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[[Inequalities]] in health stem from the conditions of people's lives, including [[living conditions]], work environment, [[age]], and other social factors, and how these affect people's ability to respond to [[illness]]. These conditions are also shaped by political, social, and economic structures. Health quality, health distribution, and social protection of health in a population affect the development status of a nation. The majority of people across the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics".<ref> (WHO)</ref> "Daily living conditions, themselves the result of these structural drivers, together constitute the social determinants of health."<ref name=WHO /> |
[[Inequalities]] in health stem from the conditions of people's lives, including [[living conditions]], work environment, [[age]], and other social factors, and how these affect people's ability to respond to [[illness]]. These conditions are also shaped by political, social, and economic structures. Health quality, health distribution, and social protection of health in a population affect the development status of a nation. The majority of people across the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics".<ref> (WHO)</ref> "Daily living conditions, themselves the result of these structural drivers, together constitute the social determinants of health."<ref name=WHO /> |
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[[Poverty]] and ill-health are inextricably linked. Poverty has many dimensions – material deprivation (food, shelter, sanitation, and safe drinking water), [[social exclusion]], lack of education, [[unemployment]], and low income – each of which "diminishes opportunities, limits choices, undermines hope, and threatens health".<ref name=char> Charlotte Loppie Ph.D and Fred Wien Ph. D. National Collaborating Centre for Aboriginal Health. Health Inequalities and Social determinants of Aboriginal People’s Health. (University of Victoria, 2009)< http://www.nccah-ccnsa.ca/docs/social%20determinates/NCCAH-loppie-Wien_report.pdf> http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/NCCAH_fs_poverty_EN.pdf</ref> "Poverty has been associated with an increased risk of [[chronic disease]], injury, poor infant development, a range of [[mental health]] issues ([[ |
[[Poverty]] and ill-health are inextricably linked. Poverty has many dimensions – material deprivation (food, shelter, sanitation, and safe drinking water), [[social exclusion]], lack of education, [[unemployment]], and low income – each of which "diminishes opportunities, limits choices, undermines hope, and threatens health".<ref name=char> Charlotte Loppie Ph.D and Fred Wien Ph. D. National Collaborating Centre for Aboriginal Health. Health Inequalities and Social determinants of Aboriginal People’s Health. (University of Victoria, 2009)< http://www.nccah-ccnsa.ca/docs/social%20determinates/NCCAH-loppie-Wien_report.pdf> http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/NCCAH_fs_poverty_EN.pdf</ref> "Poverty has been associated with an increased risk of [[chronic disease]], injury, poor infant development, a range of [[mental health]] issues ([[stress]], [[anxiety]], [[depression]], and lack of self-esteem), and [[premature death]]. The burden of poverty falls most heavily on certain groups (women, children, ethnic and minority groups, and the [[disabled]]) and geographic regions."<ref name="char" /> Social determinants of health – like [[child development]], [[education]], living and [[working conditions]], and [[healthcare]]<ref name=WHO> World Health Organization. Commission on Social Determinants of Health. Closing the Gap in a Generation- Health equity through action and the social determinants of health. Geneva: World Health Organization. 2008. <http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf> Accessed 14 March 2012. </ref>- are of special importance to the impoverished. “Socioeconomic factors, including education, poverty, income, income inequality, and [[occupation]], are some of the strongest and most consistent predictors of health and mortality.”<ref name=gend> Gender equity and socioeconomic inequality: a framework for the patterning of women's health; Social & Economic Patterning of Women''s Health in a Changing World; Nancy E Moss; Center for AIDS Prevention Studies; Social Science & Medicine; Volume 54, Issue 5, March 2002, Pages 649–661; http://www.sciencedirect.com/science/article/pii/S0277953601001150 </ref> “The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, [[income]], [[goods]], and [[services]], globally and nationally.”<ref name=WHO /> The resulting inequalities in the apparent circumstances of individual’s lives – “their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities”<ref name=WHO /> – affect people’s ability to lead a flourishing life and maintain health. “This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.”<ref name=WHO /> Therefore, the conditions of individual’s daily life are responsible for the social determinants of health and a major part of health inequities between and within countries.<ref name=WHO /> Along with these social conditions, “Gender, education, occupation, income, [[ethnicity]], and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care.”<ref name=WHO /> Social determinants of disease can be attributed to broad social forces such as [[racism]], [[gender inequality]], [[poverty]], violence, and war.<ref name= “red”> Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural Violence and Clinical Medicine. PLoS Med 3(10): e449. doi:10.1371/journal.pmed.0030449. Accessed 14 March 2012. < http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030449> </ref> Since health has been considered a fundamental human right, one author suggests the social determinants of health determine the distribution of human dignity.<ref name=teal> Influence of socioeconomic status, wealth and financial empowerment on gender differences in health and healthcare utilization in later life: evidence from India; Kakoli Roya, Anoshua Chaudhurib; Centers for Disease Control and Prevention; Social Science & Medicine; Volume 66, Issue 9, May 2008, Pages 1951–1962; http://www.sciencedirect.com/science/article/pii/S0277953608000415 </ref> |
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==Definitions and measurements== |
==Definitions and measurements== |
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{{main| Social determinants of health}} |
{{main| Social determinants of health}} |
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Social determinants of health in poverty reveal inequalities in health. [[Health]] is defined “as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do”.<ref name=edu> John Mirowsky and Catherine E. Ross, Education, social status, and health (New York: Walter de Gruyter, Inc., 2003), 1-50. </ref> Measurements of health take several forms including, subjective health reports completed by individuals and surveys that measure physical impairment, vitality and well being, diagnosis of serious chronic disease, and expected life longeveity.<ref name=WHO /> |
Social determinants of health in poverty reveal inequalities in health. [[Health]] is defined “as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do”.<ref name=edu> John Mirowsky and Catherine E. Ross, Education, social status, and health (New York: Walter de Gruyter, Inc., 2003), 1-50. </ref> Measurements of health take several forms including, subjective health reports completed by individuals and surveys that measure physical impairment, vitality and well being, diagnosis of serious chronic disease, and expected life longeveity.<ref name=WHO /> |
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[[File:WHOdeterminantsframework.png|600px|Image: 600 pixels|right|alt=Social Determinants|Commission on Social Determinants of Health Conceptual Framework]] |
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According to the [[World Health Organization]], social determinants of health include early [[child development]], [[globalization]], health systems, measurement and evidence, [[urbanization]], employment conditions, [[social exclusion]], priority public health conditions, and women and [[gender equality]].<ref name=WHO /> More generally, the WHO considers the circumstances of daily life and structural drivers, as dominant elements in determining health outcome differentials, as the social determinants.<ref name=WHO />Different exposures and vulnerabilities to disease and injury determined by social, occupational, and physical environments, result in more or less vulnerability to poor health.<ref name=WHO />Structural drivers, on the other hand, include stratification in society, biases and norms in society, economic and social policy, and governance.<ref name=WHO /> These themes are condensed into a distinct structure of defining the social determinants of health in poverty. The World Health Organization’s Social Determinants Council recognized two distinct forms of social determinants for health- [[social position]] and socioeconomic and political context. The following divisions are adapted from World Health Organization’s Social Determinants Conceptual Framework for explaining and understanding social determinants of health. |
