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Socio-­‐economic Status (SES), Poverty, and Income Inequality How do these concepts relate to the health of popula?ons? Modified from: Berkman LF, Glass T, BrisseJe I, Seeman TE. From social integra?on to health: Durkheim in the new millennium. Soc Sci Med. 2000 Sep;51(6):843-­‐57 Class Objec?ves •  Develop an understanding of key concepts including socio-­‐economic status (SES) and income inequality •  Become familiar with key measurements: –  Poverty level –  Gini coefficient •  Examine data linking SES and income inequality to health status Major theorists •  Emile Durkheim –  “The Division of Labor in Society” –  Reflects higher levels of complexity, func?onality for the society •  Karl Marx –  Rela?onship to means of produc?on –  Two key classes – owners, workers –  Focus on issues of power, control, ownership Major theorists Max Weber –  Mul?ple axes •  Class (economic) –  Defined by economic “life-­‐chances”: what can you do or hope for –  Stra?fied according to rela?ons to produc?on and acquisi?on of goods •  Status (social) –  Amorphous communi?es ?ed by “honor” –  Stra?fied according to principles of consump*on of goods as represented by “styles of life” •  “Party” (poli?cal/power) –  May be ephemeral or enduring –  Defined by ability to organize communally towards a given goal Pierre Bourdieu’s socio-­‐cultural strata High cultural capital
Low cultural capital
High economic capital
A
B
Low economic capital
C
D
-­‐ Economic capital (income, wealth) -­‐ Cultural capital (accumulated knowledge of ar?s?c and intellectual tradi?ons of society) Most commonly used in public health studies 1)  Level of income or accrued wealth (15%) 2)  Type of occupa?on (22%) 3)  Level of educa?on (45%) Percents refer to share of studies in American Journal of Epidemiology from 1982-­‐1985 using this variable as proxy for SES (Source: Kaplan and Keil 1993) UK classifica?on Brazilian Economic Classification Criteria (from www.abep.org)
Brazilian SES saying?! Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010. Available at: http://www.marmotreview.org/
AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf
UK life expectancy versus occupa?onal class U.S. Mortality vs educa?on Source: U.S. Department of Health and Human Services. 1998. “Health, United States, 1998; with Socioeconomic Status and Health Chartbook”
Least
deprived
Deprivation
twentieths
Most
deprived
Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010. Available at: http://www.marmotreview.org/
AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf
Least
deprived
Deprivation
twentieths
Most
deprived
Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010. Available at: http://www.marmotreview.org/
AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf
22 months
42 months
62 months
118
months
Adapted from Fair Society, Healthy Lives: Strategic review of health inequalities in England post-2010. February,
2010. www.ucl.ac.uk/marmotreview
Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010.
Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf.
Data source: 1958 National Child Development Study
Socioeconomic Status Birth weight by socioeconomic status, 2003-­‐4, UK Highest High middle Middle Low middle Lowest 1 2 3 4 Kilograms Socioeconomic Status Percentage of children whose mother suffered postnatal depression, by socioeconomic status, 2003-­‐4, UK Highest High middle Middle Low middle Lowest 0 5 10 15 20 Percentage Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010.
Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf.
25 Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010.
Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf.
Percentage of children 10-14 exposed to movie violence
Parent Educa4on N Percent RR 1987 35.11 Reference Some college, voca?onal/technical, or 1904 Associates degree 53.53 1.81 (1.48-­‐2.21) High school graduate or less 61.81 2.86 (2.34-­‐3.49) Bachelors, graduate, or professional degree 2615 Adapted from Worth KA, et al. Pediatrics 2008;122:306-­‐312 Development quotients of growth-retarded infants in stimulation/nutrition study,
Jamaica. WHO, 2008
Defini?ons – absolute poverty Cri?que of Orshansky method Alterna?ve calcula?ons of 2001-­‐2 poverty rates using NAS 1995 op?ons. Source: US Census: hJp://www.census.gov/hhes/www/poverty/
poverty02/table7.pdf MIS: medical out-­‐of-­‐pocket subtracted from income MIT: medical out-­‐of-­‐pocket included in threshold CMB – combined the two above Source: Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Lorenz-curve1.png. Creative Commons BY-SA.
* 0 = perfect equality; 1= perfect inequality. Source: ADB. Adapted from The Economist, August 11, 2007.
Worsening maldistribu?on of income •  The income gap between those in the top 5% of US income distribu?on and those in the boJom 40% has been steadily increasing since in the early 1980s. Source: ADB. Adapted from The Economist, August 11, 2007.
Relative poverty and health
•  Among European countries, the percentage
of overall wealth owned by the poorest 70%
of the population is positively correlated
with health status.
•  In US, increase in Gini coefficient (0-1) of
0.1 corresponds to 46% increase in
preventable deaths (Ronzio)
Proposed mechanisms rela?ng absolute income to health •  Reduced sense of control over life events –  At work and home •  Demand overload –  Lack of resources to cope with demands –  Increased “demands” in the form of less op?mal environment •  Reduced social par?cipa?on/less access to social resources (Kim 2008)
Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010. Data Source: Whitehall II study.
“Social neuroscience” •  Epigene?cs: environmental influences on gene expression •  Cri?cal periods (?) for early nurturing that –  Permanently (?) set level at which glucocor?coid receptor gene is expressed •  Varies response to stress –  Permanently (?) set level at which oxytocin receptor gene expressed •  Varies nurturing and other affilia?ve behaviors Adapted from “Fair Societies, Healthy Lives,” The Marmot Group, 2010. Data Source: Whitehall II study.
Social dis?nc?on •  Groups dis?nguish themselves through differen?al consump?on –  Partly economic but also symbolic (Bourdieu) •  Concept of “posi?onal goods” Impact of posi?onal spending -­‐ 1 Gas Grills Then and Now (Frank)
1989 Sunbeam, $90
Viking Professional, $5,000.
Impact of posi?onal spending -­‐ 2 Personal Savings Rate Decrease •  Low savings is a serious problem •  Decline in savings rate has tracked increase in income inequality Impact of posi?onal spending -­‐ 3 •  Reduced intergenera?onal mobility from lack of resources for children –  What are the opportuni?es for subsequent genera?ons to improve their SES (and thus their health)? –  What resources for healthy development are universally provided? –  What resources are dependent on family income? Diffusion of “dis?nc?on” •  Upper SES takes on new bad habit •  Habit loses dis?nc?on as: –  Learn more about risks –  Have greater resources to tolerate/treat withdrawal –  Mass marke?ng and copying make habit less dis?nc?ve Diffusion of “dis?nc?on” •  Lower SES gets stuck with habit –  Upper SES is making a profit •  “Habit” is aggressively marketed –  Lower SES has fewer resources to treat/tolerate withdrawal –  Habit is “embedded” in group that has least social mobility SES as determinant of social ?es •  SES constrains social ?es –  Diverging values –  Lack of resources that permit mobility •  Poor public transit •  Lack of public educa?on •  Deliberate segrega?on Christakis NEJM 2008;358:2249 [Colored bars are successive waves of observa?on] Christakis NEJM 2008;358:2249 [Colored bars are successive waves of observa?on] Coming up •  Lab session –  Whitehall II data on control and CHD and gender •  Next two classes –  Social networks –  Social support –  Social cap?al