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The processes that link a person’s social
context, culture, and social position to their health are often interconnected
and difficult to disentangle.            One
useful framework for this purpose comes from the World Health Organization’s
Commission on the Social Determinants of Health, which states that “people’s
health largely depends on the conditions in which they live and work—the social
determinants of health,” (Graham, 2007, 102). Models of the social determinants
of health represent them as a web of factors that influence people’s health. At
the top of the web are the cultural, social, and economic characteristics of a
society, which determine the social positions of members of that society using
an individual’s gender, race, ethnicity, age, sexuality, nationality, socioeconomic
position, and many others. The social position of an individual largely
influences their beliefs and behaviors, family structures, and the physical areas
in which they live. All of this determines the specific exposures individuals
are likely to face, such as smoking, substance abuse, air pollution, housing, structural
and interpersonal violence, and working environment, among others. These
exposures will intertwine with genetic factors and biological pathways to
produce health outcomes for individuals and populations (Graham, 2007).

In this model health is the outcome of
many processes that begin with the social structure of a society and that determine
the exposures to which those who occupy various social positions will be
subjected (Graham, 2007). The term “‘health inequalities’ is widely used to
refer to inequalities in people’s health that are linked to inequalities in
their position in society. In particular, this essay will explore how the
interconnected concepts of discrimination, gender inequality, income
inequality, and violence lead to health inequalities both on an individual and
population level.

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Discrimination and Social

One mechanism for enforcing and reifying
the social positions of groups and individuals is discrimination, which leads
to inequalities in health, income, education, housing, and many others. There
is much evidence that discrimination shapes societal distributions of health
and disease. One sociological definition of discrimination includes “the
process by which a member, or members, of a socially defined group is, or are,
treated differently (especially unfairly) because of his/her/their membership
of that group,” (Krieger, 2014, 650). As Krieger (2014) further explains,

Refers to all means of
expressing and institutionalizing social relationships of dominance and
oppression. At issue are practices of dominant groups to maintain privileges
they accrue through subordinating the groups they oppress and the ideologies
they use to justify these practices, which typically revolve around notions of
innate superiority and inferiority, difference, or deviance, (Krieger, 2014,

is important to note that random and individual acts of unfairness do not
constitute discrimination, but that discrimination must be socially structured
and condoned through actions taken by both individuals and institutions (Krieger,

Three main types of discrimination exist:
institutional, which usually refers to discriminatory policies carried out by
state, or non-state actors; structural, which refers to discrimination in areas
such as housing, employment, wages, media, health care, criminal justice, and
others; and interpersonal, which refers to discriminatory interactions between
individuals. In all instances of discrimination acts of unfairness are
perpetrated against specific groups or individuals to reinforce power dynamics
in which one group asserts dominance over a socially defined subordinate group
(Krieger, 2014). The main groups or identities that are used as the bases for
discrimination 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 some
societies, such as the UK, class is very much recognized as a criterion for
discrimination, “in the US social class is largely absent from political
discourse and popular understandings of how society works. Instead, ethnic and
racial identities serve as oblique markers of social class,” (Graham, 2007,

            Because every person embodies
multiple identities, such as their ethnicity, gender, socioeconomic status,
nationality, etc., individuals can experience multiple forms of discrimination
at once. For example, a transgender Black American woman may often be subjected
to specific stereotypes about Black American women, such as the ‘welfare
queen,’ or the hypersexualized video vixen, while simultaneously navigating
generalized sexism and racism, as well as interpersonal and institutional
herterosexism (Krieger, 2014).

In many studies of health disparities
between ethnic groups, disparities are often treated as being based in
biological differences rather than being socially determined (Krieger, 2014).

