The processes that link a person’s socialcontext, culture, and social position to their health are often interconnectedand difficult to disentangle. Oneuseful framework for this purpose comes from the World Health Organization’sCommission on the Social Determinants of Health, which states that “people’shealth largely depends on the conditions in which they live and work—the socialdeterminants of health,” (Graham, 2007, 102). Models of the social determinantsof health represent them as a web of factors that influence people’s health.
Atthe top of the web are the cultural, social, and economic characteristics of asociety, which determine the social positions of members of that society usingan individual’s gender, race, ethnicity, age, sexuality, nationality, socioeconomicposition, and many others. The social position of an individual largelyinfluences their beliefs and behaviors, family structures, and the physical areasin which they live. All of this determines the specific exposures individualsare likely to face, such as smoking, substance abuse, air pollution, housing, structuraland interpersonal violence, and working environment, among others.
Theseexposures will intertwine with genetic factors and biological pathways toproduce health outcomes for individuals and populations (Graham, 2007).In this model health is the outcome ofmany processes that begin with the social structure of a society and that determinethe exposures to which those who occupy various social positions will besubjected (Graham, 2007). The term “‘health inequalities’ is widely used torefer to inequalities in people’s health that are linked to inequalities intheir position in society. In particular, this essay will explore how theinterconnected concepts of discrimination, gender inequality, incomeinequality, and violence lead to health inequalities both on an individual andpopulation level.Discrimination and SocialExclusionOne mechanism for enforcing and reifyingthe social positions of groups and individuals is discrimination, which leadsto inequalities in health, income, education, housing, and many others. Thereis much evidence that discrimination shapes societal distributions of healthand disease. One sociological definition of discrimination includes “theprocess by which a member, or members, of a socially defined group is, or are,treated differently (especially unfairly) because of his/her/their membershipof that group,” (Krieger, 2014, 650).
As Krieger (2014) further explains,discrimination:Refers to all means ofexpressing and institutionalizing social relationships of dominance andoppression. At issue are practices of dominant groups to maintain privilegesthey accrue through subordinating the groups they oppress and the ideologiesthey use to justify these practices, which typically revolve around notions ofinnate superiority and inferiority, difference, or deviance, (Krieger, 2014,650). Itis important to note that random and individual acts of unfairness do notconstitute discrimination, but that discrimination must be socially structuredand condoned through actions taken by both individuals and institutions (Krieger,2014).Three main types of discrimination exist:institutional, which usually refers to discriminatory policies carried out bystate, or non-state actors; structural, which refers to discrimination in areassuch as housing, employment, wages, media, health care, criminal justice, andothers; and interpersonal, which refers to discriminatory interactions betweenindividuals.
In all instances of discrimination acts of unfairness areperpetrated against specific groups or individuals to reinforce power dynamicsin which one group asserts dominance over a socially defined subordinate group(Krieger, 2014). The main groups or identities that are used as the bases fordiscrimination are largely determined by race or ethnicity, gender, sexuality,immigrant status, class or socioeconomic status, age, ability or disability,and religion (Berkman and Kawachi, 2000; Krieger, 2014). While in somesocieties, such as the UK, class is very much recognized as a criterion fordiscrimination, “in the US social class is largely absent from politicaldiscourse and popular understandings of how society works. Instead, ethnic andracial identities serve as oblique markers of social class,” (Graham, 2007,42). Because every person embodiesmultiple identities, such as their ethnicity, gender, socioeconomic status,nationality, etc., individuals can experience multiple forms of discriminationat once. For example, a transgender Black American woman may often be subjectedto specific stereotypes about Black American women, such as the ‘welfarequeen,’ or the hypersexualized video vixen, while simultaneously navigatinggeneralized sexism and racism, as well as interpersonal and institutionalherterosexism (Krieger, 2014).In many studies of health disparitiesbetween ethnic groups, disparities are often treated as being based inbiological differences rather than being socially determined (Krieger, 2014).
