In the early years of the twenty first century, with so much evolution in sociological thought having already taken place, no scholar can dismiss theories concerning health inequalities in society. All societies of past and present exhibited fissures in terms of class, gender, age groups, etc. Sociologists have discovered valid correlations between these social parameters and indicators of wellbeing. In this respect, all four prominent sociological approaches to studying health and wellbeing offer their own insights and inputs about the correlations. In other words, the Social Constructionist/Artefact approach, the Social/Natural Selection approach, Cultural/Behavioural approach and the Materialist/Structuralist approach offer different perspectives on health inequalities in past and present societies.
The Biomedical model of health preceded modern sociological health paradigm, where freedom from disease, pain or defect is the core focus. The physician typically inspects the patient ‘after’ the onset of an ailment and studies the pathology of disease, physiological mechanisms at play, as well as the biochemical processes. Under the biomedical model, the emphasis is on ‘cure’ and ‘healing’ through scientific application of medical principles as and when a medical condition presents itself. While this goal is perfectly legitimate, the critics of the Biomedical model point out its narrow focus, which largely leaves aside the social, economic and psychological factors that often precede and determine the health of an individual. (Wyman, 2000, p.77) It is due to this lack of wholeness in this model of health, that scholars and thinkers have devised other wholesome perspectives. They have added newer dimensions to the study of human health, and the result is the invention of sociological analytic frameworks for studying people’s health. The dominant discourse of the social determinants of health paradigm
“assumes a socio-environmental approach to health primarily ‘concerned with risk conditions rather than risk factors’. These conditions include poverty; income, gender, racial, and sexual inequality; stressful environments; housing and living conditions; education and early child care; food security; employment and working conditions; social inclusion and exclusion; and globalization. Efforts to attend to health inequities by anyone working under this paradigm would, therefore, address some or all of these issues.” (Ashcroft, 2010, p.251)
Social determinants of health such as geographical location, gender, age, ethnic origin, education level, governance and socioeconomic status are all factors that contribute to an individual’s health status. Statistics from World Health Report 2001 supports the veracity of these connections. For example, developing nations continue to lag behind in standard of living parameters. Even as globalization has enabled technology aided interconnectivity, hundreds of thousands of people are still living under hostile health conditions (Taylor, 2002, p.25). While the rich nations are getting richer, complete swathes of sub-Saharan people still confront poverty, hunger, illiteracy and threat of infectious disease on a day to day basis. The biggest threat to people in this particular region is HIV/AIDS, an ailment that consumes a million lives every six months in Africa, with sub-Saharan African nations bearing the brunt of this epidemic. This region, according to statistics released by Joint United Nations Programme on HIV/AIDS, is home to seventy percent of people infected with HIV worldwide. Such numbers betray the socio-political realities of the region, with its attendant failure to invest in public health projects (Kazatchkine, 2007, p.77). They also clearly indicate the validity of sociological explanations for health inequalities.
The connection between the economic status of a country and its ability to deliver robust public health services is an established fact. Also, the litmus test for the efficiency and effectiveness of any public health system is its performance in a crisis situation. Civil societies have come to expect basic protections at the time of these crises. Such emergencies also test a government’s true ability to act under pressure. In other words, “they define a state’s capacity to protect its population while exposing its vulnerabilities to political upheaval in the aftermath of poorly managed crises” (Gorin, 2002, p.56). Many of modern epidemics, including AIDS, polio, and malaria may in a few years’ time even out. But, for a developing nation, new challenges in the form of cancer, road accidents and cardiovascular disease will emerge. Further, although sufficient progress has been made in checking infant mortality rates in the Third World since the 1980s, cases of easily contagious epidemics like tuberculosis have not declined. This goes on to show that the biomedical model of health is inadequate in explaining inequalities in health. It also makes a case for exploring sociological explanations for health inequalities. The Cultural/Behavioural approach, for instance, offers insights into factors affecting healthcare. For example, differences have been noted in health status across various ethnic groups both here in the UK and also in the USA. But there are disagreements and weaknesses associated with this approach. For example, some scholars argue that
“the cultural and genetic factors are of greater importance…In much of the health related literature on ethnic minorities there is a strong tendency for explanations of variations in health status in different ethnic communities to be based on oversimplistic culturalistic explanations. These culturalist explanations ignore social and economic deprivation as being causally related to the development of certain illnesses. For instance rickets among Asian groups is held to relate to the ‘Asian diet’ and lack of sunlight. The fact that Asians live in inner city areas with limited access to park space and limited mobility on account of a real fear of racial discrimination is not taken into account.” (Dein, 2006, p.68)