According to the [[World Health Organization]], social determinants of health include early [[child development]], [[globalization]], health systems, measurement and evidence, [[urbanization]], employment conditions, [[social exclusion]], priority public health conditions, and women and [[gender equality]].<ref name=WHO /> More generally, the WHO considers the circumstances of daily life and structural drivers, as dominant elements in determining health outcome differentials, as the social determinants.<ref name=WHO />Different exposures and vulnerabilities to disease and injury determined by social, occupational, and physical environments, result in more or less vulnerability to poor health.<ref name=WHO />Structural drivers, on the other hand, include stratification in society, biases and norms in society, economic and social policy, and governance.<ref name=WHO /> These themes are condensed into a distinct structure of defining the social determinants of health in poverty. The World Health Organization’s Social Determinants Council recognized two distinct forms of social determinants for health- [[social position]] and socioeconomic and political context. The following divisions are adapted from World Health Organization’s Social Determinants Conceptual Framework for explaining and understanding social determinants of health. |
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===Education=== |
===Education=== |
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[[File:Educationtrends.png|600px| right|Image: 600 pixels|alt=Trends in Male and Female life expectancy|Trends in male and female life expectancy at age 20, by educational attainment]] |
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Education plays an especially influential part in the lives of the impoverished. Education determines other factors of livelihood like occupation and income that determines income, which determines health outcomes. “Education and training in social determinants of health are vital. Educational attainment is linked to improved health outcomes, partly through its effects on adult income, employment, and living conditions (Ross & Wu, 1995; Cutler & Lleras-Muney, 2006; Bloom, 2007).”<ref name=WHO /> Life expectancy and infant mortality, which serve as measures of aggregate health, depend on social resources such as levels of education.”<ref name=HHS> U.S. Department of Health and Human Services: Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2010. Hyattsville, MD. 2011. <http://www.cdc.gov/nchs/data/hus/hus10.pdf> Accessed 13 March 2012. </ref> Education has a lasting, continuous, and increasing effect on health. “Education forms a unique dimension of social status, with qualities that make it especially important to health…. Education develops the learned effectiveness that enables [[self-direction]] toward any and all values sought, including health” (1) Education helps the impoverished develop usable skills, abilities, and resources that help individuals reach goals, including bettering health. Parent’s education level also influences health outcomes. “There are strong intergenerational effects – educational attainment of mothers is a determinant of child health, survival, and educational attainment (Caldwell, 1986; Cleland & Van Ginneken, 1988).”<ref name=WHO /> “Children born to more educated mothers are less likely to die in infancy and more likely to have higher birth weights and be immunized. Evidence from the United States suggests that some of the pathways linking maternal education to child health include lower parity, higher use of prenatal care, and lower smoking rates. In [[Taiwan]], [[China]], the increase in schooling associated with the education reform of 1968 saved almost 1 infant life for every 1,000 live births, reducing infant mortality by about 11 percent.<ref name=WDR12 /> |
Education plays an especially influential part in the lives of the impoverished. Education determines other factors of livelihood like occupation and income that determines income, which determines health outcomes. “Education and training in social determinants of health are vital. Educational attainment is linked to improved health outcomes, partly through its effects on adult income, employment, and living conditions (Ross & Wu, 1995; Cutler & Lleras-Muney, 2006; Bloom, 2007).”<ref name=WHO /> Life expectancy and infant mortality, which serve as measures of aggregate health, depend on social resources such as levels of education.”<ref name=HHS> U.S. Department of Health and Human Services: Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2010. Hyattsville, MD. 2011. <http://www.cdc.gov/nchs/data/hus/hus10.pdf> Accessed 13 March 2012. </ref> Education has a lasting, continuous, and increasing effect on health. “Education forms a unique dimension of social status, with qualities that make it especially important to health…. Education develops the learned effectiveness that enables [[self-direction]] toward any and all values sought, including health” (1) Education helps the impoverished develop usable skills, abilities, and resources that help individuals reach goals, including bettering health. Parent’s education level also influences health outcomes. “There are strong intergenerational effects – educational attainment of mothers is a determinant of child health, survival, and educational attainment (Caldwell, 1986; Cleland & Van Ginneken, 1988).”<ref name=WHO /> “Children born to more educated mothers are less likely to die in infancy and more likely to have higher birth weights and be immunized. Evidence from the United States suggests that some of the pathways linking maternal education to child health include lower parity, higher use of prenatal care, and lower smoking rates. In [[Taiwan]], [[China]], the increase in schooling associated with the education reform of 1968 saved almost 1 infant life for every 1,000 live births, reducing infant mortality by about 11 percent.<ref name=WDR12 /> |
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[[File:Infanteducation.png|600px|Image: 600 pixels|right|alt=Inequity in infant mortality rates between countries by mother’s education| Inequity in infant mortality rates between countries by mother’s education]] |
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Fig. 2.1 shows variation between countries in infant mortality from just over 20/1000 live births in [[Colombia]] to just over 120 in [[Mozambique]]. It also shows inequities within countries – an |
Fig. 2.1 shows variation between countries in infant mortality from just over 20/1000 live births in [[Colombia]] to just over 120 in [[Mozambique]]. It also shows inequities within countries – an |
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===Occupation=== |
===Occupation=== |
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[[File:Lessthan2.png|600px|Image: 600 pixels|right|alt=Regional Variation in the Percentage of people working living on less than 2 USD|Regional Variation in the Percentage of people working living on less than 2 USD]] |
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Impoverished workers are more likely to hold part time jobs, more in and out of work, be migrant workers, or experience stress associated with being unemployed and searching unsuccessfully for unemployment, which all in turn affects health outcomes. According to the WHO, “Employment and working conditions have powerful effects on heath equity… This includes employment conditions and the nature of work itself… Evidence indicates that mortality is significantly higher among temporary workers compared to permanent workers” (Kivimaki et al., 2003). “Adverse working conditions can expose individuals to a range of physical health hazards and tend to cluster in lower-status occupations… Stress at work is associated with a 50% excess risk of coronary heart disease (Marmot, 2004), and there is consistent evidence that high job demand, lower control, and effort-reward imbalance are risk factors for mental and physical health problems (Stansfeld & Candy, 2006).”<ref name=WHO /> These poor working conditions that results in lower health outcomes for the impoverished are determined by [[corporations]] and government institutions and continue. “The increasing power of large transnational corporations and international institutions to determine the labour policy agenda has led to a disempowerment of workers, [[ |
Impoverished workers are more likely to hold part time jobs, more in and out of work, be migrant workers, or experience stress associated with being unemployed and searching unsuccessfully for unemployment, which all in turn affects health outcomes. According to the WHO, “Employment and working conditions have powerful effects on heath equity… This includes employment conditions and the nature of work itself… Evidence indicates that mortality is significantly higher among temporary workers compared to permanent workers” (Kivimaki et al., 2003). “Adverse working conditions can expose individuals to a range of physical health hazards and tend to cluster in lower-status occupations… Stress at work is associated with a 50% excess risk of coronary heart disease (Marmot, 2004), and there is consistent evidence that high job demand, lower control, and effort-reward imbalance are risk factors for mental and physical health problems (Stansfeld & Candy, 2006).”<ref name=WHO /> These poor working conditions that results in lower health outcomes for the impoverished are determined by [[corporations]] and government institutions and continue. “The increasing power of large transnational corporations and international institutions to determine the labour policy agenda has led to a disempowerment of workers, [[unions]], and those seeking work and a growth in health-damaging working arrangements and conditions (EMCONET, 2007). In high- income countries, there has been a growth in job insecurity and precarious employment arrangements (such as informal work, temporary work, part-time work, and piecework), job losses, and a weakening of regulatory protections. Most of the world’s workforce, particularly in low- and middle-income countries, operates within the [[informal economy]], which by its nature is precarious and characterized by a lack of statutory regulation to protect working conditions, wages, occupational health and safety (OHS), and injury insurance (EMCONET, 2007; ILO, 2008).”<ref name=WHO /> |
