read the article Socioeconomic Disparities in Health

Question Description

The assignment for Discussion Board #2 is to first read the article Socioeconomic Disparities in Health: Pathways and Policies by: Nancy E. Alder and Katherine Newman. The article can be found under the documents ATTACHMENTS Folders!! Once you have read article: 

 1. Provide a Brief Summary of what Article is discussing in your own words.  (1 paragraph) 

 2. The authors discusses Indirect Pathways to socioeconomic inequalities; what do they mean by this? 

3. The article discusses the relationship between SES and 5 different factors. (Environmental exposures, Social environment, Health care, Behavior/lifestyle, and Chronic stress). Choose 2 of the 5 factors and briefly discuss in your own words

4. In one paragraph, discuss what the author's opinions are on how policies influence health disparities in regards to socioeconomic status and what needs to be done to eliminate to health disparities gap.

Please DO NOT copy and paste answers directly from article. I want your responses to be written in your own words. Points will be deducted if you do so!

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SES & Health Socioeconomic Disparities In Health: Pathways And Policies Inequality in education, income, and occupation exacerbates the gaps between the health “haves” and “have-nots.” by Nancy E. Adler and Katherine Newman ABSTRACT: Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country. 60 SOCIOECONOMIC DISPARITIES S ocioeconomic st at us, whether assessed by income, education, or occupation, is linked to a wide range of health problems, including low birthweight, cardiovascular disease, hypertension, arthritis, diabetes, and cancer.1 Lower socioeconomic status is associated with higher mortality, and the greatest disparities occur in middle adulthood (ages 45–65).2 J. Michael McGinnis and William Foege have provided an incisive analysis of the “actual causes” of death in which they estimated the number of U.S. deaths caused by factors such as tobacco, diet and lack of activity, and toxic agents.3 They noted the mismatch between the importance of these factors and allocation of health care resources, with most resources going to treat diseases and relatively few to modifying the predisposing factors. To modify these risk factors, one needs to look even further upstream to consider their “actual determinants.” Socioeconomic status is a key underlying factor. In this paper we examine multiple pathways through which it can influence health, and we consider the implications of Nancy Adler is professor of psychology in the Departments of Psychiatry and Pediatrics at the University of California, San Francisco (UCSF). She is also director of the UCSF Center for Health and Community. Katherine Newman is the Malcolm Wiener Professor of Urban Studies at Harvard University’s Kennedy School of Government and dean of social sciences at Harvard’s Radcliffe Institute for Advanced Study. H E A L T H A F F A I R S ~ V o l u m e ©2002 Project HOPE–The People-to-People Health Foundation, Inc. 2 1 , N u m b e r 2 S O C I O E C O N O M I C D I S P A R I T I E S these pathways for policy. While socioeconomic status is clearly linked to morbidity and mortality, the mechanisms responsible for the association are not well understood. Identifying these mechanisms provides more options for policy remedies. Given the pervasive effects of socioeconomic status, no single policy, or even one domain of policy, can eliminate health disparities. The Acheson Commission in the United Kingdom, which was charged with providing policy suggestions for reducing health disparities in that country, made thirtynine recommendations, organized around key populations (such as children, older people, and ethnic minorities) and domains (such as income and tax benefits, education, and employment).4 If a U.S. equivalent of the Acheson Commission were convened, what policies should it consider on the basis of the empirical data? Below we consider policies addressing several areas for which the empirical evidence is strongest regarding the links between socioeconomic status and health. Components Of Socioeconomic Status The most fundamental causes of health disparities are socioeconomic disparities.5 Socioeconomic status has traditionally been defined by education, income, and occupation. Each component provides different resources, displays different relationships to various health outcomes, and would be addressed by different policies. ■ Education. Education is perhaps the most basic SES component since it shapes future occupational opportunities and earning potential. It also provides knowledge and life skills that allow better-educated persons to gain more ready access to information and resources to promote health.6 Marilyn Winkleby and colleagues examined how education, income, and occupation relate to risk factors for cardiovascular disease; when these were taken together, only education remained as a significant predictor.7 While most studies have examined years of completed education, early educational