Title: “In Sickness and in Wealth” from the California Newsreel
Documentary Series Unnatural Causes: Is Inequality Making us Sick?1 – A
Discussion Guide for Health Professional Students
Prepared by: Olivia Carter-Pokras, PhD; Alexander Fischer; Ana E. Núñez, MD;
Candace Robertson, MPH; Lisa Bethune
Acknowledgements: The authors gratefully acknowledge funding from the
National Heart Lung and Blood Institute, as well as comments by dental, medical,
and nursing students at the University of Maryland Baltimore, and public health
students at the University of Maryland College Park.
(for the discussion facilitator)
Session Goals(s):
This small group discussion is intended to acquaint health professional students
with examples of specific health disparities that affect communities in the United
States, bring to their attention the role that social determinants of health play in
these disparities, and foster discussion regarding solutions and action that can
be taken to eliminate these health disparities.
Learning Objectives:
1. Describe the nature, extent, and type of health disparities in the United
States.
2. Describe and assess health disparities experienced by people due to their
income and socioeconomic status.
3. Evaluate social determinants of health and other underlying factors related
to disparities for people of low socioeconomic status, immigrants,
minorities, and their children.
Session Summary:
This is a 56 minute film segment entitled “In Sickness and in Wealth” from the
California Newsreel documentary series Unnatural Causes: Is inequality making
us sick?, followed by a 30 minute small group discussion to explore examples of
health disparities and pathways by which social conditions affect physiology.
What are the connections between healthy bodies and healthy bank accounts? In
Louisville, Kentucky, the issues faced by a CEO, a lab supervisor, a janitor, and a
welfare mother bring into sharp relief how socio-economic status shapes
opportunities to lead healthy lives. People of color face an additional burden.
Solutions, public health officials believe, lie not in more pills but in better social
policies. The small group case discussion will be facilitated by medical, health
1
UNNATURAL CAUSES: Is Inequality Making Us Sick? Produced by California
Newsreel with Vital Pictures. Presented by the National Minority Consortia.
www.unnaturalcauses.org; www.newsreel.org
professional, and/or epidemiology faculty or graduate students. Facilitators will
have familiarized themselves with material in the video and readings as well as
the provided Unnatural Causes Discussion Toolkit. Facilitators may also have
completed “A Physician’s Practical Guide to Culturally Competent Care” and/or
“Culturally Competent Nursing Care: A Cornerstone of Caring,” training programs
designed for providers to increase cultural competence through case studies
about awareness of racial and ethnic disparities in health, and through curricula
about accommodating increasingly diverse patient populations and improving the
quality of health care services given to diverse populations (available at:
http://www.thinkculturalhealth.org). Students will be provided the background
readings at least one week in advance of discussion.
Readings:
1. Barnes LL, de Leon CF, Lewis TT, Bienias JL, Wilson RS, Evans DA.
Perceived discrimination and mortality in a population-based study of older
adults. Am J Public Health 2008; 98(7):1241-1247.
2. Kopp MS, Skrabski A, Szekely A, Stauder A, Williams R. Chronic stress
and social changes: socioeconomic determination of chronic stress. Ann N
Y Acad Sci 2007; 1113: 325-338. Available at:
<http://www.annalsnyas.org/cgi/rapidpdf/annals.1391.006v1>.
3. Schulz AJ, House JS, Israel BA, Mentz G, Dvonch JT, Miranda PY,
Kannan S, Koch M. Relational pathways between socioeconomic position
and cardiovascular risk in a multiethnic urban sample: complexities and
their implications for improving health in economically disadvantaged
populations. Journal of Epidemiology and Community Health 2008; 62:
638-646. Available at: <http://jech.bmj.com/cgi/reprint/62/7/638.pdf>.
4. Raphael D. Social determinants of health: Present status, unanswered
questions, and future directions. International Journal of Health Services
2006; 36(4): 651-677. Available
at:<http://www.chronicdisease.org/files/public/HDIG_SDOH.raphael.pdf>.
5. Berkman L, Epstein AM. Beyond health care — socioeconomic status and
health. The New England Journal of Medicine 2008; 358(23): 2509-2510.
Available at: <http://content.nejm.org/cgi/content/full/358/23/2509>.
Discussion Questions:
1. In the video it is stated that “we carry our history in our bodies.”
What is meant by this?