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==Socioeconomic and political context== |
==Socioeconomic and political context== |
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===Societal psychological influences=== |
===Societal psychological influences=== |
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In impoverished communities, different [[social norms]] and stressors exist than in other populations, which can greatly affect health outcomes in disadvantaged populations. According to the National Institutes of Health: “Low socioeconomic status may result in poor physical and/or mental health by operating through various psychosocial mechanisms such as poor or “risky” health-related behaviors, [[social exclusion]], prolong and/ or heightened [[ |
In impoverished communities, different [[social norms]] and stressors exist than in other populations, which can greatly affect health outcomes in disadvantaged populations. According to the National Institutes of Health: “Low socioeconomic status may result in poor physical and/or mental health by operating through various psychosocial mechanisms such as poor or “risky” health-related behaviors, [[social exclusion]], prolong and/ or heightened [[stress]], loss of sense of control, and low [[self-esteem]] as well as through differential access to proper nutrition and to health and social services. In turn, these psychosocial mechanisms may lead to physiological changes such as raised [[cortisol]], altered blood-pressure response, and decreased [[immunity]] that place individuals at risk for adverse health and functioning outcomes. (National Institutes of Health 1998).”<ref name=HHS /> |
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===Structural violence=== |
===Structural violence=== |
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[[File:WHOprestoncurve.png|600px|Image: 600 pixels|right|alt=Preston Curve demonstrates Structural Violence|Classic demonstration of Structural Violence by comparing life expectancy to GDP per capita in 2000]] |
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Underlying social structures that propagate and perpetuate poverty and suffering- [[structural violence]]- majorly determine health outcomes of impoverished populations. Poor and unequal living conditions result from deeper structural conditions, including “poor social policies and programs, unfair economic arrangements, and bad politics,”<ref name=WHO /> that determine the way societies are organized. “The global system is so structured that many of its members suffer systematically more death than others due to an unequal distribution of resources and opportunities- in other words… [it] exhibits …structural violence.”<ref name=dia> Alcock, Norman. "Structural Violence at the World Level: diachronic findings ." Journal of Peace Research. XIV. no. 3 (1979): 255. http://jpr.sagepub.com/content/16/3/255.full.pdf </ref> |
Underlying social structures that propagate and perpetuate poverty and suffering- [[structural violence]]- majorly determine health outcomes of impoverished populations. Poor and unequal living conditions result from deeper structural conditions, including “poor social policies and programs, unfair economic arrangements, and bad politics,”<ref name=WHO /> that determine the way societies are organized. “The global system is so structured that many of its members suffer systematically more death than others due to an unequal distribution of resources and opportunities- in other words… [it] exhibits …structural violence.”<ref name=dia> Alcock, Norman. "Structural Violence at the World Level: diachronic findings ." Journal of Peace Research. XIV. no. 3 (1979): 255. http://jpr.sagepub.com/content/16/3/255.full.pdf </ref> |
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==See also== |
==See also== |
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*[[Social determinants of health]] |
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*[[Structural violence]] |
*[[Structural violence]] |
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*[[Global health]] |
*[[Global health]] |
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*[[Health inequity]] |
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==References== |
==References== |
Revision as of 01:06, 13 April 2012
Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. Health quality, health distribution, and social protection of health in a population affect the development status of a nation. The majority of people across the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics".[1] "Daily living conditions, themselves the result of these structural drivers, together constitute the social determinants of health."[2]
Poverty and ill-health are inextricably linked. Poverty has many dimensions – material deprivation (food, shelter, sanitation, and safe drinking water), social exclusion, lack of education, unemployment, and low income – each of which "diminishes opportunities, limits choices, undermines hope, and threatens health".[3] "Poverty has been associated with an increased risk of chronic disease, injury, poor infant development, a range of mental health issues (stress, anxiety, depression, and lack of self-esteem), and premature death. The burden of poverty falls most heavily on certain groups (women, children, ethnic and minority groups, and the disabled) and geographic regions."[3] Social determinants of health – like child development, education, living and working conditions, and healthcare[2]- are of special importance to the impoverished. “Socioeconomic factors, including education, poverty, income, income inequality, and occupation, are some of the strongest and most consistent predictors of health and mortality.”[4] “The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally.”[2] The resulting inequalities in the apparent circumstances of individual’s lives – “their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities”[2] – affect people’s ability to lead a flourishing life and maintain health. “This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.”[2] Therefore, the conditions of individual’s daily life are responsible for the social determinants of health and a major part of health inequities between and within countries.[2] Along with these social conditions, “Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care.”[2] Social determinants of disease can be attributed to broad social forces such as racism, gender inequality, poverty, violence, and war.[5] Since health has been considered a fundamental human right, one author suggests the social determinants of health determine the distribution of human dignity.[6]
Definitions and measurements
Social determinants of health in poverty reveal inequalities in health. Health is defined “as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do”.[7] Measurements of health take several forms including, subjective health reports completed by individuals and surveys that measure physical impairment, vitality and well being, diagnosis of serious chronic disease, and expected life longeveity.[2]
According to the World Health Organization, social determinants of health include early child development, globalization, health systems, measurement and evidence, urbanization, employment conditions, social exclusion, priority public health conditions, and women and gender equality.[2] More generally, the WHO considers the circumstances of daily life and structural drivers, as dominant elements in determining health outcome differentials, as the social determinants.[2]Different exposures and vulnerabilities to disease and injury determined by social, occupational, and physical environments, result in more or less vulnerability to poor health.[2]Structural drivers, on the other hand, include stratification in society, biases and norms in society, economic and social policy, and governance.[2] These themes are condensed into a distinct structure of defining the social determinants of health in poverty. The World Health Organization’s Social Determinants Council recognized two distinct forms of social determinants for health- social position and socioeconomic and political context. The following divisions are adapted from World Health Organization’s Social Determinants Conceptual Framework for explaining and understanding social determinants of health.