However, Berkman and Kawachi (2000), employ the ‘ecosocial’ standpoint to help
explain how experiences of discrimination can be embodied and expressed as
physical health outcomes. They explain that experiences of racism, sexism,
classism, etc., can be incorporated into the body and expressed biologically in
ways that produce health disparities between dominant groups and those who are

There are many ways in which
discrimination can lead to negative health outcomes. One example of a pathway
by which discrimination affects health includes race-based residential and
occupational segregation in the US, which, over generations, has led to
economic disadvantage among ethnic minorities, especially Black and Latinx
Americans. As a result, Black and Latinx Americans are more likely than white
Americans to live in ‘food deserts,’ or neighborhoods that lack access to good
supermarkets, thereby inhibiting their access to healthy and affordable foods,
and encouraging diets high in fat, sodium, and sugar. Further, residential
segregation into impoverished neighborhoods and undesirable areas increases the
risk that Black Americans and other minorities will be exposed to lead or
contaminated soil due to proximity to highways, industrial plant sights, and
waste dumps. Further, segregation of ethnic minorities into undesirable
neighborhoods increases their risk of exposure to violence. Another example of
how discrimination can affect health stems from the experience of
discrimination itself—the perception, or even anticipation of which can lead to
fear, anger, and elevated blood pressure, and over time can lead to
hypertension, anxiety, depression, and other stress-related diseases (Berkman
and Kawachi, 2000).

Gender Inequality

Historical and contemporary
discrimination against women has led to global gender-based inequalities in
health, education, and political and economic power, among many others. Gender
norms and inequalities between men and women are major determinants of health
outcomes globally (Davies and Bennett, 2017). Gendered roles and expectations
in terms of occupations, activities, control of resources, and decision making
lead to differential risks of exposure to infectious disease, while power
relations between men and women affect how and whether women and children are
able to protect themselves. Because women often have lower socioeconomic status
than men, they are often unable to bargain with partners for safe sex
practices, and thus are often at increased risk of HIV/AIDS and other sexually
transmitted infections. Further, the social consequences of infectious diseases
are often more severe for women than men, which can lead women to avoid seeking
care. In some cultures, preference for sons and the devaluation of daughters
leads to boys receiving priority for healthcare both within and outside the
home. Due to these factors and others, among the poorest of the global
population, 6% more women than men are killed by infectious diseases (Tolhurst
et al., 2002).

Due to social and biological differences,
discrepancies in disease outcomes often exist between men and women. While men
can have higher prevalence of infectious diseases, women often suffer more
severe outcomes of diseases, including those caused by influenza, HIV, and
haemorrhagic fever viruses (Klein and Roberts, 2015).

In many societies, such as in West Africa
during the recent Ebola outbreak, women’s traditional roles as care-givers and
those who prepare the bodies of the dead place them at increased risk of
infection. Further, in emergencies such as epidemics or natural disasters,
displaced women face disproportionate risk of violence, forced marriage, and
are less likely than men to have access to resources, such as food, medical
care, and contraceptives. This is often compounded as women and children are at
greater risk of experiencing social and economic deprivation, which both
increase their risk of exposure, and limits their ability to obtain proper
treatment (Davies and Bennet, 2017).

There have been many reported cases of
gender bias in bio-medical research. In many cases, women have often been left
out of biomedical studies, and as a result, much medical literature has only
been generalizable to men:

Despite sex being the most evolutionarily
well conserved and easily disaggregated variable by which to compare the
outcome of diseases and their treatments, it is often ignored in the biomedical
sciences. The challenges of including women in clinical trials are in some
cases obvious and include the potential of hormonal variations during menstrual
cycles and their cessation at menopause. These factors are further complicated
due to pregnancy (when hormone levels change and the fetus could be at risk
during a trial) or artificial administration of hormones as contraceptives or
for hormone replacement therapy. However, the scientific, medical, and ethical
cases for including males and females in preclinical and clinical trials are
too profound to ignore (Klein and Roberts, 2015, 389).


gender bias in biomedical research occurs in part, because in 1977 the Food and
Drug Administration recommended that women of childbearing potential be
excluded from drug-development studies. Subsequently, this led to all women
being excluded from drug and vaccine trials, until recommendations were made in
the 1990s that women be included in clinical trials. The exclusion of women in
clinical trials has led to a dearth of outcome data by sex, and as a result, it
is often not considered whether discrepancies in recommended dosage, adverse
side effects, or the efficacy of drugs will exist between men and women.

