Health Inequalities

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Health inequalities

Health inequalities have been strongly researched during the last years, in order to develop new strategies into adjusting social, economic, political and health systems so that differences in people’s health between specific population groups might be reduced. The National Health Service publication in Scotland defines health inequalities as unjust differences in people’s health that go against the principles of social justice because they are unfair. “They do not occur randomly or by chance, but are socially determined by circumstances largely beyond an individual’s control. These circumstances disadvantage people and limit their chance to live longer, healthier lives.” The EU community defines health inequality as “avoidable and unfair differences in health status between groups, population and individuals. (…) major health inequalities still exist both between and within Member States.” In order to avoid diseases and deaths attributed to unfair inequalities in death, which are a waste of human capital and must be reduced, the UE health politics assess that “Universal access to safe, high quality, efficient healthcare services and better cooperation between social and healthcare services, and effective action on risk factors can all help break the vicious circle of poor health/poverty/exclusion.”

The fundamental causes of health inequalities are divided in political, economic and social factors. Therefore, global economic forces, macro socio-political environment, political priorities and decisions, as well as societal values to equity and fairness are responsible for unequal distribution of income, power and wealth leading to poverty, marginalization and discrimination. Other wider environmental distribution in economic and work, physical, learning, services, social and cultural, as well as individual access to economic and work, physical, learning, services, social and interpersonal shaped experiences cause inequalities in wellbeing, healthy life expectancy, morbidity and mortality.

The key concept in discussing health inequities is the idea of avoidance. These inequalities arise within and between societies. “Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs.”

One of the most important determinants of health inequities is the social gradient, which means that usually the lower an individual’s socioeconomic position the worse is their health. “The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the system put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies and politics.”

Health inequalities must be considered under a global context of differential social prosperity through the global impact on international relations and domestic norms and policies. “These shapes the way society, both at national and local level, organizes its affairs, giving rise to forms of social position and hierarchy, whereby populations are organized according to income, education, occupation, gender, race/ethnicity and other factors.”

Social hierarchy affects people’s vulnerability to ill health and the consequences of ill health. Recent studies have shown that economic growth has distributed unequally its’ benefits over the last decades. The international flows of aid, inadequate and well below the levels promised, have a great impact on inequalities by uprising the scale of debt repayment obligations in the poorest countries. This causes an alarming financial outflow from poorer to richer countries.

Gender bias is also an important influence in equal health access. “Gender biases in power, resources, entitlements, norms and values, and the way in which organizations are structured damage the health of millions of girls and women. The position of women in society is also associated with child health and survival – of boys and girls.”

We could conclude that we can achieve a health equity by empowering individuals to challenge and change the unfair distribution of social resources to which everyone has equal claims and rights. The four main directions of power interactions: political, economic, social and cultural, constitute a continuum along which groups are excluded or included.

The UE policies take under great consideration the determiners of social inequalities. Research published using the European Social Survey (ES) data has contributed substantially to the exploration of how social inequalities in health vary across European coutries (Eikemo et al., 2008a; Eikemo et al., 2008b; Huijits, 2011; Van de Velde, Bracke & Levecqe, 2010).

But in order to improve our understanding on health inequalities, we must look deeper in the details of living conditions and behavioral/lifestyle factors and health outcomes. “(…) both more nuanced health outcomes and a larger set of social determinants of health need to be investigated. While health surveys often include a variety of health outcomes and determinants, thus far none has had sufficient data on the social stratification system of societies, including rich data on living conditions.”

The conclusions of the European survey on “Social inequalities in health and their determiners” state that most Europeans experience a burden of physical and mental health conditions after being exposed to social and behavioral factors associated with these conditions.

The extent of the exposure to social determiners of health depends strongly on their country of residence. “The mechanisms linking socioeconomic position and health vary across countries and health inequalities are the result of a complex interplay of national, behavioral, occupational and material conditions.”

In the United States there has been extensive critical analysis on health inequities during the last decades. They are focusing especially on race disparities, gaps between black and white citizens. “Researches have also drawn attention to substantial disparities in mortality and functional health status nationally and within race groups in relation to income, social class, education, and community characteristics. Inequalities in insurance coverage, health-care access and utilization, and more recently in quality of care have also been investigated.”

After years of study and research, the Department of Health and Human Services has launched an Initiative to Eliminate Racial and Ethnic Disparities in Health, focusing especially on cardiovascular diseases, HIV and diabetes.

