Karen Amlaev
MD, Chief of the department "Medical prevention and epidemiology of non-communicable deseases"
EITI Stavropol State Medical University.
355017, Russian Federation, Stavropol, street. Mira, 310, tel. +79283180604,
e-mail: kum672002@mail.ru
THE PRESENT STATE OF INEQUALITY
IN HEALTH (REVIEW)
Health inequity is a general
term
typically
differences,
used
to
define
changes,
health], which is unfair and unjust”
[1].
and
Some researchers suggest a definition
disproportions in the health status of
based on which unfairness in health
individuals and groups, however, not
will be related to those health
any health inequity will be unjust.
disparities
Yet, many types of health inequity are
avoidable,
undoubtedly unjust as the concept of
unjust. ([1] - [5]).
that
are
considered
removable,
unfair
and
health injustice focuses on distribution
Health inequity is increasing both
of resources and other processes that
inside countries and among them. The
drive certain types of health inequity,
gap in life expectancy between the
i.e. on systematic disparities in terms
richest and poorest countries is more
of health (or in its social determinants)
than 40 years. Besides, in all countries
among various social groups enjoying
there is a large gap in terms of health
more or less favorable opportunities.
status
In other words it focuses on health
irrespective of their income. In high
inequities that are unjust and unfair.
income
Speaking of the English terms
dividing
various
countries
there
groups
can
be
observed a more than 10-year life
“inequality” and “inequity” that are
expectancy
used
groups depending on such factors as
to
healthcare
define
the
“disparity”:
expression
in
social
the
gap
ethnicity,
between
gender,
various
social
&
inequalities in health imply the same
economic status, and the geography of
disparity [just like social inequities in
residence.
In
poor
countries
all
regions show significant difference in
When viewing the behavioral factors
child death rate depending on the
– either positively or negatively
household welfare.
affecting health – we shall come
Socio-economic conditions (social
determinants)
have
significant
showing that poorer (from socio-
impact people’s health through their
economic point of view) groups
entire life-span. People with lower
usually demonstrate poorer nutrition,
income demonstrate at least twice the
lower physical activity at their spare
likelihood of developing a serious
time, have a higher level of tobacco
disease
if
use or some other alcohol-related
compared to those with high income.
behavior patterns that seriously affect
Besides, the social disparities in health
health. Special literature available
status, which could be called the
reflecting the findings received from
social health gradient, can be observed
qualitative
through all the stages of the social
groups’
ladder and go beyond the low-income
lifestyles, serves evidence that such
group. In particular, even in the
people have more restricted choices in
middle
lower
terms of healthy lifestyles, which is
positions contract diseases and die
due to the limits on their time, space,
more often than their colleagues
and money available to them, and
holding higher positions [1]. The most
could also be accounted for by the
important
the
psycho-social mechanisms influencing
development of effective social and
them. All this is aggravated with the
economic policy are full and adequate
difference
vision of how inequality is generated,
conditions and services, which could
whether it is income or health
prevent or reduce the health damage
inequality, what factors influence this
from the socio-economic factors. For
process, how these inequalities are
instance there are differences about
related, search of the ways to reduce
access to the major medical care and
inequality up to a socially acceptable
their quality when we talk of various
level.
groups of the society, where healthier
or
a
across numerous undeniable facts
premature
class
those
conditions
death
with
for
research
living
in
into
conditions
access
to
poorer
and
goods,
2
and better-off groups enjoy more of
This assumption is based on the ideas
that access. The same holds true both
of the mechanisms connecting health
for
and socio-economic inequity. In some
preventive
services
and
for
treatment. [6].
The
cases such mechanisms are rather
economic
standpoint
obvious while in other cases they are
contains reasons showing that such
more complicated and are not so
healthcare disparities result in huge
visible from the surface. Thus, the
loss and waste of human resource,
level
which could otherwise be used both
differences in living standards – the
for individual prosperity and for the
quality and the quantity of the goods
society at large. Inequalities and
and services consumed. This, first of
inequities in health and health care are
all,
just manifestation of the more general
content, food diversity and balance,
process
protective
of
social
disintegration.
