Inequality and Health

Feb. 18, 2001

Gautam Dutta

In an unequal society, the deprived strata suffer ill health as a result of living in a poorer environment. An individualistic approach will not change this negative picture, because the social environment influences individual conditions, including health.

A nation's socio-economic model, which reflects underlying ideologies determined by specific class interests, contains the seeds of inequality. Policy makers are bound to try to uphold uling class interests, so they inevitably fail to serve the interests of the whole population. This results in disparate health outcomes for different economic groups.

Some capitalist countries have adopted more egalitarian health policies than others, but periodic acute economic crisis (which is typical of capitalist economy) will lead them towards less egalitarian policies. The new emerging world order -- the globalization of the market economy -- will increase the tendency toward crisis even more. This can be felt in the recent changes in the health policies of Canada. Canada is becoming more entrepreneurial and less egalitarian, causing more unequal health conditions.

Inequality may be socio-economic and cultural. It may be gender, race or ethnic group-based. There are many other subdivisions among a population that may be used as the basis for inequality. Inequality in the realm of health may be indicated by unequal access to health care, use of health services, treatment by medical providers, distribution of health services according to need, and expenditure for different groups.

In this paper only socio-economic inequality is discussed. To describe this parameter, different terms such as "class," "strata" and "socio-economic group" are used. This discussion concentrates more on how the socio-economic models and health policies enhance inequality and affect health, rather than on the differences in health status in various strata. While different economic models are examined here, there is an emphasis on mainstream capitalist countries. The major limitation of this study was lack of health status-related data from socialist countries (with the exception of Cuba, which is included here).

THE EFFECTS OF CLASS ON HEALTH

Social class determines the pattern of mortality and morbidity, (1) a fact that has been established by many bodies of research done in different countries. Social class or socio-economic status is related to all illness and health in general. Chris Power (2) states, "It is almost universally the case that people in lower social classes have more morbidity and disability and have shorter lives" (Power, 1994). Compared to conditions in countries with poor economies, in the industrialized countries infectious diseases no longer pose a major threat to public health. Still, social stratification is giving rise to unequal health outcomes. Individuals in the lowest income brackets have the poorest health, manifested by the highest infant mortality rate, the shortest life expectancy and the greatest morbidity.

The two major parameters of variables that affect health, environmental and individual, are in turn affected by socio-economic status. As Andrain (3) observes, "The health of a nation, social groups, and individuals reflects structural conditions within the environment, including the degree of income inequality, unemployment, workplace hazard, and residential deprivation" (Andrain, 1998, p. 185). At the same time, personal variables like attitudes, awareness, motivations, and lifestyles are greatly influenced by the environment.

The Black Report (4), published in 1980, documented that there were large differentials in both morbidity and mortality favouring the higher social classes. "The striking evidence related to mortality: around 1971 the death rate for men aged between 15 and 64 was almost twice as high for those in the bottom (unskilled manual) class as in the top (professional and managerial) one. Subsequent British data suggest that these differentials if anything widened rather than narrowed up to 1981 (Cleary & Treacy, 1997)." Some recent research in the Republic of Ireland using the same type of approach and methods has shown similar substantial differentials between socio-economic groups.

People belonging to lower socio-economic classes are also subjected to intense psychological stress, and suffer maximum job-insecurity. Unemployment has a significant effect even among the non-poor strata, with the unemployed being "five times more likely to come above the threshold of psychological distress than those who are at work or retired" (Cleary, A. & Treacy, 1997).

Homeless shelters in Canada offer a vivid example of how socio-economic inequality seriously affects health. More than 4,000 people are homeless every day in Toronto alone, and this number is gradually increasing. Studies in shelters show that more than 60% of the homeless population suffers from many communicable diseases including tuberculosis and hepatitis B. Most of these diseases are actually diseases of poverty.

Dr. Norman Bethune wrote from his experience of working among the impoverished class in China "...tuberculosis was not merely a disease of the body but a social crime." (Bethune, 1939, p 36-42). What Dr. Norman Bethune wrote sixty years ago is still valid. Infectious diseases are still major health hazards in the impoverished zones of South Asia, Africa and Latin America. Inequality on a global scale has much to do with this, and economic globalization is making it worse.

In the industrialized countries the general health status of the population has improved a lot during the previous century, as evidenced by the increased life expectancy. But inequality is still a prominent feature within these countries, in terms of wealth distribution and earning patterns.