In order to create and formulate effective programs to ameliorate health inequities a full understanding of the interrelated causes of mortality inequalities, using especially interventions in order to mitigate those causes and mechanisms. “Efforts to characterize the contribution of specific diseases and injuries, risk factors such as tobacco, alcohol, or obesity, access to effective health care, and the broader socio-economic determinants of health and disease are severely hampered by data limitations: the analysis of mortality by age and disease for specific race-counties is affected by the small numbers of deaths, such that even pooling data for ten years or more does not provide sufficient person-years of observation to draw stable and robust conclusions for some diseases, especially by age.”

In the light of these facts, one of the method used by US researchers was that of using figures from the US Census Bureau and the National Center for Health Statistics to calculate mortality rates. They combined the race-counties in different small and manageable number of groups, defined as “eight Americas” based on race-county, population density, income and homicide rate. The researchers focused on each group’s estimated life expectancy, risk of mortality from different diseases, health insurance coverage, and access to health-care services.

After applying this method on an extended period of time, 1987 – 2001, the researchers found that the health inequalities remained the same during all those years. Another conclusion drew attention upon the improvement that the health system should make in order to reduce the risk factors for chronic diseases and injuries.

If the US is trying to develop a nation-wide/across-states policy of health inequity acknowledgement and overcoming, the UE is trying a different recognition strategy of the health inequality issues. Seeing that the European States are independent nations with independent governments, the World Health Organization and the European Union can only provide a framework and different principles to encourage action in as many countries as possible. In 1998, the World Health Assembly gave a declaration in which it emphasized “the importance of reducing social and economic inequities in improving the health of the whole population”, therefore focusing, on a national level, on the health status between member states as well as between social groups within countries.

In 2005, a joint statement agreed between the Health Ministers of Belgium, Germany, Portugal, Spain, Sweeden and the United Kingdom was made. It stated that “…The fundamental values of equity, universality and solidarity underpin health systems throughout Europe. (…) Inequalities in health, whether it derives from differences in education, income, living conditions or other health determinants must be addressed and the gap need to be narrowed if we are to succeed to maintain a just and prosperous society..”.

Nations across Europe responded differently to the WHO recommendations and after a situation analysis based on questionnaires, the conclusions are that some nations focus on the ethnic differences, others on the equity commitments, on detailed quantitative terms or on a single health inequality goal. “As far as we are able to tell at this stage, a number of EU countries have not formally articulated principles or goals to guide their actions at the national policy level in relation to promoting population health equity or reducing health inequalities.”

In order for all this information and research on health inequality to be put to good use, a Health in all Policies (HiaP) approach to policy-making has been approached as a strategy that targets the structural components of the social determinants of health. “HiaP encourages policymakers across all sectors of government to consider the health impacts of policies that are, on the surface, unrelated to health. City design is a good example of a policy target that can have an immediate impact on active transportation, air quality and healthy food availability.”

This method came through with great results in countries like Finland, where in the 1970’s it was registered the world’s highest death rate from cardiovascular disease due to smoking and fat diet. Through a HiaP project, people in a region in east of Finland were educated through campaigns, health promotion and healthy food preventive programs. Through the initiative, by 1995, there was a 75% reduction in coronary heart disease in males, continuing to decline by 8% each year.

The conclusion we can draw from here is that health inequality goes beyond nation-states, regions and even groups, it comes across races, ethnics and individuals and it must be seen as a major impediment, if not the biggest, in the way of social, cultural, political and especially economic prosperity and endurance. And in order to develop strategies that could undermine this inequities we must focus on gathering information, conducting research, experimenting and developing a better health care structure and education for each individual, no matter the race, age, sexuality, origin.

Sources

European Social Survey, Social Inequalities in Health and their Determinants: Topline Results from Round 7 of the European Social Survey, ESS Topline results Series (6);

Judge, Ken; Platt, Stephen; Costongs, Caroline; Jurczak, Kasia, Health Inequalities: a Challenge for Europe, UK Presidency of the EU, 2005;

Murray, Christopher J. L. et. All, Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States, PLoS Medicine 3 (9);

Online sources

http://www.healthscotland.scot/health-inequalities/what-are-health-inequalities

http://www.health-inequalities.eu/about-hi/introduction/

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/

https://www.weforum.org/agenda/2015/01/how-can-we-reduce-health-inequality/