What is meant is that what happens in our childhood affects our
health later in life. Any chronic stress that we face, can affect our
health outcomes as well. The study of identical twins who lived in
the same household until 18 years of age, showed that different job
statuses resulted in different health statuses later in life.
2. If the United States is the country with the highest gross national
product, spending nearly half of the world’s medical dollars, why is
the U.S. the sickest out of the industrialized nations?

In the U.S. today, much of the money is being used to treat chronic
and infectious diseases, and far less money is being spent on
preventative measures or social policies to target root problems
regarding chronic and infectious diseases. Other industrialized
nations are spending more money working to improve general
health as a method of prevention as opposed to using the majority
if money to treat after contraction of disease.
3. The video looks at a very clear social gradient in which the health
along the gradient can be predicted to decrease as socioeconomic
status decreases. What needs be done to shrink the disparities in
health along socioeconomic lines?

What needs to be done is to make sure that everyone is allowed
access to the same opportunities even if they do not have the
economic resources. This would involve providing resources such
as quality education, decent housing, access to affordable health
care, and access to healthy food and safe places to exercise to
everyone despite gaps in affluence. Having access to such
resources would simulate the control felt by the affluent when they
come to make such choices regarding health.
3b. Did the experiments which proved this prediction surprise you
and do you think the results are valid?
 Two experiments were presented in the video. In one, people in
different employment grades of the hierarchy were compared in
relation to their health and they found that a poor person who
smokes has a higher rate of disease than a rich person who
smokes. The other experiment, conducted by a psychologist,
measured cortisol levels in people of different socioeconomic
status’ and found that those of higher socioeconomic status had
lower cortisol levels (meaning they had less stress). They also
exposed people to a cold virus, and people with more stress were
more likely to get sick because of a weaker immune system. The
results of these experiments are surprising, and they do provide
valid proof of health decreasing with socioeconomic status.
4. The video states that education gives people the opportunity to
move up the social gradient, and having money is vital for feelings of
optimism and control over health. Yet are the resources to move up
the social gradient accessible to everyone?

Access to resources is greatly hindered if you do not have the
money to access them, or are constantly having to worry about not
being able to access them. There is inequality in the public school
systems as wealthier neighborhoods tend to have better schools
than less affluent neighborhoods. Not everyone can afford higher
education, meaning that it is that much harder to afford a ticket out
of poverty. College graduates live on average two years longer
than high school graduates. Life expectancy should not have to
depend on the resources you have access to.
5. The video looks at social class and the control that it brings as the
most important determinant of health above any other risk factor.
What is it about the ability to influence the events that impinge on
our lives that is so important to determining our health?

If we are able to control our lives enough that we can keep stress
levels down to normal spikes, and leave time to relax, we are much
better off. A lack of control can result in stress, and chronic feelings
of stress can lead to excessive cortisol in the body, and thus
excessive levels of glucose in the blood. Heart rate and blood
pressure can go up. We become more vulnerable to diseases as
stress takes its toll on the body.
6. What is it about chronic stress that makes us more susceptible to
disease?

Chronic stress wears down the body, causing a weakened immune
system. This makes the body more susceptible to contracting
diseases, and accelerates the aging process. Biochemically when
the body is under constant stress, it signals the body to continually
pump out stress hormones such as cortisol, which in large
quantities can be detrimental to the body. Large amounts of
cortisol will result in excessive levels of glucose in the bloodstream,
which can in turn result in plaque build-up in the arteries, increased
heart rate, and high blood pressure.
7. What are the lifelong consequences of childhood poverty? To catch
the problem at its root, what can be done to limit childhood poverty?

As a child, when stress levels go up and stay up as a result of
constantly having to worry about shelter and food, high hormone
levels interfere with the development of brain circuitry and
connection, causing long term chemical damage. Studies showed
that the immune system of participants was stronger if their parents
had the security of home ownership while the participants were
growing up. Policies to reduce child poverty need to be enacted as
an investment in the future of the country. Such action in Europe
has lowered child poverty rates to about 4%, compared to U.S.
rates of over 20%.
8. What role does hunger play in behavioral issues, violence and
truancy?
 In addition to the inability to learn if the brain has insufficient
energy, attention and focus can not occur without food.
 Irritability associated with hunger can contribute to behavioral
problems and violence
9. The video states that 83,000 excess deaths occur annually in the
black community. How can we account for such staggering
numbers?

