Socio-economic issues create barriers in health care. Economic factors and social inequity are some of the most important causes of ill health, since poverty may result in poor nutrition overcrowded living conditions, inadequate clothing, low levels of education, housing or work sited in areas with greater environmental dangers as well as exposure to physical and psychological violence, psychological stress and drug and alcohol abuse are just some of the internal or external barriers that prevent effective health care to a large portion of society.

The unequal distribution of wealth and resources and of access to health care facilities can also lead to this situation. An early study of these health disparities in the UK, the Black Report of 1982, showed how health could clearly be correlated with income, and people in the poorer social class had more illness and a much higher mortality than their fellow citizens in the more affluent classes. In recent years this situation in Britain has worsened, with a widening difference in life expectancy between the social classes.

In England and Wales in 1972-76, the life expectancy for those in professional occupations was 5. years longer for men, and 5. 3 years longer for women, compared with those in unskilled manual occupations, by 1992-96, however, this class gap in life-expectancy had widened to 9. 5 years for men and 6. 4 for women. In many western societies these disparities are particularly evident in ethnic or cultural minority groups, whether they are immigrants or native born. In the USA, several studies indicate that members of minority groups suffer disproportionately from conditions such as heart disease, diabetes, asthma, cancer, and other diseases.

The reasons for these health disparities are complex and they include the many effects of poverty, but also the biases and lack of flexibility of the health care system itself. Also ethnic minorities in the USA have much lower rates of coverage by health insurance. For example, while Latinos are only 13 percent of the population, they represent 25 percent of those without any health insurance. People with low incomes may not only be able to afford good health care, they may also be unable to take time off work to make use of whatever health care is available.

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A further factor in damaging the health of minority groups may be discrimination, racism r persecution by the host population, as well as a general unwillingness to take not of their health beliefs, practices and expectations (Betancourt, Green, Carillo & Ananeh-Firempong, 2003). In the developing world too, whatever the local culture, poor health is usually associated with a low income and poverty, since this influences the sort of food, water, clothing, sanitation, housing and medical care that people are able to afford.

Health disparities and the physical environment in which poor communities live can directly impact on their health, resulting in an inability to afford clean water supply or adequate sewerage disposal. In 2005, the United Nations Development Program estimated that 1. 2 billion people still lacked access to safe drinking water, while 2. 4 billion people had no access to proper sanitation, and both situations could lead to increased rates of waterborne diseases, which already kill some 2 million children every year.

An example of the relationship of inequality to health status was described in Unterhalters study of infant mortality rates among different ethnic communities in Johannesburg, South Africa, between 1910 and 1979. She found very much higher rates of infant mortality among blacks and other non-white groups than among whites, and this clearly correlated with the economic and social inequalities imposed upon them by the apartheid system. Preston-Whyte has described how the legacy of this political system of racism has made the control of acquired immunodeficiency syndrome or AIDS in South Africa much more difficult today.

This is because apartheid was a system that in the rural areas often separated men from their wives, sending them to work in the cities for many years. Here they lived in male only hostels, and this helped institutionalize multiple partner sex relationships for many of them. At the same time, in the rural areas poor women sometimes had to depend on selling sex in order to earn money for their own survival and that of their children (Kleinman, 1981).

The effects of social inequality on health and life expectancy can also apply to affluent societies; deprivation can be relative, as well as absolute. Marmot had described the status syndrome in which, for people above a thresh old of material well being, other factors such as the sense of autonomy and control over their lives and opportunities for full social engagement and participation are crucial for their health, well being and longevity.

Research indicates that the higher and more successful one is in the social hierarchy, or even within a particular organization, such as a business, corporation, or bureaucracy, the greater one’s health and life expectancy. The lower the social ranking, the higher the health risks, for example, he quotes research showing that movie actors who win an Academy Award live on average 4 years longer than their co-stars, and other actors who were nominated for the Award but never got it. This social gradient in health seems to be found in all societies, rich and poor, where hierarchy or social inequality is a feature.

An example of this from Britain was the famous Whitehall study, a 25 year detailed study of the health of 18,000 government employees, which found a much higher morbidity and mortality, especially from heart disease, in the lower ranks of the bureaucracy. Top administrators and executive officers had much better health, and a greater life expectancy, than clerical or other lower staff. Factors such as income or level of education played a part in this, but so did the subjective sense of control that people had over their particular life circumstances, both at work and at home.

Marmot notes that a key factory here may be psychological, since the psychological experience of inequality has profound effects on body systems. The subjective experience of stress and a lack of control over it may be a major factor in causing physiological changes, which in turn lead to the social gradient of health (Marmot, 2004). People at the same level in the occupational hierarchy with different amounts of control had markedly different rates of disease and low control consistently led to more disease.

Another factor is the degree of social cohesion that exists, and whether the individual is imbedded in supportive networks of family, friends, or workmates. On a national level societies that are characterized by high social cohesion, whether rich or poor, have better health that others with the same wealth but lower social cohesion. When poorer societies undergo rapid economic and social development, the health of many of their citizens may improve, but that of others may deteriorate.

For example, a study in China in the mid 1990’s showed how far groups whose socioeconomic status improved, the odds of their having a healthier lifestyle actually decreased. New affluence meant a shift towards eating more processed food, rich in fats, salt and refined sugar, as well as a more sedentary lifestyle. Paradoxically, those groups who remained at a lower socioeconomic level seemed to maintain a healthier lifestyle, leading a more active life, and eating more natural foods such as fruits, vegetables and grains (Landy, 1977).

This phenomenon of lifestyle transition in poorer developing countries, may partly explain why nutrition related non-communicable diseases are more prevalent in the developing world among people with a higher socioeconomic status, whereas the opposite is found in developed societies. These new diseases in the population include obesity, diabetes, and cardiovascular disorders. In the United States health care it is not a citizen’s right but a commodity for sale. The result is a two tier system of medical care, superior care for those who can afford the cost, and inferior care for those who cannot.

Unlike the middle and upper classes, few poor people have a personal physician and they usually must spend hours waiting in crowded public health clinics. After waiting most of a day, some don’t even get to see a doctor but instead are told to come back the nest day. And when the poor are hospitalized, they are likely to find themselves in understaffed and under funded public hospitals, where they are treated by rotating interns who do not know them and cannot follow up on their progress.


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