Social position
Poverty gradient and severity
Within the impoverished population exists a wide range of real income, from less than $2 USD a day, to the United States poverty threshold,[2] which is $22,350 for a family of four.[8]Within impoverished populations, being relatively versus absolutely impoverished can determine health outcomes, in their severity and type of ailment. According to the World Health Organization, “The poorest of the poor, around the world, have the worst health. Those at the bottom of the distribution of global and national wealth, those marginalized and excluded within countries, and countries themselves disadvantaged by historical exploitation and persistent inequity in global institutions of power and policy-making” suffer worse health outcomes.”[2] As such, there is a way to distinguish between relative severity of poverty. “Poverty is defined, conceptualized, and measured within two broad frameworks. Absolute poverty is the severe deprivation of basic human needs such as food, safe drinking water and shelter, and is used as a minimum standard below which no one should fall regardless of where they live. It is measured in relation to the ‘poverty line’ or the lowest amount of money needed to sustain human life. Relative poverty takes a more country specific approach and is defined as the inability to afford the goods, services, and activities needed to fully participate in a given society.”[3] Relative poverty still results in bad health outcomes because of the agency of the impoverished.[9] Certain personal, household factors, such as living conditions, are more or less unstable in the lives of the impoverished and represent the determining factors for health amongst the poverty gradient.[10] These factors prove challenging to individuals in poverty and are responsible for health deficits amongst the general impoverished population.[10]Having sufficient access to a minimum amount of food that is nutritious and sanitary plays an important part in building health and reducing disease transmission.[10]Access to sufficient amounts of quality water for drinking, bathing, and food preparation determines health and exposure to disease.[10]Clothing and bedding prove important in that clothing must provide appropriate climatic protection and both clothes and bedding must be cleaned appropriately to prevent irritation, rashes, and parasitic life.[10]Housing, including size, quality, ventilation, crowding, sanitation, and separation, prove paramount in determining health and spread of disease.[10]Availability of fuel for adequate sterilizing of eating utensils and food and the preservation of food proves necessary to promote health.[10]Transportation, which provides access to medical care, shopping, and employment, proves absolutely essential.[10]Hygienic and preventative care, including soap and insecticides, and vitamins and contraceptives, are necessary for maintaining health.[10]
Gender
Gender can determine health inequity in general health and particular diseases, and is especially magnified in poverty. In impoverished populations, there are pronounced differences in the types of illnesses and injuries men and women contract. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women. ( [Adler and Ostrove, 1999], [Huisman et al., 2003] and [McDonough and Walters, 2001]).[6]According to the WHO, the health gap between the impoverished and other populations will only be closed if the lives of women are improved and gender inequalities are solved. Therefore, “Empowerment of women is key to achieving fair distribution of health[2] “The rate at which girls and women die relative to men is higher in low- and middle-income countries than in high-income countries. “Globally, excess female mortality after birth and “missing” girls at birth account every year for an estimated 3.9 million women below the age of 60. About two-fifths of them are never born, one-fifth goes missing in infancy and childhood, and the remaining two-fifths do so between the ages of 15 and 59”.[11] “Globally, girls missing at birth and deaths from excess female mortality after birth add up to 6 million women a year, 3.9 million below the age of 60. Of the 6 million, one-fifth is never born, one-tenth dies in early childhood, one- fifth in the reproductive years, and two-fifths at older ages.[9] “These excess deaths have persisted throughout the decades, and some even increased…in the countries hardest hit by the HIV/AIDS epidemic, things got worse. In South Africa, excess female deaths increased from (virtually) zero between the ages of 10 and 50 in 1990 to 74,000 every year by 2008.”[9] In respect to differentials in particular diseases that are likely to determine health in poor women, poor women have more heart disease, diabetes, cancer, and infant mortality.[12] Poor women also have significant comorbidity, or existence of two ailments, such as psychiatric disorders with psychoactive substance use.[12]They are also at greater risk for contracting endemic conditions like tuberculosis, diabetes, and heart disease.[12] “Low income women in urban areas are more likely to have unplanned pregnancies or sexually transmitted diseases”.[12] “Studies in Denmark, England, Wales, Columbia, Finland, and for many states and ethnic groups in the United States, show that a woman’s risk for cervical cancer increases as her socio-demographic status goes down”.[12]
Household causes
The way in which resources such as “money, food, and emotional warmth are exchanged in the household influences psychosocial health, nutritional well-being, access to health services, and the expression of violence. Resource exchange mediates the effects of geopolitical, cultural, and household patterns of equity and inequality on health status and outcomes. Health-related mediators of inequality and equity include health behaviours; access to and use of health services; stressors; and psychosocial resources and strategies including social ties, coping and spirituality”.[10] “Missing girls at birth arise from household discrimination. After birth, although discrimination remains salient in some countries, in many other countries high female mortality reflects poorly performing institutions of service delivery.”[9]
Societal causes
With respect to socioeconomic factors poor institutions of public health and services can cause worse health in women.[9]”Gender inequities influence health through discriminatory feeding patterns, violence against women, lack of decision-making power, and unfair divisions of work, leisure, and possibilities of improving one’s life.”[2] “Determinants of women's health in the geopolitical environment include country-specific history and geography, policies and services, legal rights, organizations and institutions, and structures that shape gender and economic inequality.”[4] These structures, like socieo-demographic status and culture, norms and sanctions, shape women’s productive role in the workplace and reproductive role in the household, which determine health.[4] “Social capital, roles, psychosocial stresses and resources, health services, and behaviors mediate social, economic and cultural effects on health outcomes.”[4] Also, Women facing financial difficulty are more likely to report chronic conditions of health,[13] which occurs often in the lives of the impoverished. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women. ( [Adler and Ostrove, 1999], [Huisman et al., 2003] and [McDonough and Walters, 2001]).[6] Differences in socioeconomic status and resulting financial empowerment for women explain the poorer health and lower healthcare utilization noted among older women compared to men in India.[6]Psycho-social factors also contribute to differences in reported health.[6] First, women might report higher levels of health problems as a result of differential exposure or reduced access to material and social factors that foster health and well-being (Arber & Cooper, 1999)[6] Second, women might report higher health problems because of differential vulnerability to material, behavioral, and psychosocial factors that foster health (McDonough & Walters, 2001).”[6]
Prenatal care
Prenatal care also plays a role in the health of women and their children, with excess infant mortality in impoverished populations and nations representing these differentials in health. Insufficient prenatal care represents one facet of women receiving differential healthcare. “Poverty is the most important factor consistently associated with insufficient prenatal care…. Three factors separate poor women from prenatal care. They are: 1. The sociodemographic correlates of poverty (age, ethnicity, marital status, high parity and low educational attainment); 2. Barriers within the system, and 3. Barriers based on beliefs, knowledge, attitudes and life-styles” Study after study shows the complex associations between poverty and education, employment, teen births, and the health of the mother and child. Sixty percent of children born into poor families have at least one chronic disease.[12]