However, Berkman and Kawachi (2000), employ the ‘ecosocial’ standpoint to helpexplain how experiences of discrimination can be embodied and expressed asphysical health outcomes. They explain that experiences of racism, sexism,classism, etc., can be incorporated into the body and expressed biologically inways that produce health disparities between dominant groups and those who aremarginalized.There are many ways in whichdiscrimination can lead to negative health outcomes. One example of a pathwayby which discrimination affects health includes race-based residential andoccupational segregation in the US, which, over generations, has led toeconomic disadvantage among ethnic minorities, especially Black and LatinxAmericans. As a result, Black and Latinx Americans are more likely than whiteAmericans to live in ‘food deserts,’ or neighborhoods that lack access to goodsupermarkets, thereby inhibiting their access to healthy and affordable foods,and encouraging diets high in fat, sodium, and sugar. Further, residentialsegregation into impoverished neighborhoods and undesirable areas increases therisk that Black Americans and other minorities will be exposed to lead orcontaminated soil due to proximity to highways, industrial plant sights, andwaste dumps. Further, segregation of ethnic minorities into undesirableneighborhoods increases their risk of exposure to violence.
Another example ofhow discrimination can affect health stems from the experience ofdiscrimination itself—the perception, or even anticipation of which can lead tofear, anger, and elevated blood pressure, and over time can lead tohypertension, anxiety, depression, and other stress-related diseases (Berkmanand Kawachi, 2000).Gender Inequality Historical and contemporarydiscrimination against women has led to global gender-based inequalities inhealth, education, and political and economic power, among many others. Gendernorms and inequalities between men and women are major determinants of healthoutcomes globally (Davies and Bennett, 2017). Gendered roles and expectationsin terms of occupations, activities, control of resources, and decision makinglead to differential risks of exposure to infectious disease, while powerrelations between men and women affect how and whether women and children areable to protect themselves. Because women often have lower socioeconomic statusthan men, they are often unable to bargain with partners for safe sexpractices, and thus are often at increased risk of HIV/AIDS and other sexuallytransmitted infections. Further, the social consequences of infectious diseasesare often more severe for women than men, which can lead women to avoid seekingcare. In some cultures, preference for sons and the devaluation of daughtersleads to boys receiving priority for healthcare both within and outside thehome. Due to these factors and others, among the poorest of the globalpopulation, 6% more women than men are killed by infectious diseases (Tolhurstet al.
, 2002). Due to social and biological differences,discrepancies in disease outcomes often exist between men and women. While mencan have higher prevalence of infectious diseases, women often suffer moresevere outcomes of diseases, including those caused by influenza, HIV, andhaemorrhagic fever viruses (Klein and Roberts, 2015). In many societies, such as in West Africaduring the recent Ebola outbreak, women’s traditional roles as care-givers andthose who prepare the bodies of the dead place them at increased risk ofinfection. Further, in emergencies such as epidemics or natural disasters,displaced women face disproportionate risk of violence, forced marriage, andare less likely than men to have access to resources, such as food, medicalcare, and contraceptives. This is often compounded as women and children are atgreater risk of experiencing social and economic deprivation, which bothincrease their risk of exposure, and limits their ability to obtain propertreatment (Davies and Bennet, 2017). There have been many reported cases ofgender bias in bio-medical research. In many cases, women have often been leftout of biomedical studies, and as a result, much medical literature has onlybeen generalizable to men:Despite sex being the most evolutionarilywell conserved and easily disaggregated variable by which to compare theoutcome of diseases and their treatments, it is often ignored in the biomedicalsciences.
The challenges of including women in clinical trials are in somecases obvious and include the potential of hormonal variations during menstrualcycles and their cessation at menopause. These factors are further complicateddue to pregnancy (when hormone levels change and the fetus could be at riskduring a trial) or artificial administration of hormones as contraceptives orfor hormone replacement therapy. However, the scientific, medical, and ethicalcases for including males and females in preclinical and clinical trials aretoo profound to ignore (Klein and Roberts, 2015, 389). Thegender bias in biomedical research occurs in part, because in 1977 the Food andDrug Administration recommended that women of childbearing potential beexcluded from drug-development studies. Subsequently, this led to all womenbeing excluded from drug and vaccine trials, until recommendations were made inthe 1990s that women be included in clinical trials. The exclusion of women inclinical trials has led to a dearth of outcome data by sex, and as a result, itis often not considered whether discrepancies in recommended dosage, adverseside effects, or the efficacy of drugs will exist between men and women.Additionally, eight out of every ten drugs recalled from the US pharmaceuticalmarket in 2005 were due to disproportionate adverse side effects in women ascompared to men (Klein and Roberts, 2015; McGregor, 2017).