A society is an organic system despite being split into multiple strata. If one stratum is seriously crippled, a negative impact will eventually be felt by the society as a whole. In his article "Health Effects of Economic Inequality," Dr. Dennis Raphael (5) draws our attention to the results of some interesting studies that prove this. "After decades of rapidly increasing economic inequality, the most well-off in Britain now have higher death rates among adult males and infants than the least well-off in Sweden" (Raphael, 1999, p 4). There are also findings that the well-off in economically unequal American communities are showing health problems at greater rates than the well-off in relatively equal communities (Raphael, 1999, p 4).

HEALTH SYSTEMS UNDER DIFFERENT SOCIO-ECONOMIC MODELS

"Medicine is a social science and politics is medicine on a large scale." (Virchow, 1849). With the advent of society, medicine gradually became a highly institutionalized service. As the cost of medical care increased, two kinds of medical care came into existence - one for the rich and the other for the poor. Initially, charitable and voluntary agencies tried to bridge the gap, but ultimately in many countries it was felt that only the socialization of medicine could provide a meaningful solution. Germany led the way by instituting compulsory sickness insurance in 1883. Other countries -- England in 1911, France in 1928 and so on -- followed this example. Great Britain nationalized its health services in 1946. Russia was the first country to socialize medicine completely and to give its citizens a constitutional right to all health services. (However, due to ideological changes this system has now become dysfunctional).

The socialist transformation of Cuba permitted a rapid reconstruction of its health-care system. Prior to the revolution Cuba's health system was rudimentary. After the socialist transformation a large proportion of the country's physicians emigrated. In the context of such adverse conditions and prior underdevelopment, the implementation of the socialist approach led to remarkable changes in morbidity and mortality.

"Within fifteen years of the revolution, diphtheria, polio, tetanus, and malaria - cases of which still occurred in the United States - were eradicated in Cuba. Infant mortality fell from 52 to 27 per 1,000 within the same period, and maternal mortality declined from 118 to 63 per 100,000. By the 1970s, Cuba resembled economically developed countries in illness and mortality patterns, as heart disease and cancer became the leading causes of death." (Waitzkin, 2000).

There are still many problems remaining in the Cuban health care system resulting from underdevelopment and the United States' economic embargo. Yet the rapidity of transformation of "rudimentary and crisis-ridden medical services into a rationalized and accessible system is startling even to the most skeptical observers." (Waitzkin, 2000). Socialization is a noble idea because it eliminates competition among physicians in search of patients, and ensures social equity. Medical care that is paid for by the state becomes free for the patient.

Capitalism, a profit-oriented economy, treats various labour forces (including intellectual labour) as commodities. In the feudal era class exploitation was obvious. In the capitalist era the emerging bourgeois class replaced the feudal class. They came with slogans about democracy and free competition. But the new system gave rise to a huge working class which had no control over the means of production. A small minority owned all the means of production, and the class gap increased more than ever.

To minimize the internal conflicts, capitalist countries expanded their markets beyond their own geographical territories, developing the stage of imperialism. But in the twentieth century, due to the rise of socialism in various parts of the world, capitalism was forced to modify some of its more brutal tactics. The same economic structure was preserved with the addition of some superficially benevolent features.

The three major trends of present day capitalism are entrepreneurial, corporatist and social democratic. The health policies designed under these models sometimes incorporate each other's properties. This intermingling can cause a big difference in the health outcome of the population in general. The following passages will discuss health policies under various capitalist models, with some emphasis on Canadian health policies.

ECONOMIC MODELS ADAPT TO STRUCTURAL SHIFTS

The entrepreneurial model, as in the USA, reflects fragmented, dispersed power arrangements. In this model, central control over the health care sector is weak; private sectors and regional governments make the major decisions. But low-income people depend solely on public health programs. The entrepreneurial model therefore creates health inequalities by splitting the population into different groups determined by their socio-economic status.

The corporatist model, as in Germany today, is elitist in nature. A strong central authority designs the policies, which are mediated through private agencies and regional governments. Health policies secure different benefits (6) for different groups, such as specific insurance programs for distinct occupations. Hence lower-status employees receive less generous, comprehensive benefits.

The social democratic model, as in Sweden, displays a stronger commitment to egalitarian values. It embodies the view that individuals should not only have equal access to health care but should also enjoy equal health treatment and conditions.

Canadian health policies are rather a blend of all the three models. It operates a fragmented and dispersed system similar to the United States. Provincial health ministries, rather than private health insurance corporations, manage medical care and nonprofit institutions (e.g. hospitals and nursing homes), and thus assume greater importance than in the United States. But the egalitarian component is becoming weaker. The health policies adopted in 1995 are more entrepreneurial than egalitarian in nature. The federal government has reduced its payments to the provinces, which had received block grants for health, post-secondary education and income maintenance services. These policy changes have exacerbated the existing inequalities. Low-income individuals are suffering the most from decreased health expenditures and reduced benefits.

