The Influence of Inequality on Health Outcomes
Health and wealth have always been closely related (Wilkinson, 1994), and economically disadvantaged racial/ethnic minority populations in the United States experience worse health status on multiple indicators of physical health (Williams, in press). The existence of inequality —a property of the population in question—thus has important consequences for the health of individuals and groups. Better understanding of the mechanisms involved may suggest concrete ways to improve the health of both individuals and population subgroups.
SOCIOECONOMIC STATUS AND HEALTH
Health is related to both the quantitative and qualitative aspects of material and social change. Social environments that are less divisive, less undermining of self-confidence, less productive of social antagonism, and more supportive of developing skills and abilities are likely to contribute to the overall health and welfare of the population.
Socioeconomic Factors Influencing Health
An extensive literature, dating back more than a century (Sorokin, 1927; Antonovsky, 1967; Bunker et al., 1989; Williams, 1990) documents inverse associations between position in socioeconomic hierarchies and morbidity and mortality. These hierarchies have usually been defined by household income, years of education, and occupational prestige or grade.
In both industrialized and less industrialized countries, persons of higher socioeconomic status (SES) live longer and have lower rates of most diseases than their less favored counterparts (Behm, 1980; Grosse and Auffrey, 1989; Holzer et al., 1986; Department of Health and Social Security, 1980). Some studies from less industrialized countries, such as a study of Nigerian civil servants (Markovic et al., 1998), have found a positive association between SES and chronic disease. This may reflect differences in the historical time period across societies in the secular distribution of disease. In the United States, for example, higher position in the SES hierarchy was associated with greater prevalence of heart disease earlier this century, but SES is currently inversely related to cardiovascular risk (Morgenstern, 1980). Thus, apparently discrepant findings highlight the importance of attending to broader social and historical contexts.
Of particular importance is a gradient in the relationship between SES and health: each level of the hierarchy exhibits less morbidity and mortality than lower levels (Adler et al., 1994, 1999; Marmot et al., 1991). Most of the evidence supporting this relationship derives from European and North American populations, where the data are consistent and robust. At the same time, several studies document that the gradient is nonetheless characterized by a threshold, usually around the median for income, where additional increases in SES have a diminished effect in reducing morbidity and mortality rates (Kitagawa and Hauser, 1973; Pappas et al., 1993; McDonough et al., 1997; Wilkinson, 1986). Research is needed to provide greater understanding of the conditions under which particular markers of SES manifest patterns of linear or nonlinear associations with health status. We need to identify the thresholds after which weaker SES effects are observed and to characterize the social, psychological, and material risks and resources that are associated with each level of the SES hierarchy.
A growing body of research also reveals that even though overall mortality rates have been declining, socioeconomic differentials in mortality have been widening in recent decades. Comparing data from the 1960s to those for the late 1970s and 1980s, U.S. studies reveal that income and educational differentials have widened over time (Duleep, 1989; Pappas et al., 1993; Feldman et al., 1989). Similarly, widening socioeconomic differentials in mortality have been observed in England, Wales, France, Finland, Norway, and the Netherlands (Department of Health and Social Security, 1980; Kunst and Mackenbach, 1994; Mackenbach et al., 1989). Widening health disparities appear to be primarily driven by larger improvements in the health of high-SES groups compared to their lower-SES counterparts. For some health conditions, however, there has been no change in health or worsening health status over time for economically disadvantaged populations (Williams and Collins, 1995). Although differences between SES groups in access, utilization, and the quality of medical care probably play
some role in the widening health inequality (Makenbach et al., 1989), increases in income and wealth inequality in both the United States and Western Europe (Danziger and Gottschalk, 1993) appear to be the driving force behind the widening health disparities (Williams and Collins, 1995).
A high degree of inequality in a given location (e.g., country, state, county, district, city) may itself be a health hazard. The countries with the smallest spread of incomes and the smallest proportion of the population in relative poverty have the longest life expectancies (Wilkinson, 1994). Evidence from multiple sources suggests that the greater the concentration of income at the upper end of the income distribution, the higher the mortality and morbidity rates (Wilkinson, 1994; Kaplan et al., 1996; Lynch et al., 1998). Socioeconomic inequality also affects health in more complicated ways. It is widely recognized that at the aggregate level average health is negatively correlated to the degree of income inequality. However, if health status depends not on absolute income but on income relative to that of some reference group, then the relationship between income and health is determined by the relative size of within-group and between-group inequality (Deaton, 1999). When the ratio of between-group to within-group inequality changes, the mix of high- and low-income status in any particular group changes. This change alters the measure of the relationship between health and income. Existing community-level evidence about socioeconomic inequality and its relationship to health implies the need for more detailed inquiries into appropriate measures of inequality.
