Health inequalities and their social determinants

Health Inequalities

Several factors have been identified to exert considerable impact on health. The factors having most remarkable effect, both favorably and adversely, are extensively recognized as the prime determinants of health. Irrespective of the fact that health and social services have a positive influence on health, the crucial determinants of health-such as education, employment, housing and environment etc., are found as external of the direct impacts exerted by health and social care. Commonly, three types of inequality in health are indicated such as inequality with regard to the access to health care, inequalities with regard to health or health outcomes, and inequalities with regard to the determinants of health. The varied groups and categories of people have very distinguishing experiences with regard to the determinants of health. (Wider determinants of health and health inequalities)

Such varied experiences can have a wider impact on health conditions. Some of the groups and categories associated with this, such as gender, class, ethnic group, age and geographical area, are more prominent while some others like "disability, single parenthood, quality of school, age of housing stock, type of road user etc.," are considered less apparent. The inequalities are found to be deep-rooted when such categories overlie, as is visualized in case of combination of ethnic group, age, area etc. In such cases there appears to be a snowballing impact where it is not transparent as to really how the determinants are interrelated, however, the combined adverse impact is found to be enormous. The factors like age, poverty etc. are seen to be more dynamic. (Wider determinants of health and health inequalities)

It has been widely acknowledged that poverty, racism, gender inequality and violence are the crucial factors exerting wide unequal influence of disease globally. Even though laboratory research has generated remarkable progress in the field of modern medicines, such advancements have the advantages of a small portion of the world's population and mostly amidst affluent settings. The racial and economic inequalities exert considerable public health problems in United States. In underdeveloped regions the infectious disease still continues to be a leading cause of premature demise and the health inequalities in such regions are found to be more considerable. It has been noticed that the treatment of diseases like HIV / AIDS and tuberculosis have an overwhelming success in affluent societies while are considered a death sentence in case of poor. The impacts of insufficient health care are prominent, the most important being staggering human cost. The cost of illness on the poor and disenfranchised aggravates poverty and throwing many to a gleam future of poor health and suffering. The nations shouldering a high disease responsibility confront loss of productivity, missed educational prospect and astounding health care costs. (Social Medicine & Health Inequalities)

According to a major statistical survey a number of people are dying of heart disease as a result of health inequalities. The British Health Foundation employing government data formulated the study on the impact of social inequalities on death from coronary heart disease. It could reveal that about 5000 men under the age group of 65 years are dying every year as a result of the social differences. The premature death rate among the manual workers is estimated to be about 58% more than for non-manual workers like lawyers and accountants. In this connection the inequalities are found to be more in case of the female manual workers in comparison to their non-manual counterparts. The inherent cause of this is attributed to the increasing rates of smoking among manual workers. The smoking rate during 1996 has been estimated to be 35% and 33% of men and women respectively among the manual workers which is only 21% and 22% among the non-manual groups. (Health inequalities kill thousands)

Besides it has been observed that such data are dropping rapidly among the non-manual groups. Dr. Vivienne Press, the assistant medical director of the British Heart Foundation opined that irrespective of the fact that the general CHD death rate is diminishing nationally, the overall trend conceals the fact that the absolute number of people living with illness and disability from CHD is not declining and may be increasing. It is evident that the particular and more vulnerable groups in UK are not succeeding in exploiting the advantages of health care and are now imbibing the main burden of heart and coronary diseases. It has also been estimated that the CHD has the burden on UK economy to the tune of £10bn per annum out of which £8.5bn on working days lost as a result of death, illness and having to care for the ill and the rest £1.6bn on provision of health care facilities. The official statistics have exhibited considerable regional differences. The British Heart Foundation revealed that this is due to the fact that people living in Scotland, Northern Ireland and the North of England take significantly less fruit and vegetables. (Health inequalities kill thousands)