experiences also may be important. Although health effects have not been established, programs such as Head Start and the Perry Preschool Project provide suggestive evidence that there are critical periods when intervention may confer longterm benefits.8 To the extent that education is key to health inequality, policies encouraging more years of schooling and supporting early childhood education may have health benefits. When policymakers debate the merits of increasing access to education, they rarely consider improvements in the health of the population. Other virtues—increasing human capital, boosting productivity, augmenting lifetime earnH E A L T H A F F A I R S ~ M a r c h / A p r i l 2 0 0 2 SES & HEALTH 61 SES & Health 62 SOCIOECONOMIC DISPARITIES H E A L T H ings, and improving the socialization of the next generation—follow from improvements in educational attainment. But in this area, as in others, collateral benefits such as decreasing health care costs also might emerge from increased investment in education. ■ Income. In addition to providing means for purchasing health care, higher incomes can provide better nutrition, housing, schooling, and recreation. Independent of actual income levels, the distribution of income within countries and states has been linked to rates of mortality.9 Although controversial, one explanation is that underinvestment in public goods and welfare and the experience of inequality are both greater in more stratified societies and that these, in turn, affect health.10 If this is correct, then highly stratified societies take an additional toll on health beyond that associated with absolute deprivation. Although the association between income and health is stronger at lower incomes, income effects persist above the poverty level.11 Health effects at the upper part of the distribution may more strongly reflect relative status, while at the lower part they may be more linked to absolute deprivation. Redistributive policies. U.S. economic policies are a mix of those that address poverty or diminish economic disparities and those that result in increased disparity. At different points in its history, the United States has created policy tools that explicitly reduced economic inequality. The prime example is the introduction of the progressive income tax in 1913. Social Security and the welfare policies developed in the 1930s also influenced the contours of inequality, although other forces acting simultaneously (for instance, the expansion of the white-collar labor force) created countertendencies. Policies that might be said to have moved the country in the opposite direction—toward wealth inequalities—include the mortgage deduction allowance built into the tax code, decreases in capital gains taxes, and local financing of education budgets (which produce more advantaged districts where wealthier families reside). Tax-and-transfer policies may exert less influence than labormarket trends that have increasingly rewarded highly skilled and educated workers, but they are important to consider nonetheless as we look to understand the overall relationship between stratification and health inequality.12 Although health effects of relative SES occur across the whole range of the SES hierarchy, the burden is particularly great for those in poverty. Given this fact, policies intended to increase the income (and income security) of the poor should have the greatest positive impact on health outcomes. The Earned Income Tax Credit (EITC) is a contemporary example of a federal policy that has raised the income of working-poor families, while welfare reform in general A F F A I R S ~ V o l u m e 2 1 , N u m b e r 2 S O C I O E C O N O M I C D I S P A R I T I E S has pushed in the opposite direction, cutting the stipend levels for recipients.13 These interventions have affected the distribution of resources and therefore the contours of inequality, which at least in theory should leave their traces in health outcomes. A randomized trial in Canada of income supplements for single parents on assistance who began working full time shows how complex the effects can be. These supplements did help to increase employment and income in the experimental group. To date no health data have been reported on the adults, but children in the experimental group who were three to eight years old at baseline were subsequently reported to have fewer health problems and better cognitive functioning. However, there were no effects for younger children and some negative effects on school achievement and problem behavior for older children.14 Research challenges. We found little research in the United States examining how redistributive policies or other income distribution changes affect health outcomes. Those interested in the relationship between inequality and health should be able to show that when the former changes, the latter does too. One challenge in doing so is specifying the time lags between change in economic conditions and when health effects can be seen. The rapid drop in life expectancy in Eastern Europe around the time of the fall