Under the 1996 Canada Health and Social Transfer program, the Canadian federal government allocated block grants to the provinces by redistributing the resources from wealthier provinces like Ontario, Alberta, and British Columbia to the seven other poorer provinces. This didn't improve the health infrastructure in those seven provinces, because inequalities in other sectors remained unchanged. In several provinces Canadians no longer received public funds for child care, adult eye examinations, circumcisions, and sterilization reversals.

What happened to Ontario, Alberta, and British Columbia? "Because of reduced grants, provincial leaders lowered expenditures for health care. Hospitals closed or converted into community health centers. Hospital physicians performed fewer operations each year; patients remained in the hospital for shorter time. Provincial health ministers raised fees for some prescription drugs and removed others from the reimbursement list. ... Cost containment policies caused shortages of registered nurses." (Andrain, 1998).

Different economic models determine how devastating such changes will be. During the period from 1980 to 2000, throughout the whole industrialized capitalist world, structural shifts intensified economic inequalities and pressured policy makers to institute cost-containment programs that reduced health care services. But there were significant differences between each type of economic model. As Andrain observes: "Swedish leaders enacted fewer inegalitarian policy changes than did their North American counterparts. ... United States officials enacted the least egalitarian and the most private commercial programs. ... Many children, youths, and part-time, temporary employees lacked access to either public programs or to private health insurance plans administered by private firms." (Andrain, 1998).

Canada took an intermediate path, not as good as Sweden but better than the United States. But, as mentioned earlier, Canada is gradually becoming more entrepreneurial in character. This trend is likely to increase because of increasing internal conflicts between provinces, unequal economic treaties with United States, and the rise of other economic competitors (especially the Southeast Asian economic block, which is putting United States into an economic crisis and thus dragging down the US-dependent Canadian economy).

INSIGHTS IN LITERATURE

The obvious is difficult to prove, and it becomes more so when there is a widespread desire to ignore the truth. It is not really difficult to understand the relationship between poverty and ill health. Neither is it difficult to understand that if the world's resources were equally distributed, poverty wouldn't exist. It is surprising that a significant amount of research work has been done to determine the sociological reasons for poor public health. While some of these works recognize poverty as a cause for poor health, the sociopolitical reasons have rarely been explored. The mass media has always placed more emphasis on individual lifestyle rather than socioeconomic issues such as inequality, state politics and policies. Some enthusiasts have tried to establish the idea that poor health causes poverty! This conclusion may be comparable to the observation that the sun revolves around the earth.

The correlation of health and inequality is well perceived in different sections of intelligentsia ---- by literary figures, economists, philosophers and sociologists. Charles Dickens, in his novel Hard Times, showed how poor economic conditions have deleterious effects on people's health. In the book, the rapidly growing commercial center Coketown was enveloped in a black mist of smoke and dust. Most of the people lived in impoverished, unhealthy conditions, suffered deplorable working conditions, and rarely breathed fresh air. Mill workers labored until an early death. For the Coketown elites, profit and economic growth took priority over public health.

In his play An Enemy of the People (1882), Henrik Ibsen highlighted the dependence of doctors on government policies. He showed how a doctor's proposal to close a bath -- the water of which contained harmful bacteria and endangered the community with typhoid fever -- was vehemently opposed by the bureaucrats and party politicians because of their vested interests.

Friedrich Engels, in his work The Condition of the Working Class in England (1844) gave vivid examples of the social origin of illness. He showed how infectious diseases were spread in large part by poor housing conditions and bad sanitation. He noted how overcrowding and insufficient ventilation contributed to high mortality from tuberculosis in London and other industrial areas. He also showed how poor living and working conditions caused malnutrition, alcoholism, pollution, musculoskeletal disorder, lung diseases, poor eyesight and other illnesses.

Rudolf Virchow elaborated upon Engels' work. Based on his study of a typhus and cholera epidemic in some parts of Europe, he concluded that defects of society were a necessary condition for the emergence of epidemics. Many such observations can be cited.

Karl Marx's famous observation notes that although philosophers and thinkers have tried to describe the world in many different ways, the important task is to find out how to change it (Marx, 1848). This mandate has not lost its relevance in the present day's context. There must be structural changes made in the working models of economy, otherwise inequality will continue to be a persistent social problem, and the idea of "health for all" will remain a remote dream.

SIDEBAR:
NAFTA and GATS UNDERMINE CANADA'S HEALTH CARE SYSTEM