In view of the fact that health inequalities are avoidable and are fundamentally unfair, the measures to tackle health inequalities have been at the top of government policy perspectives. The Government is seen to be committed to have a clear focus on reducing the yawning health gap between disadvantaged groups, communities and regions of the nation along with general improvement of health. (Introduction to health inequalities) The relations of socio-economic class to the health inequalities have been observed since long. The report brought out by Edwin Chadwick in 1842 as General Report on the Sanitary Conditions of the Laboring Population of Great Britain has revealed that the mean age of death in Liverpool during the period was 35 for gentry and professionals but only 15 for laborers, mechanics and servants, irrespective of the fact that the life expectancy has improved a lot for all such classes in Britain since the Health inequalities continued till the present day. The Black Report brought out in 1980 revealed that there had been a persistent improvement in health conditions in all the classes but there still exist a relationship between social class and infant mortality rates, life expectancy and inequalities in taking benefits of the medical services. (The Black Report and Inequalities in Health)

This gave rise to the introduction of the National Statistics Socio-Economic Classification or NS-SEC since then. Chandola and Jenkinson have devised a measure of health outcomes, the Short Form Health Survey or SF-36, to reveal the correlations between social class and health inequalities increasingly significant. Several reasons have been advanced for the prevalence of such inequalities. The different system of measurement of social class that incorporates occupation, property ownership, educational status and access to social resources give rise to the health inequalities. According to Sally Macintyre the gradient of class difference in health is determined to some extent in the way the class and health are quantified. The concept of social drift is quite evident in this context where the poor health gives rise to decline in their socio-economic position.

However, conversely it cannot be derived that the healthy ones persistently rise in their class, since many of health problems are seen to occur in their adulthood after choice of the careers have been completed. Poverty is considered adverse to the health. However, material explanations are not adequate on their own to represent the class variations in health. While the life expectancy is seen to be low among the poorer class, and in underdeveloped countries some diseases are more widespread in the advanced nations. However, a close watch on the distribution of such diseases in the advanced nations reveals that it prevails in greater degree in comparatively poorer regions. The viewpoint that Social isolation is bad for health is corroborated by the studies that reveal the housewives, the unemployed and the retired are seen to be remarkable poorer health in comparison to those who are employed. (The Black Report and Inequalities in Health)

Bruce Link and Jo Phelan in their study Policy Challenges in Modern Health Care dealt in the primary reasons of health inequalities and brought out significant questions about the models through which we visualize the root cause of the disease. They point out that the dominant epidemiological model detects risk factors associated with the disease results and seeks policies and programs to decline such risks. However, the risk factors vary from one period to another but socioeconomic status that is associated with such risks at any single point in time continues to be strongly linked with health returns even as the risk factors vary. According to them the social status is considered as most fundamental effect since not withstanding the risks, the persons with additional resources, information, power and beneficial networks are in advantaged position to direct such resources to exploit the ways of preventing disease and maintaining health. Taking into consideration such facts, the authors recommended identifying policies that can equalize such coping benefits so as to deter ones' socio-economic status from being a powerful determining factor of health. (Link; Phelan, 2005)

The study made by Dr. Richard Mitchell and Professor Daniel Dorling from the University of Leeds and Dr. Mary Shaw from the University of Bristol on the parliamentary constituencies of Britain revealed a number of social policy scenarios. The study traced the impact of the variations to society that might be brought through the effective execution of three social and economic policies. Firstly, they examined the efficacy of the policy of modest redistribution of wealth to counteract the health inequalities. During the decades 1980s and 1990s there were a considerable variation in the wealth possessions of rich and poor reflected in the major variations in their health enumerated by mortality rates. The study revealed that by returning to the inequalities in wealth of 1983 about 7500 deaths annually could have been prevented. (Reducing health inequalities in Britain)

The study assessed the impact of such policy to be most effective in the Birmingham Ladywood constituency in the West Midlands and found that in the early 1990s, 275 constituents under the age of 65 years died per annum which is estimated to be 93 more than that of the national average of 182. Out of such 93 excess deaths 17 are assessed to be due to poverty in manual working classes and inequality of wealth and income. The policy entailing redistributive effect could have reduced the differences in life chances to this effect. Second is the policy for attainment of full employment that implies that people may be temporarily in jobs, no one is in loner term receipt of unemployment benefit. The studies in Birmingham Ladywood constituency revealed that about 8800 people were found unemployed during 1990 having vulnerable to death prior to attaining the age of 65 years and it has been estimated that the 14 out of 93 excess deaths are only due to such unemployment.