of communism suggests that fundamental changes in social life may take a toll quite quickly; the subtler changes associated with growing inequality may take longer to observe.15 A second challenge is to isolate the impact of redistributive policies and separate their effects from other social and economic trends occurring at the same time. Economic historians interested in health may help us to understand the relationship of inequality and health. For now, we merely note that there is some suggestive evidence. For example, the introduction of Social Security dramatically reduced the proportion of elderly who lived in poverty. One legacy of this policy may be the fact that SES differences in health now narrow after age sixty-five. More research is needed to determine whether interventions in income distribution of this kind produce the sorts of outcomes that the theoretical literature on inequality and health would predict. Welfare benefits. Addressing the link between income inequality and health, the Acheson Commission focused attention on tax-andtransfer benefits. In particular, they suggested increases in transfer payments, upgrading of state pensions, and measures to increase the take-up rates of existing benefits. The U.S. political climate is far more hostile to welfare benefits than are those in the social welfare states of Western Europe. Reductions in U.S. welfare stipends have been particularly severe since 1996, and the household incomes of H E A L T H A F F A I R S ~ M a r c h / A p r i l 2 0 0 2 SES & HEALTH 63 SES & Health “Policies that affect the health of the labor market are perhaps the most important medicine we can apply.” 64 SOCIOECONOMIC DISPARITIES H E A L T H nonworking poor families have declined as a result. Labor-market policies. Policies that affect the health of the labor market are perhaps the most important medicine we can apply, although its ingestion may raise inequality levels at the same time that we benefit from the “great American job machine.” In recent years the U.S. economy has outstripped virtually all other industrial states in generating jobs, albeit at the extremes of well-paid jobs available only to the highly skilled and poorly compensated jobs for the low skilled. Labor-market inequality may be widening the gaps between the health “haves” and “have-nots.” Yet tight labor markets have been beneficial for the working poor in particular.16 Late 1990s’ Federal Reserve policies that lowered interest rates and encouraged economic expansion cut unemployment and led to wage increases (even at the bottom of the distribution). The additional impact of the EITC has raised the income of working-poor households. The point here is that many policy domains affect the distribution of income, some redistributive and some oriented toward economic expansion in which a rising tide lifts more boats than many once thought possible. Following Acheson, we suggest that reform proposals of all kinds be examined with more than economic efficiency or security in mind. Impact on the nation’s health profile must be considered to be at the bottom line as well. ■ Occupation. Occupational status is a more complex variable, and its measurement varies depending on one’s theoretical perspective about the significance of various aspects of work life. One aspect is simply whether or not one is employed, since the employed have better health than the unemployed have.17 Although some of this association is a function of the “healthy worker” effect, there is evidence that being unemployed and the length of unemployment affect health status. However, some types of benefits for the unemployed can buffer the adverse effects on health. Entitlement benefits appear to reduce some negative health effects, while means-tested benefits do not.18 Threat of unemployment and job insecurity can affect health as well. Ralph Catalano and Seth Serxner found elevated rates of low birthweight in geographic locales threatened with high rates of unemployment.19 Anticipation of plant closings or other job threats have been linked to increases in blood pressure, although these increases may not become chronic.20 Among the employed, occupations differ in their prestige, qualifiA F F A I R S ~ V o l u m e 2 1 , N u m b e r 2 S O C I O E C O N O M I C D I S P A R I T I E S cations, rewards, and job characteristics, and each of these indicators of occupational status is linked to mortality risk.21 Lower-status jobs expose workers to both physical and psychosocial risks. They carry a higher risk of occupational injury and exposure to toxic substances. In addition, job strain and lack of control over work are greater the lower one’s occupational status. In the Whitehall study of British civil servants, differences of coronary heart disease incidence by occupational grade were largely accounted for by differences in job control.22 Government regulation of occupational conditions is also a domain fraught with political conflict. As a rule, we intervene to protect basic physical health and safety but tend not to go further by, for example, mandating work reorganizations