weaken health (life-course approach); or a lack of money to pay for needed resources and services (materialist model). All are social causes of health inequalities.
A global trend
The OECD has now confirmed that, over the last thirty years, the income gap between rich and poor has been steadily increasing not only in most of its member countries, but also in several developing countries. Moreover, wealth-distribution mechanisms (income taxes, social transfers, etc.) are decreasing in efficiency, particularly in Canada. According to Angel Gurria, Secretary-General of the OECD, the observed trend refutes the hypothesis that, without any state intervention, profits from economic growth will end up profiting all, since the income gaps have grown during a long period of economic growth.
(Continues...)
Excerpted from Scandinavian Common Sense by Marie-France Raynault, Dominique Côté. Copyright © 2015 Baraka Books. Excerpted by permission of Baraka Books.
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Table of Contents
Contents
ACKNOWLEDGMENTS,THE AUTHORS,
PREFACE TO THE ENGLISH EDITION,
PREFACE TO THE FIRST EDITION,
INTRODUCTION,
CHAPTER 1 Social Inequalities in Health: a Real and Persistent Problem,
CHAPTER 2 The Best Strategies for Reducing Social Inequalities in Health,
CHAPTER 3 The Example of the Nordic Countries,
CHAPTER 4 The Characteristics of the Nordic Countries' Policies,
CHAPTER 5 Family and Work-Life Balancing Policies,
CHAPTER 6 Policies to Support Housing,
CHAPTER 7 Gender Equity Policies,
CHAPTER 8 Education Policies,
CHAPTER 9 Policies of Social Inclusion,
CHAPTER 10 Sustainable Development at the Local Level,
CHAPTER 11 Critical Views on the Nordic Countries' Policies,
CONCLUSION,
BIBLIOGRAPHY,