Clinical drug trials are not theonly instances of gender-bias in biomedical research. The influence of sex onboth infectious disease risk and the physical presentation of disease symptomshave often been ignored. Many diseases, including HIV/AIDS and heart diseasehave been clinically defined and diagnosed based on male symptoms, even whensymptoms had distinct and differential presentations in women (Tolhurst et al.,2002). Gender bias in various forms has ledwomen to bare a disproportionate global burden of disease, which can oftenexacerbate unequal circumstances by further restricting them from the labormarket, education, and other opportunities.Poverty and IncomeInequality Another category of the major socialdeterminants of health includes poverty and income inequality.
Over the lastfew centuries, economic expansion in high-income countries like the US and UKhas been associated with overall decreases in morbidity and mortality as wellas increasing life expectancy. In high-income countries the most importantcauses of death have shifted from infectious diseases to lifestyle-related non-communicablediseases, which typically develop as a result of long-term exposure to riskfactors. In many lower income countries, which have fewer resources such asvaccines, infectious diseases are still primary causes of death for many people.However, in some developing countries, particularly those most affected byHIV/AIDS and malaria, a phenomenon known as the ‘double burden of disease’ hasdeveloped in which a society in economic transition suffers high mortality fromboth communicable and non-communicable disease (Graham, 2007). There is a well-established relationshipbetween socioeconomic status of both individuals and populations and health(Bramba, 2010; Berkman and Kawachi, 2000). Those who are of highersocioeconomic status fair better in terms of health and happiness due tosocial, political, and institutional factors which allow them increased accessto health-enhancing resources, while those of lower socio-economic status oftenface greater numbers of health damaging exposures (Berkman and Kawachi, 2000;Wilkinson and Pickett, 2009). While deaths from non-communicablediseases are declining across all sectors of society in high-income countries,they are declining faster in individuals with higher socioeconomic status thanthey are in those of lower socioeconomic status. Because economically deprivedindividuals are more likely to work in high-risk conditions, live in areas withgreater environmental risk factors, live in undesirable housing, and havereduced access to healthy and affordable foods, exposures to diseases onceassociated with economic prosperity, such as smoking, overweight and obesity,and alcohol consumption, have become associated with those of lowersocioeconomic status (Graham, 2007).
Due, in part, to reduced access to qualityhealth care and increased environmental stressors, studies have shown thatdespite lower overall consumption of alcohol, those of a lower socioeconomicstatus often carry a higher burden of alcohol related disease (Blas and Kurup,2010). In many cases external factors exacerbate conditions that lead to poorerhealth in economically deprived areas. Targeted advertising of tobacco andalcohol products to low-income communities increases risks of addiction, aswell as other associated adverse health outcomes (Berkman and Kawachi, 2000;Krieger, 2014).
These effects seem to be compounded byincome inequality. Poor health, HIV, violence, teen pregnancy, and others areall more common in more unequal societies, such as the US, in which there aregreater disparities in the incomes between the rich and the poor (Wilkinson andPickett, 2009; Gillespie, Kadiyala, et al.2007).Forms of Violence andImpact on Health Outcomes Inmany cases, those who are socially and economically deprived are morevulnerable to both institutional and interpersonal violence. Studies have alsofound a positive relationship between macro-level income inequality andviolence, in which societies, and even cities with greater levels of incomeinequality also had higher rates of homicide and assault than did more equalsocieties (Wilkinson and Pickett, 2009). Globalinequalities can also lead to political instability and political violence.