There is considerable variation in health outcomes at all levels of socioeconomic hierarchies. Of particular importance, health outcome variance is greater at the bottom of these hierarchies—for low levels of education and income—than at the upper end. The fact that some persons low in these hierarchies have unexpectedly positive health outcomes (compared to the norm for their level) calls for future inquiry regarding the psychological, social, behavioral, and biological factors that confer protection for some individuals at the low end of the socioeconomic hierarchy.
Cumulative Pathways to Illness or Health
The provision of defensible explanations for associations between position in socioeconomic hierarchies and morbidity and mortality requires integrated investigation of psychosocial and physiological interrelationships over the life course. Most studies attempting to identify stressful life experiences and other features that predict later disease and mortality have incorporated neither long-term processes nor cumulative experience. There is a singular lack of studies integrating community-level and individuallevel behavioral influences with parallel physiological dynamics to identify multilevel pathways to diverse health outcomes. Evidence does suggest that
cumulative processes across multiple life domains at the individual and community levels are of central importance for understanding the relationship between SES and health (Singer and Ryff, 1999; Ryff and Singer, 2000).
Studies of income dynamics and its connection to health over the life course points to the importance of economic inequality resulting from cumulative processes, particularly permanent income (Lynch et al., 1997a, b; Felitti et al., 1998). For example, elevated permanent income, rather than current income level, shows a strong protective effect on mortality over time (Deaton, 1999). The cumulative negative impact of persistent poverty on health has also received considerable attention (Korenman and Miller, 1997). The bidirectional relationships between health and both income and wealth suggest the need for more extensive investigation of the role of permanent and transitory changes in income and unemployment on health risks (see Smith, 1999).
The import of cumulative effects also holds for psychosocial experiences. It has long been argued that early life conditions, including the fetal environment, are linked with later life expectancy and disease risks (Elo and Preston, 1992; Barker et al., 1989). However, there is great plasticity in factors influencing later-life health and length of life, and cumulative adversity and advantage are consequential. Studies of social stress and its consequences for mental health frequently also evaluate childhood and lifetime traumas as well as track chronic, enduring conditions (Singer et al., 1998). This is illustrated by results showing that a single stressor or no stressor at all produced a 1 percent increment in psychiatric disorders in children (Garmezy, 1993a, b). Two stressors in the family complex provide a 5 percent rise in the disorder rate; three stressors a 6 percent increment, and four or more stressors a 21 percent increment in the rate of childhood psychiatric disorders. Cumulatively, the presence of stressors accounted for a 33 percent rise in the disorder rate, with multiple stressors accounting for the largest proportion of the disorders.
Early life disadvantage and adversity need not lead to later negative outcomes, however, provided there are compensating positive experiences in the intervening years. Recent animal studies provide dramatic evidence that genetic predisposition can be overcome by exposure to particular environmental conditions in infancy and later life (Francis et al., 1999; Caldji et al., 1998; Liu et al., 1997). Rat pups reared in impoverished environments have greater physiological reactions to stress throughout their lives than rats reared in enriched environments (Lui et al., 1997). The effect, however, is reversible. Rats exposed to inadequate nurturing in early infancy can, if subsequently reared by a high-licking and -grooming foster mother, exhibit normal responses and healthy adult lives (Francis et al., 1999; see Chapter 4).
Recovery from and Resilience to Adversity
Equally important is clarification of mechanisms of recovery from and resistance to adversity. It is important to give equal consideration to positive aspects of people's lives and particularly to accumulation of advantage. The components leading to cumulative advantage may come in the form of starting resources (e.g., growing up in an intact family), personal capacities and abilities (e.g., intelligence, coping strategies), positive behavioral practices (e.g., exercise, proper diet), the realization of expected life transitions (e.g., job promotions, marriage), or having positive evaluations of one's life (e.g., job satisfaction, marital quality, and positive personal relationships with children, siblings, and friends).