Additionally, eight out of every ten drugs recalled from the US pharmaceutical
market in 2005 were due to disproportionate adverse side effects in women as
compared to men (Klein and Roberts, 2015; McGregor, 2017).

            Clinical drug trials are not the
only instances of gender-bias in biomedical research. The influence of sex on
both infectious disease risk and the physical presentation of disease symptoms
have often been ignored. Many diseases, including HIV/AIDS and heart disease
have been clinically defined and diagnosed based on male symptoms, even when
symptoms had distinct and differential presentations in women (Tolhurst et al.,

            Gender bias in various forms has led
women to bare a disproportionate global burden of disease, which can often
exacerbate unequal circumstances by further restricting them from the labor
market, education, and other opportunities.

Poverty and Income

Another category of the major social
determinants of health includes poverty and income inequality. Over the last
few centuries, economic expansion in high-income countries like the US and UK
has been associated with overall decreases in morbidity and mortality as well
as increasing life expectancy. In high-income countries the most important
causes of death have shifted from infectious diseases to lifestyle-related non-communicable
diseases, which typically develop as a result of long-term exposure to risk
factors. In many lower income countries, which have fewer resources such as
vaccines, infectious diseases are still primary causes of death for many people.

However, in some developing countries, particularly those most affected by
HIV/AIDS and malaria, a phenomenon known as the ‘double burden of disease’ has
developed in which a society in economic transition suffers high mortality from
both communicable and non-communicable disease (Graham, 2007).

There is a well-established relationship
between socioeconomic status of both individuals and populations and health
(Bramba, 2010; Berkman and Kawachi, 2000). Those who are of higher
socioeconomic status fair better in terms of health and happiness due to
social, political, and institutional factors which allow them increased access
to health-enhancing resources, while those of lower socio-economic status often
face greater numbers of health damaging exposures (Berkman and Kawachi, 2000;
Wilkinson and Pickett, 2009).

While deaths from non-communicable
diseases are declining across all sectors of society in high-income countries,
they are declining faster in individuals with higher socioeconomic status than
they are in those of lower socioeconomic status. Because economically deprived
individuals are more likely to work in high-risk conditions, live in areas with
greater environmental risk factors, live in undesirable housing, and have
reduced access to healthy and affordable foods, exposures to diseases once
associated with economic prosperity, such as smoking, overweight and obesity,
and alcohol consumption, have become associated with those of lower
socioeconomic status (Graham, 2007). Due, in part, to reduced access to quality
health care and increased environmental stressors, studies have shown that
despite lower overall consumption of alcohol, those of a lower socioeconomic
status often carry a higher burden of alcohol related disease (Blas and Kurup,
2010). In many cases external factors exacerbate conditions that lead to poorer
health in economically deprived areas. Targeted advertising of tobacco and
alcohol products to low-income communities increases risks of addiction, as
well as other associated adverse health outcomes (Berkman and Kawachi, 2000;
Krieger, 2014).

These effects seem to be compounded by
income inequality. Poor health, HIV, violence, teen pregnancy, and others are
all more common in more unequal societies, such as the US, in which there are
greater disparities in the incomes between the rich and the poor (Wilkinson and
Pickett, 2009; Gillespie, Kadiyala, et al.


Forms of Violence and
Impact on Health Outcomes

many cases, those who are socially and economically deprived are more
vulnerable to both institutional and interpersonal violence. Studies have also
found a positive relationship between macro-level income inequality and
violence, in which societies, and even cities with greater levels of income
inequality also had higher rates of homicide and assault than did more equal
societies (Wilkinson and Pickett, 2009).

inequalities can also lead to political instability and political violence. Political violence can increase the
burden of disease and facilitate epidemics such as the Ebola outbreaks in
Liberia, Guinea, and Sierra Leone. All three countries were affected by the
epidemic while still recovering from the devastating effects of civil war or
military coup on their economies, infrastructures, and resources. Some have
argued that the international community failed to recognize the ways that
political violence left these countries particularly vulnerable to this
horrible epidemic, and to respond appropriately in order to halt the spread of Ebola
(Davies and Bennett, 2017).