that promote autonomy, control, and other psychosocial factors that could affect health. Recognizing the link between job control and health, the Acheson Commission did push in that direction, recommending that wherever possible, private and public employers alter management practices to increase employees’ levels of control over the daily conduct of work (pacing, decision making, variety). In the U.S. context, researchers need to show that such changes in work conditions will either increase—or at least not decrease—profits; improved profits could result from increased productivity, reduced absenteeism, or reductions in medical costs. Indirect Pathways Marcia Angell has observed that income, education, and occupation are powerful yet mysterious determinants of health; they are not likely to have a direct effect but serve as proxies for other determinants.23 Hence, what appears to be a direct impact of SES inequality may instead be operating through differential exposure to conditions that have more immediate effects on health. Pathways by which socioeconomic status influences health should be those that affect health more generally, including those identified by McGinnis and Foege.24 They used data from a broader analysis of the relative impact of four inputs to health: biological determinants, health care, environmental exposure, and behavior and lifestyle. These factors were identified earlier in the Lalonde report as the key causes of morbidity and mortality in Canada.25 Socioeconomic status underlies three determinants, which together are associated with an estimated 80 percent of premature mortality. The largest contribution is from behavior and lifestyle, accounting for about half of premature mortality, with environmental exposure accounting for another 20 percent, and health care, 10 percent.26 Below we consider how SES may shape each of these pathways. H E A L T H A F F A I R S ~ M a r c h / A p r i l 2 0 0 2 SES & HEALTH 65 SES & Health 66 SOCIOECONOMIC DISPARITIES H E A L T H ■ SES and environmental exposures. Exposure to damaging agents in the environment, including lead, asbestos, carbon dioxide, and industrial waste, varies with socioeconomic status. Those lower on the SES hierarchy are more likely to live and work in worse physical environments. Poorer neighborhoods are disproportionately located near highways, industrial areas, and toxic waste sites, since land there is cheaper and resistance to polluting industries, less visible. Housing quality is also poorer for low-SES families. As a result, compared with high-income families, both children and adults from poor families show a sixfold increase in rates of high blood lead levels, while middle-income adults and children show a twofold increase.27 Low-SES persons also experience greater residential crowding and noise. Crowding within the home appears to be more problematic for health than is area density.28 Noise exposure has been linked to poorer long-term memory and reading deficits and to higher levels of overnight urinary catecholomines (epinephrine and norepinephrine) among children and to hypertension among adults.29 Childhood asthma incidence is rising, especially in urban neighborhoods among low-SES children, and the severity is greater among these children.30 Although the jury is out on why, candidate explanations include crowding, a decline in housekeeping as a result of increased adult work hours, and deteriorating housing stock.31 Concerns about the health impact of environmental pollution has resulted in increasing regulation. The first class-action suit using civil rights statutes challenged a sanitary landfill proposed near a middle-class African American suburb in 1979. Protests and lawsuits since then have raised the visibility of environmental racism.32 The broader concept of environmental justice is part of government policy dating from 1994, when Executive Order 12898 ordered federal agencies to develop relevant policies. The Environmental Protection Agency (EPA) now defines environmental justice as the “fair treatment for people of all races, cultures, and incomes, regarding the development of environmental laws, regulation, and policies.”33 Despite these actions, however, poor minorities are still at far greater risk for environmental exposure than are whites in general, or middle-class adults and children of any race and ethnicity. There are many types of environmental exposures, and each has a different policy solution. Advocates have recommended, for example, that environmental impact reports consider SES disparities in exposure. In another realm, in Massachusetts it is illegal to sell a house with high lead levels to a family with a child under age six; enforcement is built into the property transfer system. States vary in how much they regulate lead exposure and in the resources they put A F F A I R S ~ V o l u m e 2 1 , N u m b e r 2 S O C I O E C O N O M I C D I S P A R I T I E S “SES-related health effects of social environments may be even more important than those of physical environments.” ...
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