Simultaneous consideration of cumulative adversity and advantage as they pertain to understanding health outcomes, including resilience, has been the theme of several recent investigations (Ryff et al., 1998). In understanding pathways into and recovery from episodes of depression, for example, the cumulative processes of both negative and positive valence must be identified (Singer et al., 1998). The basic point is that pathways to diverse health outcomes depend on an interplay of both positive and negative experiences across multiple life domains. (See also Chapter 3.)
At the level of physiology, an indicator of the long-term physiological response to stress conceptualized as allostatic load (McEwen, 1998; McEwen and Stellar, 1993) provides the important beginnings of a bridge between measures of cumulative psychosocial adversity relative to advantage and their biological signature. The conceptualization and measurement of this construct are described in detail in Chapter 2. Representing an index of risk across multiple physiological systems, allostatic load has been found to predict later-life incident cardiovascular disease, decline in physical and cognitive functioning, and mortality (Seeman et al., 1997). Allostatic load also represents a physiological signature of cumulative adversity relative to advantage in the domains of economic resources and social relationship (Singer and Ryff, 1999). An important research topic for the future is further investigation of linkages between cumulative SES-related adversity and cumulative physiological risk, represented by allostatic load, as well as assessment of psychosocial and behavioral factors that can offset the accumulation of such load.
The Need for Integrative Longitudinal Studies
There are few longitudinal data sets that both cover long stretches of lives (e.g., 35 plus years) and include both psychosocial and physiological risk factors as well as health outcomes. National surveys of the birth cohorts of 1946 and 1958 in England (Power and Matthews, 1997; Wadsworth and Kuh, 1997) represent valuable sources of psychosocial
evidence for specification of pathways that combine sources of cumulative adversity and advantage over time. Both data sets show evidence of negative mental health consequences in adolescence and adulthood that accrue from adverse experience in early childhood as well as the influence of cumulative experience from early childhood on self-reported midlife physical health. Until recently, direct physiological assessments of these populations had not been made. With planned future longitudinal follow-up on both psychosocial and physiological indicators, the British birth cohorts represent promising sources of data for constructing integrative life history accounts of cross-time associations between socioeconomic standing and health.
In the United States, the Wisconsin Longitudinal Study (WLS; Hauser et al., 1993), which is focused on the birth cohort of 1939, is the closest to the British birth cohorts in richness of psychosocial information but goes well beyond the British studies with its in-depth assessments of educational attainment and occupational experience as well as accompanying data from siblings, spouses, and parents. WLS is, however, a random sample of the high school graduating class of 1957 in the state of Wisconsin and lacks the in-depth psychosocial assessments of infancy and early childhood found in the British birth cohorts. WLS also does not include the lowest level of the education hierarchy. Nonetheless, the age 52-53 round of WLS data collection initiated extensive inquiry on physical health and psychological well-being, and a subsample (N = 115) of respondents was resurveyed at age 59, at which time extensive physiological assessments were also obtained. These data have afforded an evidential basis for linking cumulative economic and relational adversity to high allostatic load (Singer and Ryff, 1999). WLS and the British birth cohorts represent the best of what is currently available on psychosocial experience across multiple life domains through time. Other important longitudinal resources, although more restricted in length of follow-up and/or coverage of psychosocial experience, are the Alameda County Study (Berkman and Syme, 1979), the Panel Study of Income Dynamics (McDonough et al., 1997), the National Long Term Care Survey (Corder et al., 1993), the Whitehall II Study of the British Civil Service (Marmot et al., 1991), and the Malaysian Life History Survey (Da Vanzo, 1984; Haaga et al., 1994).
Shifting to an emphasis on direct physiological assessment, the Framingham Study of heart disease (Allaire et al., 1999; Dawber, 1980) is an invaluable longitudinal data source with biennial physical health assessments running over 45 years. Regrettably, this rich study of physical health is nearly devoid of parallel psychosocial assessments. The implication for NIH funding priorities is that there is need to develop and maintain longitudinal studies of new birth cohorts that contain the necessary psychosocial and physiological assessments in parallel. Equally important is the need to
augment judiciously selected extant surveys in the United States and other countries as the central sources for investigating inequalities in health, including assessment of predisease pathways, collective community influences, macro-level socioeconomic change, and intervening psychosocial and behavioral factors (positive and negative).