A society characterized by racial discrimination may be to blame for
such staggering statistics. The health prognosis for those who are
not white also follows a social gradient, but with health outcomes
that are on average worse than those of white Americans. Racism
can be the source of a constant stressor that adds on stress to the
body in addition to everything else. Society has taught certain
groups that they have to constantly stay on guard, and the resulting
overtime stress can make them more vulnerable to sickness.
Studies show black members of the community with excessively
high blood pressure, infant mortality rates, and coronary artery
disease rates.
10. Disparities and gaps in health have been widening and shrinking in
our recent history. Consequently we know that such inequalities in
health are not fixed, so what can be done now to shrink the gap in
society?

Social policies have been made over the years to improve our
health, such as universal education, an 8-hour work day, and other
social programs. Vast improvements have been made in the
distribution of wealth, health, and education, but sometimes not for
everyone. After World War II, blacks were excluded from most
policy, yet in the 1960s and 1970s the civil rights and anti-poverty
movements, along with Medicare and Medicaid caused the health
statuses between blacks and whites to narrow. But the trend
reversed in the 1980s as social policy was cut because of the
recession, and the black-white gap in health began to widen again,
and continues to do so today. We must learn from the fact that
social policies can make a difference in improving health outcomes,
and bring the needed reform to shrink the disparities gap in health.
10b. What kinds of specific policies would you propose to decrease
the gaps in health today? (what kinds of policies do we need today
and what policies do you think would be most effective in reforming
healthcare today?)
 Answers will vary; however encourage learners to propose specific
policy examples rather than just saying we need to reform our
current social/health policies.
11. As the health outcomes are better in other industrialized nations,
what are they doing right that we can apply to health policy in the
United States?

The U.S. exhibits the most unequal distribution of wealth of the
world’s rich democracies, but still our health depends heavily on our
individual ability to access resources. If we don’t have the wealth,
most of the time we are out of luck. Many other industrialized
nations have a different approach, in which resources are used to
ensure that the citizens are able to lead flourishing lives. Citizens
are provided with universal health care, better vacation benefits,
free or affordable university education, housing support,
recreational support, and lower poverty. A more equitably
distributed wealth would result in a healthier nation.
12. What sorts of innovative initiatives are shown in the video that favor
community empowerment and social change? Could a similar
initiative flourish here?

The Health Equity Center in Louisville, Kentucky showed amazing
strides to get the community involved with their own future. The
focus of the center was to train citizens to take political action and
design policies that address the health needs of their community.
In this way the community is self-empowered and ready to fight for
health equity and social justice.
13. The unhealthy state of the United States is very inefficient, as an
estimated one trillion dollars in productivity per year are lost due to
chronic illness. What can be done to reduce this number so that
society as a whole can benefit from the renewal of lost productivity?

Social policy is the place to start, yet the focus needs to not be
feeding the money into treatment but rather on primary prevention.
Without prevention, money will continue to be squandered, as
constant resources are pulled aside to treat a continuing influx of
new cases. Feeding money into primary prevention will allow us to
get to the source of the problem, and work to become more
efficient, as those who can contribute to society are not drawing on
resources because of illness.
14. As a health professional student, these problems may seem very ‘big
picture’ and overwhelming. After watching this video, what do you
think you can do as a health professional student, and future health
professional to address these issues?