Differential health for men
There also exists differentials in health with respect to men. “Excess female mortality is not a problem in all countries. In the Russian Federation and some other post-transition countries, mortality risks have increased for both sexes—but particularly for men. In these contexts, there is excess male mortality relative to high-income countries today. Unlike mortality risks among women, which arise from poor institutions, excess male mortality is often tied to behavior deemed more socially acceptable among men, such as smoking, heavy drinking, and engaging in risky activities.”[9] Women are more likely to experience role strain and overload that occur when familial responsibilities are combined with occupation-related stress.”[4]
Ethnicity
Ethnicity can play an especially large part in determining health outcomes for impoverished minorities. Poverty can overpower race, but within poverty, race highly contributes to health outcomes.[14] “African Americans in some of the most prosperous U.S. cities (such as New York, Washington, or San Fransisco) have a lower life expectancy at birth than do most people in immensely poorer China or even India”[14] “For black people in south Africa, the proximate cause of increased rates of morbidity and mortality is lack of access to resources: ‘Poverty remains the primary cause of the prevalence of many disease and widespread hunger and malnutrition among black South Africans.’[14] A disproportionate number of cases of the AIDS epidemic in North America are from American minorities: “72 percent of AIDS cases among women are either African- American or Hispanic. The single largest group of HIV-infected females is African-American women”[12]The growing mortality differentials between whites and blacks must be attributed to class differentials-[14]which includes recognizing race within impoverished populations. Recognition of race as a determining factor for poor health without recognizing poverty has misled individuals to believe race is the only factor.[12]
Health differentials amongst races can also serve as determining factors for other facets of life. “Hispanic women with AIDS have lower average salaries than women as a group; live in poorer families to begin with, and are overrepresented as heads-of-households.” “Black teenagers from dysfunctional households… were most likely to experience serious health problems either for themselves or their babies”[12]
Education
Education plays an especially influential part in the lives of the impoverished. Education determines other factors of livelihood like occupation and income that determines income, which determines health outcomes. “Education and training in social determinants of health are vital. Educational attainment is linked to improved health outcomes, partly through its effects on adult income, employment, and living conditions (Ross & Wu, 1995; Cutler & Lleras-Muney, 2006; Bloom, 2007).”[2] Life expectancy and infant mortality, which serve as measures of aggregate health, depend on social resources such as levels of education.”[15] Education has a lasting, continuous, and increasing effect on health. “Education forms a unique dimension of social status, with qualities that make it especially important to health…. Education develops the learned effectiveness that enables self-direction toward any and all values sought, including health” (1) Education helps the impoverished develop usable skills, abilities, and resources that help individuals reach goals, including bettering health. Parent’s education level also influences health outcomes. “There are strong intergenerational effects – educational attainment of mothers is a determinant of child health, survival, and educational attainment (Caldwell, 1986; Cleland & Van Ginneken, 1988).”[2] “Children born to more educated mothers are less likely to die in infancy and more likely to have higher birth weights and be immunized. Evidence from the United States suggests that some of the pathways linking maternal education to child health include lower parity, higher use of prenatal care, and lower smoking rates. In Taiwan, China, the increase in schooling associated with the education reform of 1968 saved almost 1 infant life for every 1,000 live births, reducing infant mortality by about 11 percent.[9]
Fig. 2.1 shows variation between countries in infant mortality from just over 20/1000 live births in Colombia to just over 120 in Mozambique. It also shows inequities within countries – an infant’s chances of survival are closely related to her mother’s education. In Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births; the infant mortality rate of babies born to mothers with at least secondary education is under 40/1000.All countries included in Fig. 2.1 show the survival disadvantage of children born to women with no education.”[2]
Occupation
Impoverished workers are more likely to hold part time jobs, more in and out of work, be migrant workers, or experience stress associated with being unemployed and searching unsuccessfully for unemployment, which all in turn affects health outcomes. According to the WHO, “Employment and working conditions have powerful effects on heath equity… This includes employment conditions and the nature of work itself… Evidence indicates that mortality is significantly higher among temporary workers compared to permanent workers” (Kivimaki et al., 2003). “Adverse working conditions can expose individuals to a range of physical health hazards and tend to cluster in lower-status occupations… Stress at work is associated with a 50% excess risk of coronary heart disease (Marmot, 2004), and there is consistent evidence that high job demand, lower control, and effort-reward imbalance are risk factors for mental and physical health problems (Stansfeld & Candy, 2006).”[2] These poor working conditions that results in lower health outcomes for the impoverished are determined by corporations and government institutions and continue. “The increasing power of large transnational corporations and international institutions to determine the labour policy agenda has led to a disempowerment of workers, unions, and those seeking work and a growth in health-damaging working arrangements and conditions (EMCONET, 2007). In high- income countries, there has been a growth in job insecurity and precarious employment arrangements (such as informal work, temporary work, part-time work, and piecework), job losses, and a weakening of regulatory protections. Most of the world’s workforce, particularly in low- and middle-income countries, operates within the informal economy, which by its nature is precarious and characterized by a lack of statutory regulation to protect working conditions, wages, occupational health and safety (OHS), and injury insurance (EMCONET, 2007; ILO, 2008).”[2]
Socioeconomic and political context
Location
Nation-state/ Geographical Region
Which particular nation an impoverished person lives in deeply affects health outcomes. This can be attributed to governmental, environmental, geographical, and cultural factors. Using life expectancy as a measure of health indicates a difference between countries in likeliness of living to a certain age. People “have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years”[12] “Of every 1,000 adults between the ages of 15 and 60 in the rich countries, somewhere between 56 (Iceland) and 107 (United States) …will die each year… In Central and West Africa, adult mortality rates are higher, routinely exceeding 300 and in many countries 400… And in HIV/AIDS-affected countries, the numbers rise to… 772 (Zimbabwe). (WHO 2010.)”[9] Also, the type of health affliction varies by countries for populations in poverty. Over 80% of cardiovascular disease deaths, that totaled 17.5 million people globally in 2005, occur in low- and middle-income countries (WHO). 13500 people die from smoking every day, and soon it will become the leading cause of death in developing countries, as in high income countries. (Mathers & Loncar, 2005).[2]
Infant and maternal mortality also reveals disparity in health between nations. “The distribution of infant deaths is most unequal, both between countries and within them. [There is] variation between countries in infant mortality from just over 20/1000 live births in Colombia to just over 120 in Mozambique… [as well as there are] dramatic inequities within countries.” “The lifetime risk of maternal death is one in eight in Afghanistan; it is 1 in 17 400 in Sweden, (WHO et al., 2007).”[2] “In 1985, the World Health Organization estimated that maternal mortality is on average, approximately 150 times higher in developing countries than in developed nations. In Haiti… maternal mortality is as high as fourteen hundred deaths per one hundred thousand live births… these deaths are almost all registered among the poor”[16]
Urban or Rural location
Urban