RACIAL AND ETHNIC INEQUALITY AND DISCRIMINATION
In the United States race is strongly associated with socioeconomic inequality. For example, blacks, Hispanics, and Native Americans have lower levels of income and education and higher rates of poverty and unemployment than whites. Given the strong association between race/ethnicity and SES, race/ethnicity not surprisingly is a strong predictor of health status in the United States. Moreover, available data suggest that the gap in health status between the advantaged white population and disadvantaged racial/ethnic minorities is widening over time for multiple indicators of health status (Williams, in press).
Racial/Ethnic Differences in Health Status
The association between race and health is complex and varies by the health status indicator and the particular racial group under consideration (Williams, in press). There is no generic minority health model, but all of the economically disadvantaged racial/ethnic minority populations have higher morbidity and mortality than whites for some health conditions. National mortality rates in the United States reveal that blacks consistently have higher death rates than whites for almost all the leading causes of death (National Center for Health Statistics, 1998). The notable exception to this pattern is markedly lower suicide rates for blacks compared to whites, despite rising rates of suicide over time. Hispanics consistently have lower death rates than non-Hispanic whites for the two leading causes of death in the United States (coronary heart disease and cancer) but higher death rates for several other causes of death, including diabetes, homicide, cirrhosis of the liver, and HIV/AIDS. Death rates of Hispanics exceed those of whites in the 15-44 age group (Fingerhut and Makuc, 1992). Hispanics also have elevated rates of infectious diseases such as measles, rubella, tetanus, tuberculosis, and syphilis (Vega and Amaro, 1994). Native Americans have lower death rates than whites for heart disease and cancer but higher mortality rates from injuries, flu and pneumonia, diabetes, suicide, and cirrhosis of the liver. In addition, the health status of the 60 percent of Native Americans who are covered by the Indian Health Service (a federal agency that provides medical care to Native Americans who live on or near reservations) is considerably worse than that of the national average for Native Americans (U.S. Department of Health and Human Services, 1997).
There is considerable ethnic heterogeneity within the major racial/ethnic categories. These ethnic differences predict variations in socioeconomic and demographic characteristics and access to and utilization of health care. For example, the Hispanic category encompasses more than 25 national origin groups that share a common language, religion, and traditions but that vary dramatically in terms of the timing of immigration, regional concentration, incorporation experiences, and socioeconomic status. Not surprisingly, there is considerable variation in health status within the Hispanic group (Sorlie et al., 1993; Vega and Amaro, 1994). Similarly, the Asian and Pacific Islander (API) category aggregates diverse groups from 28 Asian countries and 25 Pacific Island cultures (Lin-Fu, 1993). Although the API population has higher median income than whites, some subgroups of this population (e.g., Hmong, Laotians, and Cambodians) have poverty rates that exceed those of the black and Hispanic populations (U.S. Bureau of the Census, 1990). Although the API population has mortality rates that are markedly lower than whites, some subgroups have high rates of disease and death. For example, Native Hawaiians have the highest death rates from heart disease of any racial group in the United States (Chen, 1993) and death rates from liver cancer for Chinese Americans are four times higher than those for the white population (Lin-Fu, 1993).
Sources of Racial/Ethnic Differences in Health
Given the strong association between race/ethnicity and SES, adjusting racial disparities in health for SES sometimes eliminates but always substantially reduces these differences (Williams and Collins, 1995; Lillie-Blanton et al., 1996). However, even when education and income are held constant, blacks frequently exhibit higher levels of ill health than whites (Williams, 1996). Some studies show increasing racial differences with rising socioeconomic status (Schoendorf et al., 1992; Singh and Yu, 1995). Thus, race is more than just SES, and a growing body of research is attending to other factors associated with race that might affect health.
Racial and ethnic hierarchies usually are not clearly defined within most countries or within smaller jurisdictions, such as provinces, states, or districts. Races are socially meaningful groupings with differential access to societal resources and rewards. The basis for such hierarchies, such as they are, is usually attributed to discrimination and stigmatization of one form or another. Historically, ideologies and attitudes about racial groups translated into policies and social arrangements that limited the opportunities and life chances of stigmatized groups. The disproportionate representation of minority groups at the low end of the socioeconomic spectrum in the United States reflects social policies that limited benefits to socially marginalized groups.