The Structuralist/Materialist approach to studying health inequalities throws further light on the subject. Recent discussion in the field towards effective actions to tackle health inequalities has seen an increasingly explicit focus on addressing ‘unjust social structures’. Scholars and human rights advocates such as Whitehead, Braveman and Gruskin have attempted to clarify prevailing understandings of health and equity specifically for research and policy purposes. They argue that
“while structures of exploitation and discrimination prevail, the right to health is seriously circumscribed. From this perspective, health inequities are strongly associated ‘with unjust social structures; those structures (that) systematically put disadvantaged groups at generally increased risk of ill health and also compound the social and economic consequences of ill health’. This is significant because the right to health is a basic human right established and ratified by the Constitution of the WHO (1946) and international human rights treaties. Governments who are signatories to such treaties are therefore publicly committed to the implementation of the principles and practices of justice that will secure the right to health for all. Further, such a right is contingent on the equalisation of opportunities to be healthy.” (Schofield, 2007, p.105)
Further illustrating the Structuralist/Materialist constraints for equitable healthcare, the former chief of the World Health Organization, Dr. Gro Brundtland, agrees that there is a disconnection between wealth creation and wider access to public health in a world dominated by globalization. He observes: “Technologies are spreading, communication is worldwide, people know what is available, and yet the dramatic gaps and lack of access to healthcare become greater and greater. We must look upon the world as a shared responsibility so that we deal with the gaps and help those technologies become available for those who don’t have access. That’s the only way to keep globalization from becoming really unhealthy.” (Brundtland, 2001, p.28)
Coming to the Social/Natural selection approach to studying health inequalities, the dominant theory is drawn from Social Darwinism, where health inequalities are seen as a result of cold apathetic processes of Mother Nature with its motto being ‘survival of the fittest’. The pervasive finding that wealth is directly related to health, whether measured at the level of nations or at the level of individuals, might lead one to the inference that these ‘income/health gradients’ are inevitable. They might seem “to reflect the natural ordering of societies along some fixed, idealized teleology of economic development. At the individual level, the gradient might appear to be the result of the natural selection of the most “fit” members within society who are thus better able to garner socioeconomic advantage.” (Daniels, et.al, 1999, p.215) But we should remember that human beings are unique in their capacity to supersede their natural inclinations. Moreover, altruism and compassion toward fellow humans are not qualities ‘outside’ natural behaviour. To this extent, the Social/Natural Selection view of health inequalities should be treated critically. In a similar vein, the Constructionist/Artefact approach to health also reveals fundamental social injustices.
As an acknowledgement of the injustices, inequalities and disadvantages inherent in the dominant biomedical model, and also as a consolidation of the insights offered by sociological explanations of inequalities in health, a consensus is emerging within the international community toward the formation of a more equitable public health system. Such conceptions as the international development targets, which were discussed in recent WHO meetings try to deal with diseases of poverty head on. Simultaneously, there has been a growing concern from private corporations to involve themselves in civil society organizations. The global health initiative is a product of these developments. The report by WHO Commission on the Social Determinants of Health (CSDH) suggests a comprehensive array of changes to give all societies world class health care. These recommendations could have the widest impact on patients, families, and communities, including treatment of people with substance abuse and more aggressive management of obesity. If implemented properly, we may see a more equitable global health system in the not-distant future. But for this dream to be fulfilled, private corporations and government health agencies need to put in concerted and coordinated efforts based on shared values. In these times of radical change to the economic organization of the world, the need to build bridges between medicine and public health and between ethics and human rights become all the more important. (Lietz, 2006, p.372)
References:
Ashcroft, R. (2010). Health Inequities: Evaluation of Two Paradigms. Health and Social Work, 35(4), 249+.
Brundtland, G. H. (2001, January). Achieving Global Health Equity. Presidents & Prime Ministers, 10, 28.
Daniels, N., Kennedy, B. P., & Kawachi, I. (1999). Why Justice Is Good for Our Health: The Social Determinants of Health Inequalities. Daedalus, 128(4), 215.
Dein, S. (2006). Race, Culture and Ethnicity in Minority Research: a Critical Discussion. Journal of Cultural Diversity, 13(2), 68+.
Gorin, S. H. (2002). The Crisis of Public Health Revisited: Implications for Social Work. Health and Social Work, 27(1), 56+.
Kazatchkine, M. (2007, December). Combatting HIV/AIDS in Sub-Saharan Africa: Investing in Health Can Make the Difference. UN Chronicle, 44, 77+.
Lietz, K. (2006). Betrayal of Trust: The Collapse of Global Public Health. Journal of International Affairs, 59(2), 372+.
Schofield, T. (2007). Health Inequity and Its Social Determinants: a Sociological Commentary. Health Sociology Review, 16(2), 105+.
Taylor, T. (2002, Spring). The Truth about Globalization. Public Interest 24+.
Ward, P., Redgrave, P., & Read, C. (2006). Operationalizing the Theory of Social Quality: Theoretical and Experiential Reflections from the Development and Implementation of a Public Health Programme in the UK. European Journal of Social Quality, 6(2), 9+.
Wyman, B. P. (2000). Biomedical and Behavioral Research on Juvenile Inmates: Uninformed Choices and Coerced Participation. Journal of Law and Health, 15(1), 77+.