Impoverished people’s health outcomes are especially determined by whether they live in a metropolitan area or rural area. “Where people live affects their health and chances of leading flourishing lives… Almost 1 billion [people globally] live in slums.”[2] With the prevalence of inner city ghettos and slums across the globe in cities, living situation is an especially strong determining factor of health of the lives of the impoverished in particular. Urban areas present health risks through poor living conditions, limited food resources, traffic accidents, and pollution. “Urbanization is reshaping population health problems, particularly among the urban poor, towards non-communicable diseases, accidental and violent injuries, and deaths and impact from ecological disaster (Capbell &Campbell, 2007; Yusuf et al., 2001)… The daily conditions in which people live have a strong influence on health equity. Access to quality housing and shelter and clean water and sanitation are human rights and basic needs… growing car dependence, land-use change to facilitate car use, and increased inconvenience of non-motorized modes of travel, have knock-on effects on local air quality, greenhouse gas emission, and physical inactivity (NHF, 2007).”[2]
- a. Obesity
Living in a city increases probability of obesity in disadvantaged populations: “Obesity …is a pressing problem, particularly among socially disadvantaged groups in many cities throughout the world (Hawkes et al., 2007; Friel, Chopra & Satcher, 2007).”[2] The increased amount of obesity can be contributed to the nutrition transition that describes how people are now increasingly turning to high-fat, sugar, and salt food sources because of their availability and price. This food transition has fueled the obesity epidemic. This nutrition transition tends to start in cities because of “greater availability, accessibility, and acceptability of bulk purchases, convenience foods, and ‘supersized’ portions (Dixon et al., 2007). Physical activity is strongly influenced by the design of cities through the density of residences, the mix of land uses, the degree to which streets are connected and the ability to walk from place to place, and the provision of and access to local public facilities and spaces for [[recreation] and play. Each of these plus the increasing reliance on cars is an important influence on shifts towards physical inactivity in high- and middle-income countries (Friel, Chopra & Satcher, 2007).”[2]
- b. Crime
“Violence and crime are major urban health challenges. “Of the 1.6 million violence-related deaths worldwide (including those from conflict and suicide) that occur each year, 90% happen in low- and middle-income countries (WHO, 2002).”[2] A large number of deaths and injuries occur because of crime, which affects health.[2]
- c. Traffic
“Urban areas are by far the most affected by road-traffic injuries and vehicle-related air pollution, with approximately 800 000 annual deaths from ambient urban air pollution and 1.2 million from road-traffic accidents (Roberts & Meddings, 2007; Prüss- Üstün & Corvalán, 2006).”[2] This results in greater health risks, like death,[2] for impoverished populations in cities.
- d. Other
“The statistics consistently show a patterned incidence of HIV in urban areas along the eastern seaboard from New York to Florida, secondary concentrations in other urban areas, and show prevalence rates for African- American women five to fifteen times higher than for white women in the same state.” “[Inner-city women] are the most likely of all women in this country to have dead or desperately ill babies… [and] there has been an enormous erosion of availability of prenatal care since 1980”[12] “In Nairobi, where 60% of the city’s population live in slums, child mortality in the slums is 2.5 times greater than that in other areas of the city.”[2] “In Manila’s slums, up to 39% of children aged between 5 and 9 are already infected with TB, twice the national average”[2] “In low- and middle-income countries, people with disabilities are vulnerable to health threats, particularly in urban areas due to the challenges of a high population density, crowding, unsuitable living design, and lack of social support (Frumkin et al., 2004).”[2]
Rural
Living in a rural community, whether in the United States, or across the globe, reduces access to medical services, health insurance, and changes health culture. Differences in health outcomes are revealed between rural and urban communities, with certain disadvantages in rural communities for impoverished people. “Population health is better in geographic areas with more primary care physicians.”[2] “Premature mortality (before 75 years of age) is greater among rural residents than among urban residents, and rural–urban mortality differences vary by age….The age-adjusted death rate among persons aged 1 to 24 years who lived in the most rural counties was 31% higher than among children and young adults who lived in the most urban counties…The age-adjusted death rate among adults aged 25 to 64 years who lived in the most rural counties was 32% higher than among residents who lived in suburban counties, and the rate was similar to that among working -age adults who lived in the most urban counties…Compared with more highly urbanized counties, rural counties in the United States had higher death rates from unintentional in- juries, suicide, and chronic obstructive pulmonary disease…Broader measures of health and well-being have shown that rural populations have poorer health status. In 1997 and 1998, 18% of rural adults (aged 18 years and older) reported chronic health conditions that caused activity limitation compared with 13% of adults who lived in sub- urban counties. Similarly, 1998 data from the National Health Interview Survey showed that 16% of adults who lived in the most rural counties reported being in fair or poor health. Demographic and socioeconomic factors, such as race, ethnicity, education, and income, also are strongly related to health and vary between rural and urban settings, and these factors contribute to health differences among rural and nonrural residents. Poor and near-poor rural residents also were less likely to report having Medicaid coverage than residents of the most urban counties (21% vs 30%). Among persons aged younger than 65 years whose family incomes were 200% of the federal poverty threshold or higher, 11% of residents in the most rural counties lacked health insurance versus 7% of suburban county residents. Thus, lower in- comes were partially responsible for the higher proportion of uninsured persons in rural counties.”[17] For extremely poor rural communities, “Community-level variables- ecological setting- the ecological setting including climate, soil, rainfall, temperature, altitude, and seasonality- are important for health. In rural subsistence societies, these variables can have strong influence on child survival by affecting the quantity and variety of food crops produced, the availability and quality of water, vector-borne disease transmission”[10]
Governance/Policy
‘Government structure and type as well as corresponding economic and social policy can more deeply determine health of the impoverished than other populations in certain ways. Every aspect of government and the economy has the potential to affect health and health equity – finance, education, housing, employment, transport, and health.[2] “Variations in life expectancies of rich counties… can in part be explained by the type of political regime (using the regime types of Fascist, Communist, Conservative, and Social-Democratic”[18] “The dismantling of the apartheid regime has not yet brought the dismantling of the structures of oppression and inequality in South Africa, and persistent social inequality is no doubt the primary reason that HIV has spread so rapidly in sub-Saharan Africa’s wealthiest nation”[14] Also, the “political economy, which Includes organization of production, physical infrastructure and political institutions”[10] play a large role in determining health inequalities for children.[10]
Social Service and Healthcare Availability
Impoverished people depend on healthcare and other social services to be provided in the social safety net, which are all responsible for determining heath outcomes, and therefore availability greatly determines health outcomes. “Countries with more generous social protection systems tend to have better population health outcomes, at least across high- income countries for which evidence is available (Lundberg et al., 2007). More generous family policies, for example, are associated with lower infant mortality rates (Fig. 8.3). Similarly, countries with a higher coverage and greater generosity of pensions and sickness, unemployment, and work accident insurance (taken together) have a higher LEB (Lundberg et al., 2007), and countries with more generous pension schemes tend to have lower old-age mortality (Lundberg et al., 2007).”[2] “The system barriers are formidable and center on the structural problems endemic to poor people. The first is financing. Medicaid and or other maternity coverage also have complicated, time-consuming processes for registration, difficult procedures… long waits, and intermitted eligibilities.” “Low living standards are a powerful determinant of health inequity…. Generous universal social protection systems are associated with better population health… including lower mortality levels… among socially disadvantaged groups.”[12]