The conditions of chronic discrimination in South Africa under apartheid provide an exceptionally clear picture of these relationships. In that setting, discrimination was legislated and the ordering of groups labeled “White,” “Asian/Indian,” “Colored,” and “African”—in increasing order of formally defined discrimination—showed a clear association with mortality and a diverse set of disease categories (Singer and Ryff, 1997). Tuberculosis and TB-specific mortality were related to racial/ethnic category at both the individual and community levels throughout the apartheid period (Packard, 1989). A similar relationship is evident for HIV/AIDS from the 1980s to the present (Hope, 1999; Webb, 1997).
Racism can affect racial disparities in multiple ways. First, racial differences in socioeconomic status, one of the strongest predictors of variations in health, partly reflect the impact of economic discrimination produced by large-scale societal structures. Racial segregation determines access to educational and employment opportunities and importantly constrains socioeconomic mobility of blacks and Native Americans (Jaynes and Williams, 1987; Massey and Denton, 1993). There are racial differences in the quality of education, income returns for a given level of education or occupational status, wealth or assets associated with a given level of income, purchasing power of income, stability of employment, and health risks associated with occupational status (Williams and Collins, 1995; Kaufman et al., 1997). Health of racial/ethnic minorities can also be influenced by large-scale policy change (e.g., welfare reform), effects that warrant further scientific inquiry.
Second, segregation can affect health by creating differential neighborhood and community conditions (see Chapter 6). These include unequal access to municipal services and medical care, lower levels of social participation, higher levels of undesirable land uses, higher rates of crime, and poor-quality housing (Alba and Logan, 1993; Roberts, 1997; Shihadeh and Flynn, 1996; LeClere et al., 1997; Greenberg and Schneider, 1994). Even after adjusting for job experience and training, blacks are more likely than whites to be exposed to occupational hazards and carcinogens at work (Robinson, 1984). Hazardous waste sites are more likely to be located in poor, minority urban and rural communities than in other residential areas (Bullard, 1997; Camacho, 1998; Cole and Foster, 2000; Commission for Racial Justice, 1987).
National data reveal that blacks and Hispanics are disadvantaged compared to whites on indicators of both access to ambulatory medical care and the quality of the care received (Blendon et al., 1989; Council on Ethical and Judicial Affairs, 1990; Anderson et al., 1986; Trevino et al., 1991). Even after adjustment for health insurance and clinical status, whites are more likely than blacks to receive coronary angiography, bypass surgery, angioplasty, hemodialysis, total knee arthroplasty for osteoarthri-
tis, intensive care for pneumonia, and kidney transplants (Giles et al., 1995; Council on Ethical and Judicial Affairs, 1990; Wilson et al., 1994).
Subjective Experience of Racism and Stigmatization
A small but growing literature indicates that chronic and acute experiences of discrimination in the lives of minority group members is a source of stress adversely affecting their physical and mental health. Laboratory studies reveal that exposure to discrimination leads to cardiovascular and psychological reactivity (Anderson, 1989; Armstead et al., 1989; Dion, 1975; Pak et al., 1991). Negative emotional responses associated with racism, particularly those that are chronic, are also associated with adverse health outcomes (Ryff and Singer, in press). Epidemiological data indicate that at least under some conditions racial discrimination is positively related to blood pressure among African Americans (Krieger, 1990; Krieger and Sidney, 1996). Other recent epidemiological studies reveal that perceptions of discrimination are adversely related to other measures of physical and mental health for a broad range of population groups (Kessler et al., 1999; Noh et al., 1999; Williams et al., 1999; Dion et al., 1992). Two recent studies have found that perceptions of discrimination make an incremental contribution over education and income in accounting for racial differences in self-reported measures of physical health (Williams et al., 1997; Ren et al., 1999).
