Dr.

Wutich Social Structure, Injustice, and Global Health

Slide 1
Hi, This is Professor Amber Wutich. This module is about the relationship between poverty,
structural injustice, and global health inequities. In essence, it asks how the society people are
born into – that is, the ways that the economy, political system, and social relations are
structured – affects their health outcomes.

Slide 2
Everybody knows that poor people are more likely to get sick, less likely to be treated
successfully, and more likely to die sooner. In fact, Muenning’s 2010 study in the American
Journal of Public Health found that poverty had the biggest negative impact on health – bigger
than smoking, obesity, binge drinking, and other factors that are known to directly cause illness.
The relationship between poverty and ill-health is a strong one – it holds across history, across
cultures, across nationalities. But many people misunderstand WHY poor people are sicker.
Let’s talk about a few of these misconceptions.

Slide 3
The first misconception is that: “Poor people are more likely to get sick because they are
irresponsible.” This argument is that if poor people made better choices, they would not get
sick as often. Certainly there is evidence, as Lynch et al reported in 1997, that: “lower
socioeconomic status is generally associated with … obesity, poorer dietary habits, [and] lower
levels of physical activity”. It’s likely that some of these health risks could be improved with
better decision making.

Yet poor people can’t simply choose to live in neighborhoods that aren’t polluted, to work in
jobs that provide good health insurance, or to live in high-income neighborhoods with good-
quality grocery stores and safe parks. Cerin and Leslie (2008) found in a review of the literature
that low income neighborhoods have worse access to sport and recreational spaces, less safe
and less attractive public spaces, and – ironically – fewer cost-free physical activity resources.
Being poor means that many of the amenities that help us make good, healthy choices are out
of the reach for the poor.

Slide 4
The second misconception is that “Poor people are more likely to get sick because they are
lazy”. Certainly it is true that poor people may not do some of the things that are
recommended to stay healthy – things like cook healthy homemade meals or exercise. But, as
de la Rocha explains, in her 2001 study of the working poor in Mexico, “the resources of
poverty have traditionally been the hands and arms of the working poor”. What she means is
that the only resource poor families have to try to improve their situation is their own labor--
and being poor makes you very busy.
Many poor people have to work longer hours or multiple jobs because they are paid so little.
And they have to waste hours every day riding the bus, fetching water, cutting firewood, and
doing other labor intensive-tasks that prevent them from earning more income. For instance,
Zizilirmak and Memis (2009) that in South Africa “poverty increases women’s time spent on
unpaid work by increasing their time spent on water and fuel collection”. Being poor typically
keeps people very busy, but unfortunately usually not busy doing things that enhance health.

Slide 5
The third misconception is that “Poor people are more likely to get sick because they are
ignorant”. The source of this misconception is probably the fact that is high education is
consistently associated with good health. Yet, Cutler and Lleras-Muney (2007) found that
“health behaviors alone cannot account for health status differences between” those with high
and low education—lots of other factors, including people’s family backgrounds, income and
work conditions, and social networks, can explain why highly educated people tend to be
healthier. Yet it is the mistaken assumption that poor people are ignorant that often leads
public health professionals to try to “educate” people out of certain health risks.

In reality, it’s often the lack of material resources – no access to medicine or doctors,
overburdened hospitals, or too little money to buy healthy water, food, or housing – that leads
poor people to make decisions that can look ignorant to an outsider. For instance, Russell
(1996) argues that “to mobilize resources [to pay for health-related costs, the poor] may
sacrifice other basic needs such as food and education” – this means that making one healthy
decision often forces poor people to sacrifice another. Being poor constrains and curtails
people’s choices so profoundly that it can be difficult or even impossible to make healthy
choices.

Slide 6
Social structure refers to the ways in which social relations are organized in a society. The way
that society is set up – including the economy, the political system, demography, class, gender,
and ethnic relations – all have important implications for people’s health. And the sad truth is
that even the most educated, hard-working, dependable poor person is likely to suffer
disproportionate and – some might argue deeply unfair – health risks, regardless of their best
efforts to avoid them. To illustrate how this works, I’ll give you just a few examples.

Slide 7
Economics is one way in which social structure creates health outcomes. It turns out that some
kinds of economies are much better at producing poverty and ill-health that others. These tend
to be economies with what we call “high income inequality”, or - in layman’s terms - a big gap
between the rich and the poor. In fact, Wilkinson’s pioneering (1992) study found that Western
industrialized countries with lower income inequality has higher life expectancy. Since then,
these results have been reproduced in 131 analyses (Wilkinson and Pickett 2006). Scholars are
still exploring why income equality has such severe health effects – some say that individual
poverty drives the relationship, others say that areas with high income inequality also under-
invest in needed health, education, and environmental infrastructure, while others argue that
that places with high income inequality also have social problems that undermine health (Torre
and Myrskylä 2011). Whatever the exact mechanism, the relationship between income
inequality and ill-health provides us strong evidence that social structure drives health
outcomes.

Slide 8
Another way that social structure affects health is through the organization of the political
system. Politics is a complex and multifaceted issue, but one aspect of a political system is the
“social safety net”—that is, the health, unemployment, disability, and other benefits the state
provides to the needy. In a study of 18 wealthy countries in Asia, Europe, and North America,
Chunga and Muntaner (2006) found that countries with a larger social safety net—and
especially those with more public medical coverage—had less infant mortality, fewer low-birth-
weight babies, and less mortality for children under 5. The World Health Organization
Commission on Social Determinants of Health (2007) argues that these kind of results are “an
illustration of the powerful impact of political variables on health outcomes”.

Slide 9
Social organization can take many forms, including religion, class, and race/ethnicity. Each one
of these can have profound health effects. Take the example of religion. Across cultures and
religions, regular attendance at religious services is associated with good health (Levin 1994)
once we control for other factors like income. In particular, Levin found, “behaviorally strict
religions or denominations (such as Mormons, Seventh-day Adventists, Orthodox Jews, and
clergy of all faiths) [are at lower risk for a host of diseases including] cardiovascular disease,
hypertension, stroke, uterine and cervical cancer, [and] numerous other cancer[s].” This is
because virtually all major religions emphasize the importance of behaviors (such as abstaining
from alcohol abuse) and beliefs (such as hopefulness) that safeguard good health.

While some aspects of social structure, such as religion, have health-giving properties, others
have the opposite effect. For instance, in societies with a legacy of rigid and highly
discriminatory racial systems such as the United States and South Africa, being assigned to a
“minority group” can carry serious health disadvantages. Another of the lectures in this module
explains how the stresses related to racial minority status begin to affect African Americans
before they are even born – setting them on a lifetime path of disproportionate health risks.

Slide 10
As we’ve seen, the way that a society is structured has incredibly important implications for our
health. Around the world, poor people are much more at risk for getting sick, getting poor-
quality healthcare, and even dying prematurely than other people. Paul Farmer, a well known
physician and scholar, has called this “structural violence”. What he means is that the structure
of a society can hurt people – even make them sick or die – through no fault of their own. And
even for people who aren’t at the bottom of a social hierarchy, the way a society is structured
can have real impacts on health outcomes. Therefore one important job for global health
experts is to study how social structures affect health, and make suggestions about how
changing things – even at a local, community level – might people less likely to suffer ill-health.