Political violence can increase theburden of disease and facilitate epidemics such as the Ebola outbreaks inLiberia, Guinea, and Sierra Leone. All three countries were affected by theepidemic while still recovering from the devastating effects of civil war ormilitary coup on their economies, infrastructures, and resources. Some haveargued that the international community failed to recognize the ways thatpolitical violence left these countries particularly vulnerable to thishorrible epidemic, and to respond appropriately in order to halt the spread of Ebola(Davies and Bennett, 2017).Another form of violence that pervadesevery country, race, and socioeconomic bracket is Intimate Partner Violence(IPV). Many studies exist linking IPV with negative physical and mental healthoutcomes (Loxton et al., 2017; Horon and Cheng, 2001; Campbell, et al., 2003). Healtheffects of IPV include injury, psychological trauma and Post Traumatic StressDisorder, depression, anxiety, suicidal ideation and suicide attempts.
Adversemental health effects can, in turn, contribute to drug and alcohol abuse,cardio vascular disease, and somatic symptoms such as irritable bowel, chronicpain, and chronic pelvic pain. IPV can also lead to a lack of autonomy over thevictim’s body and resources. The victim may be unable to ensure safe, orconsensual sex practices, leading to heightened risk of sexually transmitteddiseases, unplanned pregnancy, abortion, and difficulty seeking medicaltreatment (Scott, 2015; Abdollahi et al., 2015;Loxton et al., 2017, Coker et al., 2002).A significant number of women experienceintimate partner violence for the first time during pregnancy, meaning thatpregnancy itself is a risk factor for IPV (Hall, et al., 2014; World HealthOrganization, 2011).
Prevalence of IPV among pregnant women is estimated to bebetween 1-8% in developed countries and 4- 29% in developing countries (Abdollahi, et al., 2015). Health outcomes of IPV for pregnant womencan include low birth weight, preterm birth, loss of pregnancy, and death(Scott, 2015; Hall et al., 2014; WHO, 2011; Martin et al., 2007; Horon andCheng, 2001; Campbell, et al., 2003). Most studies of IPV have neglectedmembers of the lesbian, gay, bisexual, and transgender (LGBT) communities,focusing most attention on heterosexual couples (Ard and Makadon, 2011). Thisis problematic, as studies of IPV among LGBT couples revealed that IPV occurredat the same, or higher rates as it did in heterosexual couples, with 21% of menand 35% of women who had ever cohabited with a same-sex partner, as well as34.
6% of transgender individuals reporting experiences of physical IPV (Walters,Chen, and Brieding (2013); Ard and Makadon, 2011; Houston and McKirnan, 2007).Due to heteronormative beliefs regardingwho can be regarded as a victim, members of the LGBT community often have extradifficulties reporting IPV and receiving care. In some studies, gay men werefound to be less likely to report IPV to the police because of cultural ideasthat, as men, they should have been able to defend themselves. Further, inviolent lesbian relationships, friends, family, and even domestic violence serviceproviders were less likely to believe that the victim was in danger because ofthe feminine appearance of the perpetrator (Anderson, 2005).Among the most serious health outcomesassociated with IPV is death (Scott, 2015; WHO, 2011; Al Dosary, 2016).
Homicide, or femicide, defined as thehomicide of women because they are women, has been identified as a leadingcause of death for pregnant women, is theleading cause of death for young African American women (aged 15-45), and isthe seventh leading cause of death for women globally (Shadigian,and Bauer, 2005; Campbell,et al., 2003; Brennan, 2016). The severity of the adverse health outcomesassociated with IPV, as well as the global prevalence of IPV make it a globalpublic health issue of paramount importance.Conclusion Inequality and various forms ofdiscrimination lead to a multitude of adverse health outcomes.
Social exclusionand discrimination in forms of gender bias, racism, heterosexism, and otherscan limit individuals’ economic, political and social opportunities, and keepthem from engaging fully in society. This process creates conditions thatreinforce social hierarchy and perpetuate cycles of poverty and deprivation.Poverty and deprivation can, in turn, result in violence that is oftenperpetrated against groups or individuals based on those socially excludedidentities, such as gender, sexuality, race, etc. Paying close attention to thesocial determinants of health can help to illuminate the drivers of populationhealth and health inequalities so that policies can be developed which will helpto advance health equity (Krieger, 2014).