From least to most:
i. AT LEAST:
1. Join student groups that include advocacy (e.g. AMSA)
2. Register to vote, ask questions and hold politicians
accountable.
3. Identify easy to search websites and listserves and keep
up with what is going (e.g. Kaiser Health watch) and pay
attention.
4. Participate in community outreach programs and find out
what is working and what isn’t. Ask patients their opinion.
ii. MORE:
1. Encourage your patients to register to vote and to vote.
2. Get formal training about lobbying and being a resource to
elected officials (e.g. AMSA)
3. Find mentors and faculty who care about these issues and
see if there are ways you can work with them / learn from
them.
4. Get formal training in a skill called “Motivational
Interviewing”
5. Employ health literacy skills like the “Teach Back”
approach in patient-doctor communication.
iii. MOST:
1. Do a rotation in health policy (at city health departments,
with State legislators, with foundation or organizations who
focus on policy changes)
2. Create a project or student outreach program to make a
difference (early) and later develop culturally appropriate
interventions that you test (as a research project.)
15. The video presented people of four different socioeconomic
statuses. The CEO, lab supervisor, and janitorial worker were all
linked later in the video because they all worked in the same
hospital. Were you surprised that people of such differing
socioeconomic statuses would all be working in the same place? Are
other jobs like this too?

It was interesting how the video linked the people of different
socioeconomic statuses to the same place of work. Although you
don’t normally think about it everyday, most places of work are
divided into a hierarchy according to your socioeconomic status.
This means that people are always under the stress of their
socioeconomic status, at home and at work.
Additional Resources:
1. The Sanctuary Model:
a. Bloom S. Creating Sanctuary: Toward the Evolution of Sane
Societies. Routledge Publisher. NY, NY. 1997. [Discusses the
impact of violence and neurobiologic changes; stress and health]
b. The Sanctuary Model: http://www.sanctuaryweb.com/ [Resources
and information about skills training]
2. Motivational Interviewing:
a. Lussier MT. Richard C. The motivational interview. Canadian
Family Physician. 2007;53(11):1895-1896.
b. Levensky ER, Forcehimes A, O'Donohue WT, Beitz K. Motivational
interviewing: an evidence-based approach to counseling helps
patients follow treatment recommendations. American Journal of
Nursing. 2007;107(10):50-58.
3. “Teach Back” Approach
a. Institute of Medicine. Health Literacy: A Prescription to End
National Academies Press. Washington, DC. 2004.
4. Food Hunger
a. Rose-Jacobs R. Black MM. Casey PH. Cook JT. Cutts DB. Chilton
M. Heeren T. Levenson SM. Meyers AF. Frank DA. Household food
insecurity: associations with at-risk infant and toddler development.
Pediatrics. 2008;121(1):65-72.
b. Chilton M. Booth S. Hunger of the body and hunger of the mind:
African American women's perceptions of food insecurity, health
and violence. Journal of Nutrition Education & Behavior.
2007;39(3):116-25.
c. Rose D. Bodor JN. Chilton M. Has the WIC incentive to formulafeed led to an increase in overweight children?. Journal of Nutrition.
2006;136(4):1086-1090.
d. Cook JT. Frank DA. Levenson SM. Neault NB. Heeren TC. Black
MM. Berkowitz C. Casey PH. Meyers AF. Cutts DB. Chilton M.
Child food insecurity increases risks posed by household food
insecurity to young children's health. Journal of Nutrition.
2006;36(4):1073-1076.
5. Economic Inequality
a. Sen AK. On Economic Inequality, Oxford: Clarendon Press, 1973;
New York: Norton, 1975.
b. Sen AK. "On Economic Inequality after a Quarter Century" [jointly
with James Foster], Oxford University Press, NY, NY.1997.
c. Sen AK. Commodities and Capabilities. Amsterdam: North-Holland,
1985; New Delhi: Oxford University Press, 1987.
d. Sen AK. Inequality Reexamined, Oxford: Clarendon Press, New
York: Russell Sage Foundation, and Cambridge. MA: Harvard
University Press, 1992.
e. Sen AK. Development as Freedom, New York: Alfred Knopf, 1999
f. Sen AK. “The Concept of Well-being,” in S. Guhan and M. Shroff,
eds., Essays on Economic Progress and Welfare: In Honour of I.G.
Patel. Oxford University Press. 1986.
g. Aband S, Peter F, Sen A (eds). Public Health, Ethics, and Equity.
Oxford University Press, 2006.
h. Farmer P. Pathologies of Power: Health, Human Rights, and the
New War on the Poor. (California Series in Public Anthropology, 4)
University of California Press. 2004.
i. Sen A. Poverty and Famines: An Essay on Entitlement and
Deprivation. Oxford University Press. 1983.