The policy of full employment could have prevented deaths to such an extent. Thirdly, it is believed that about one-third of the children in Britain live in poverty and it is their stated objective to bring those children out of poverty. It aims at enhancing the life chances of the 20% of children whose parents work in the most poorly paid occupations those were raised to equate those of their peers not living in poverty. The impact of this policy on Birmingham Ladywood constituency would prevent about 8 of the children in the age group of 0-14 years out of the 93 excess deaths. In this manner, the three policies combined tantamount to the saving of 39 lives out of the 93 excess deaths. (Reducing health inequalities in Britain)

Concentrating on all these facts the British Government initiated the most complete program ever formulated in the nation to handle and solve health inequalities. The Department of Health with the cooperation of 11 other Departments of the Government committed to reduce health inequalities and brought out the policy document 'Tackling Health Inequalities: A Program for Action' during the year 2003. The Public Service Agreement in this regard is to reduce the inequalities in health outcomes by 10% by 2010 in terms of infant mortality and life expectancy. Such a broad objective is aimed to be attained by achieving two particular detailed objectives, firstly, to reduce by at least 10% in the gap in mortality between routine and manual groups and the population as a whole in case of the children under one year by 2001 and secondly, to reduce by at least 10% the gap between the fifth of areas with the most low levels of life expectancy at birth and the population as a whole among the local authorities, by 2010. (Introduction to health inequalities)

It has been emphasized that the primary requirement for achieving the targets of the PSA is to work in partnership and to address the various inherent causes of health inequalities in collaboration. In response to the Treasury-led cross cutting review of health inequalities made in 2002 a small team in the Department of health with cross government concentration was established. The functioning of this Unit was remolded with the objective and targets of Public Service Agreement of reducing inequalities in health outcomes. (Introduction to health inequalities) The task of the Health Inequalities Unit is concentrated on the drive delivery of the government commitments outlined in the program, stressing upon their implementation and that they attain the required results essential to attain the PSA health inequalities objective. (Programme for Action overview and documents)

The program envisaged a clear practical strategy seen to be evidence based in targeting resources and efforts in case of the four delivery mechanisms: firstly, supporting the families, mothers and children; secondly, engaging the support of communities and individuals; thirdly, preventing illness and providing efficient treatment and care and finally, dealing with the underlying determining factors of health. The Program for Action at the first instance strived to strengthen the support for mothers, families and children especially in the early years along with further enhancing the scope for children and young people. The primary efforts in this direction are Sure Start, inclusive of local programs and nursery places for all the children in the age group of three to four years, the emergence of Child Tax Credit, and the emerging children's NSF. (Programme for Action overview and documents)

The Program for Action then concentrated on the recommendation made in the Acheson Inquiry Report of preventing illness and providing effective treatment and care that emphasized on the fact that the major achievements in reducing health inequalities can be achieved from tackling those health problems that result most commonly among the disadvantaged populations and those are amenable to efficient prevention and treatment. The Program for Action concentrated on strengthening of disadvantaged communities and strengthening of individuals ensuring that within a decade or two no body is seriously disadvantaged or affected by where they live. The Acheson Inquiry Report concentrated on the necessity for effective interventions to broad impacts on health inequalities. Government Departments were impressed upon to address such inherent determinants like improving the quality of housing, tackling joblessness and inactivity, bettering education attainment and dealing with low basic skills. However, attaining of better health returns it is essential to have stronger links between such areas. By taking concerted action by means of joined up policy making and implementation across departmental boundaries there seems a possibility of narrowing the gap in health outcomes. (Programme for Action overview and documents)