“The health care system is itself a social determinant of health influenced by and influencing the effect of other social determinants. Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care.”[2] “Health care is inequitably distributed around the world. The pattern of inequity in utilization is pronounced in low- and middle-income countries, but inequity is prevalent in high- income settings too. In the United States, minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer than whites. Patients in lower socioeconomic strata are less likely to receive recommended diabetic services and more likely to be hospitalized for diabetes and its complications (Agency for Health Care Research and Quality, 2003). Inequities in health care are related to a host of socioeconomic and cultural factors, including income, ethnicity, gender, and rural/urban residency.” “Health-care systems contribute most to improving health and health equity where the institutions and services are organized around the principle of universal coverage (extending the same scope of quality services to the whole population, according to needs and preferences, regardless of ability to pay), and where the system as a whole is organized around Primary Health Care (including both the PHC model of locally organized action across the social determinants of health, and the primary level of entry to care with upward referral)”[2]
These structural problems result in worse healthcare and therefore worse health outcomes for impoverished populations. Health care costs can pose absolutely serious threats to impoverished populations, especially in countries without proper social provisions. According to US HHS, “In 2009, children 6–17 years of age were more likely to be uninsured than younger children, and children with a family income below 200% of the poverty level were more likely to be uninsured than children in higher-income families.” “Among the under-65 population, persons with a family income less than 400% of the poverty level were 3.1 to 5.3 times as likely to be uninsured…as persons in higher income families in 2009” “In 2009… children with a family income below 200% of the poverty level were more likely to be uninsured than children in higher-income families” “In 2009, 19%–21% of adults 18–64 years of age in families with income below 200% of poverty did not receive needed prescription drugs due to cost in the past 12 months, compared with 12% of those with a family income 200%–399% of poverty and 4% of those with a family income 400% of poverty or higher.”[15] “In Asia, health-care payments pushed 2.7% of the total population of 11 low- to middle-income countries below the very low poverty threshold of US$ 1/day.”[2]
Societal psychological influences
In impoverished communities, different social norms and stressors exist than in other populations, which can greatly affect health outcomes in disadvantaged populations. According to the National Institutes of Health: “Low socioeconomic status may result in poor physical and/or mental health by operating through various psychosocial mechanisms such as poor or “risky” health-related behaviors, social exclusion, prolong and/ or heightened stress, loss of sense of control, and low self-esteem as well as through differential access to proper nutrition and to health and social services. In turn, these psychosocial mechanisms may lead to physiological changes such as raised cortisol, altered blood-pressure response, and decreased immunity that place individuals at risk for adverse health and functioning outcomes. (National Institutes of Health 1998).”[15]
Structural violence
Underlying social structures that propagate and perpetuate poverty and suffering- structural violence- majorly determine health outcomes of impoverished populations. Poor and unequal living conditions result from deeper structural conditions, including “poor social policies and programs, unfair economic arrangements, and bad politics,”[2] that determine the way societies are organized. “The global system is so structured that many of its members suffer systematically more death than others due to an unequal distribution of resources and opportunities- in other words… [it] exhibits …structural violence.”[18]
Definition
Structural violence is a term devised by Johan Galtung and liberation theologians during the 1960s to “describe social structures—economic, political, legal, religious, and cultural—that stop individuals, groups, and societies from reaching their full potential.”[19] Structural violence is structural because the causes of misery are “embedded in the political and economic organization of our social world; they are violent because they cause injury to people.”[19] Structural violence is different from personal or behavioral violence because it exclusively refers to preventable harm done to people by no one clear individual, but “emerges from the unequal distribution of power and resources …. [which is] built into our structure.”[20] “Structural violence [is] a broad rubric that includes a host of offensives against human dignity: extreme and relative poverty, social inequalities ranging from racism to gender inequality, and the more spectacular forms of violence that are uncontestably human rights abuses”[14] The idea of structural violence is as old as the study of conflict and violence,[20] and so it can also be understood as related to social injustice and oppression.[19]
Effects
Structural violence is often embedded in longstanding "ubiquitous social structures, normalized by stable institutions and regular experience".[19] These social structures seem so normal in our understanding of the world that they are almost invisible, but "disparate access to resources, political power, education, health care, and legal standing"[19] are all possible perpetrators of structural violence.[19] Structural violence occurs “whenever persons are harmed, maimed, or killed by poverty and unjust social, political, and economic institutions, systems, or structures”[21]”Structural violence, liked armed violence, can have two effects- it either kills its victims or harms them in various ways short of killing.”[21] ”This unintended harm perpetuated by structural violence slowly promotes misery and hunger that erodes and finally kills human beings.[20] “Ehrlich and Ehrlich (1970, p. 72) report that: ‘Of the 60 million deaths that occur each year, between 10 and 20 million are estimated to be the result of starvation or malnutrition…about one billion lives…. were being extinguished [between 1948 and 1967] in the third world by some combination of behavioral and structural violence.’”[21]
Structural violence connection to health
“Inequality in the conditions of daily living is shaped by deeper social structures and processes. The inequity is systematic, produced by social norms, policies, and practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources.”[2] “Every aspect of government and the economy has the potential to affect health and health equity- finance, education, housing, employment, transport, and health”[2] First of all, structural violence is often a major determinant of the distribution and outcome of disease.[19] It has been known for decades that epidemic disease is caused by structural forces.[19] “Throughout the usually decade-long process of HIV progression, detrimental social structures and constructs—structural violence—have a profound influence on effective diagnosis, staging, and treatment of the disease and its associated pathologies. Each of these determinants of disease course and outcome is itself shaped by the very social forces that determine variable risk of infection.”[19] Understanding how structural violence is embodied at the community, individual, and microbial levels is vital to understanding the dynamics of disease.[19] The consequences of structural violence is post pronounced in the world's poorest countries and greatly affects the provision of clinical services in these countries.[19] Elements of structural violence such as “social upheaval, poverty, and gender inequality decrease the effectiveness of distal services and of prevention efforts” presents barriers to medical care in countries like Rwanda and Haiti[19]
See also
References
- ^ (WHO)
- ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq World Health Organization. Commission on Social Determinants of Health. Closing the Gap in a Generation- Health equity through action and the social determinants of health. Geneva: World Health Organization. 2008. <http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf> Accessed 14 March 2012.