Another form of violence that pervades
every country, race, and socioeconomic bracket is Intimate Partner Violence
(IPV). Many studies exist linking IPV with negative physical and mental health
outcomes (Loxton et al., 2017; Horon and Cheng, 2001; Campbell, et al., 2003). Health
effects of IPV include injury, psychological trauma and Post Traumatic Stress
Disorder, depression, anxiety, suicidal ideation and suicide attempts. Adverse
mental health effects can, in turn, contribute to drug and alcohol abuse,
cardio vascular disease, and somatic symptoms such as irritable bowel, chronic
pain, and chronic pelvic pain. IPV can also lead to a lack of autonomy over the
victim’s body and resources. The victim may be unable to ensure safe, or
consensual sex practices, leading to heightened risk of sexually transmitted
diseases, unplanned pregnancy, abortion, and difficulty seeking medical
treatment (Scott, 2015; Abdollahi et al., 2015;
Loxton et al., 2017, Coker et al., 2002).

A significant number of women experience
intimate partner violence for the first time during pregnancy, meaning that
pregnancy itself is a risk factor for IPV (Hall, et al., 2014; World Health
Organization, 2011). Prevalence of IPV among pregnant women is estimated to be
between 1-8% in developed countries and 4- 29% in developing countries (Abdollahi, et al., 2015). Health outcomes of IPV for pregnant women
can include low birth weight, preterm birth, loss of pregnancy, and death
(Scott, 2015; Hall et al., 2014; WHO, 2011; Martin et al., 2007; Horon and
Cheng, 2001; Campbell, et al., 2003).

Most studies of IPV have neglected
members of the lesbian, gay, bisexual, and transgender (LGBT) communities,
focusing most attention on heterosexual couples (Ard and Makadon, 2011). This
is problematic, as studies of IPV among LGBT couples revealed that IPV occurred
at the same, or higher rates as it did in heterosexual couples, with 21% of men
and 35% of women who had ever cohabited with a same-sex partner, as well as
34.6% 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 regarding
who can be regarded as a victim, members of the LGBT community often have extra
difficulties reporting IPV and receiving care. In some studies, gay men were
found to be less likely to report IPV to the police because of cultural ideas
that, as men, they should have been able to defend themselves. Further, in
violent lesbian relationships, friends, family, and even domestic violence service
providers were less likely to believe that the victim was in danger because of
the feminine appearance of the perpetrator (Anderson, 2005).

Among the most serious health outcomes
associated with IPV is death (Scott, 2015; WHO, 2011; Al Dosary, 2016).

Homicide, or femicide, defined as the
homicide of women because they are women, has been identified as a leading
cause of death for pregnant women, is the
leading cause of death for young African American women (aged 15-45), and is
the seventh leading cause of death for women globally (Shadigian,
and Bauer, 2005; Campbell,
et al., 2003; Brennan, 2016). The severity of the adverse health outcomes
associated with IPV, as well as the global prevalence of IPV make it a global
public health issue of paramount importance.


            Inequality and various forms of
discrimination lead to a multitude of adverse health outcomes. Social exclusion
and discrimination in forms of gender bias, racism, heterosexism, and others
can limit individuals’ economic, political and social opportunities, and keep
them from engaging fully in society. This process creates conditions that
reinforce social hierarchy and perpetuate cycles of poverty and deprivation.

Poverty and deprivation can, in turn, result in violence that is often
perpetrated against groups or individuals based on those socially excluded
identities, such as gender, sexuality, race, etc. Paying close attention to the
social determinants of health can help to illuminate the drivers of population
health and health inequalities so that policies can be developed which will help
to advance health equity (Krieger, 2014).

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