A stigma of inferiority may create certain expectations, anxieties, and reactions that can affect the motivation, performance, and psychological well-being of some proportion of minority group members (Steele, 1997). Research across a broad range of societies reveals that socially stigmatized groups score lower on standardized tests (Fischer et al., 1996). A minority group member's endorsement of the dominant society's negative stereotype of the minority group may also have health consequences. African Americans who believe that blacks are inferior have higher levels of psychological distress and alcohol use (Taylor and Jackson, 1990; Taylor et al., 1991). The National Study of Black Americans shows that African Americans who endorse negative stereotypes of blacks as accurate are more likely to report poorer physical and mental health than those who rejected those stereotypes (Williams and Chung, in press).
Inclusion of Discrimination and Stigmatization in Longitudinal Health Studies Longitudinal Health Studies
The National Survey of Black Americans (Jackson, 1991) provides a useful source of measures of alienation that can be linked to self-reported chronic conditions and disease. Longitudinal data are available for a
subsample of this survey, and they provide a basis for constructing pathways to various health outcomes associated with perceived discrimination. The longitudinal assessments in this survey do not compare with those in the British birth cohorts or in WLS. Thus, there is a need to include a range of racial/ethnic groups in a wider array of longitudinal data bases to improve understanding of the nature and roots of health inequality.
Comparative analyses of the fine-grained assessments of perceived discrimination in African, Hispanic, and Asian subpopulations and its connection to other forms of adverse and compensating psychosocial experience have not been conducted. Although discrimination and stigmatization are associated with a range of negative health outcomes, these features have not been integrated into characterizations of the pathways of adversity and advantage across multiple life domains that lead to specification of how health outcomes come about. Understanding pathways of resilience in the face of discriminatory challenges will likely contribute important insights into why some do well and others do poorly in the face of persistent challenges.
In the United States race/ethnicity is also a strong predictor of foreign birth. A large proportion of the Hispanic and especially the Asian American populations is foreign born. The health profile of these groups reflects in part the impact of immigration. Immigrants of all racial/ethnic groups experience better health status than their native-born peers, even when these immigrants are lower in SES (Singh and Yu, 1996; Hummer et al., 1999). However, with increasing length of stay in the United States and adaptation to mainstream behavior, the health status of immigrants declines (Vega and Amaro, 1994; Marmot and Syme, 1976). For example, several behaviors that adversely affect health, such as the use of cigarettes and alcohol, have been shown to increase with length of stay and acculturation for Hispanic populations. Thus, it is likely that the health advantages evident for some subgroups of the Asian and Hispanic populations may diminish over time.
The lower levels of suicide for African Americans compared to whites is consistent with other mental health data and reflect a well-documented paradox. Blacks tend to have higher levels of ill health for most measures of physical health and are disadvantaged compared to whites on measures of subjective well-being, such as life satisfaction (Hughes and Thomas,
1998). At the same time, blacks have comparable or lower rates of psychiatric illness (Kessler et al., 1994; Robins and Regier, 1991). Thus, despite disproportionate exposure to a broad range of conditions that are risk factors for mental health problems, blacks do not have higher rates of suicide or higher rates of mental illness than whites. Similarly, although Mexican Americans are low in SES and have the lowest rates of prenatal care use of any racial/ethnic group in the United States, they have infant health outcomes that are comparable or better than that of the white population. These findings emphasize the need for research to identify the cultural strengths and health-enhancing resources resident in racial/ethnic groups. Strong family ties, religious involvement, and participation in other as yet unspecified cultural resources have been nominated as potential factors that buffer minority populations from at least some of the adverse consequences of social adversity (Williams, 1997). Research that conceptualizes and operationalizes the specific beliefs and behaviors that may be promotive of health is an important frontier of research on social inequalities and health.
Moving beyond the current NIH initiatives on socioeconomic status and health, the committee recommends the following:
characterization of behavioral and environmental risks associated with educational, economic, and occupational disparities;
elaboration of the subjective experiences of racism, discrimination, and stigmatization and their effects on behavior as well as their neurobiological substrates;
assessment of health-related impacts of large-scale societal structures (e.g., racial segregation, economic discrimination, differential access to services and medical care);
development of integrative longitudinal studies that connect the SES and racial/ethnic-related risk factors to intervening biological systems and subsequent health outcomes;
identification of cultural strengths and health-enhancing resources resident in racial/ethnic groups and their role in accounting for resilience vis-à-vis socioeconomic inequality.
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