- ^ a b c Charlotte Loppie Ph.D and Fred Wien Ph. D. National Collaborating Centre for Aboriginal Health. Health Inequalities and Social determinants of Aboriginal People’s Health. (University of Victoria, 2009)< http://www.nccah-ccnsa.ca/docs/social%20determinates/NCCAH-loppie-Wien_report.pdf> http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/NCCAH_fs_poverty_EN.pdf
- ^ a b c d e Gender equity and socioeconomic inequality: a framework for the patterning of women's health; Social & Economic Patterning of Womens Health in a Changing World; Nancy E Moss; Center for AIDS Prevention Studies; Social Science & Medicine; Volume 54, Issue 5, March 2002, Pages 649–661; http://www.sciencedirect.com/science/article/pii/S0277953601001150
- ^ Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural Violence and Clinical Medicine. PLoS Med 3(10): e449. doi:10.1371/journal.pmed.0030449. Accessed 14 March 2012. < http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030449>
- ^ a b c d e f g Influence of socioeconomic status, wealth and financial empowerment on gender differences in health and healthcare utilization in later life: evidence from India; Kakoli Roya, Anoshua Chaudhurib; Centers for Disease Control and Prevention; Social Science & Medicine; Volume 66, Issue 9, May 2008, Pages 1951–1962; http://www.sciencedirect.com/science/article/pii/S0277953608000415
- ^ John Mirowsky and Catherine E. Ross, Education, social status, and health (New York: Walter de Gruyter, Inc., 2003), 1-50.
- ^ US. Department of Health and Human Serivces. “The 2011 HHS Poverty Guidelines.” Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638. <http://aspe.hhs.gov/poverty/11poverty.shtml> Accessed 1 April 2012.
- ^ a b c d e f g h World Bank. World Development Report 2012: Gender Equality and Education. (Washington DC: World Bank, 2012). 84.
- ^ a b c d e f g h i j k l m An Analytical Framework for the Study of Child Survival in Developing Countries. W. Henry Mosley and Lincoln C. Chen; Population and Development Review , Vol. 10, Supplement: Child Survival: Strategies for Research (1984), pp. 25-45. Published by: Population Council; <http://www.jstor.org/stable/2807954> http://www.jstor.org/stable/10.2307/2807954
- ^ World Bank. World Development Report 2012: Gender Equality and Education. (Washington DC: World Bank, 2012). 84.
- ^ a b c d e f g h i j k l Ward, Martha C. “A different disease: HIV/ AIDS and health care for women in poverty”. Culture, Medicine, and Psychiatry. Vol 17. Number 4. 413-430. <http://www.springerlink.com/content/m4j45w87x3377921/>
- ^ Gender and health: reassessing patterns and explanations; Peggy McDonougha; Social Science & Medicine; Volume 52, Issue 4, February 2001, Pages 547–559; http://www.sciencedirect.com/science/article/pii/S0277953600001593
- ^ a b c d e f Farmer, Paul. Pathologies of power: health, human rights, and the new war on the poor. University of California Press. 2003. Los Angeles. 8. < http://books.google.com/books?id=2sbP7J-lckoC&printsec=frontcover#v=onepage&q&f=false>
- ^ a b c U.S. Department of Health and Human Services: Center for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2010. Hyattsville, MD. 2011. <http://www.cdc.gov/nchs/data/hus/hus10.pdf> Accessed 13 March 2012.
- ^ Paul Farmer. On Suffering and Structural Violence: A View from Below. Vol 125, No 1, Social Suffering (Winter, 1996)(pp. 261-283) < http://www.jstor.org/stable/20027362?seq=15>
- ^ Eberhardt and Pamuk. Rural Health and Health Care Disparities. American Journal of Public Health. 2004. < http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.94.10.1682>
- ^ a b Alcock, Norman. "Structural Violence at the World Level: diachronic findings ." Journal of Peace Research. XIV. no. 3 (1979): 255. http://jpr.sagepub.com/content/16/3/255.full.pdf
- ^ a b c d e f g h i j k l Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural Violence and Clinical Medicine. PLoS Med 3(10): e449. doi:10.1371/journal.pmed.0030449. Accessed 14 March 2012. <http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030449>
- ^ a b c Weigert, Kathleen. Structural Violence. Washington DC: Elseiver, 2008. <http://books.google.com/books?hl=en&lr=&id=rOq4XV94wLsC&oi=fnd&pg=PA126&dq=structural+violence+galtung&ots=nLx5D-hC3i&sig=Ifhnn0qeBeS0HL8zWG1MHUkPZjA#v=onepage&q=structural%20violence%20galtung&f=false>
- ^ a b c Gernot Köhler and Norman Alcock. An Empirical Table of Structural Violence. <http://www.jstor.org/stable/10.2307/422498>