of
income
affects
the
determines
nutrition
and
the
calorie
sanitary-hygiene
Therefore, the activities aimed at
features of the clothes and footwear,
overcoming inequalities and inequities
as
in health, could be a means of
convenience of the living micro-
focusing efforts and opportunities to
environment. Differences in the living
restore or revival of social cohesion.
conditions develop unequal capacities
Health
a
to adjust and to cope with physical
significant part of the society has no
and emotional stress. Inequity in
chance to reach their full health
living conditions determines unequal
potential, and this cuts them from
access to efficient ways of coping
access and a chance to enjoy other
with
basic human rights. The conclusion
mechanisms
here implies that the society should be
inequity “rubbing off” onto health is
equal and fair in distributing the
linked to the hypothesis stating that
resources available so that to make
the relationship between the health
these accessible for everyone. [7].
and the socio-economic status could
inequity
Socio-economic
means
factors
that
are
meaningful factors in health inequity.
be
well
as
health
the
comfort
disturbances.
of
expressed
and
Such
socio-economic
through
the
interconnection of “better economic
3
status – better health status”. The
Such
health status is subject to the influence
comprehension of social mechanisms
of individual behavior – smoking,
in the development of health and how
alcohol, poor or imbalanced nutrition,
much health inequity is due to
and lack of physical activity. The
economic and social changes that the
differences in health status that are
society faces; this will also bring
due to lifestyle shall be unfair when
about the idea of the trends – either
the choice of the lifestyle is restricted
increasing or decreasing – in health
with socio-economic factors never
inequity
directly depending on the person
groups. Such research projects are of
himself. For instance, poorer (from
great
the socio-economic viewpoint) groups
developing a social policy aiming at
have been shown to tend to adopt
better public health, as well as of
behavior patterns posing potential
assessing
threat to their health. [8].
currently implemented measures. ([5],
The findings from a number of
research
will
between
deeper
different
importance
the
help
in
social
terms
efficiency
of
of
the
[9], [10]). According to the documents
European research projects suggest
of
the
leading
that the death rate among those found
organizations
at the “lowest” rank of the social
nowadays policy of public healthcare
ladder is typically 2-3 times as high,
is based on the concept of health as a
while the life expectancy in non-
specific public benefit the access to
qualified employees is 5 years shorter
which should be determined following
if compared with qualified personnel;
the principles of social justice. This
also there is a 9-12-year gap between
implies equal opportunities in getting
the poor and the well-off in terms of
the key health resources for people
their life expectancy free from any
representing various social groups.
disabling condition. ([5], [9], [10]).
The
([2],
implementation
international
[11]),
of
the
this
Studying social inequity in
requirement would involve special
health and its change over time is one
attention towards the groups whose
of the key areas in the modern
status is less favorable compared to
research into the sociology of health.
others. ([5], [12]).
4
Mention should be made here
increasing inequity, which puts them,
that a policy aimed at reducing the
too, among the top concern objects
health-related burden in low-status
from the point of view of public
social groups will not just meet the
healthcare.
justice principles, yet it will also
aggravation of women’s health, in
contribute to significant improvement
particular in those belonging to
in the population’s health in general.
vulnerable social groups, has become
([9], [13], [14]).
an issue that is attracting more and
The
differentiated
Even though the latest decade
more attention from policy-makers in
has seen measures to reduce inequity
those countries. In some countries
taken across Europe, there are still
there is direct evidence of health
many
inequity depending on the ethnicity.
countries
concern
that
with
the
a
growing
disparities
and
The findings received from the United
inequities are expanding, which is
Kingdom as well as from other places
especially obvious in the Central and
suggest that this is largely a result of
Eastern Europe where the phenomena
the poor socio-economic conditions of
in question have adopted in this
certain ethnic groups.
century an unprecedented scale if
compared
with
industrial
different and vary from area to area in
countries. In some countries (the
different periods of time, which is
Russian Federation being one of
evidence to the fact that they are not
them) where the worsening general
fixed
health status in people is a common
actually, be altered. The best results
fact, the increasing inequity and
gained or underway in a particular
disparities are a dramatic consequence
country should become a sample and a
of
shock.
guide for other countries in their
However, even countries with a good
attempt to reach achievable aims in
state of things in healthcare (e.g.
improving their people’s health.
severe
Denmark,
other
Inequity and injustice are quite
socio-economic
the
inevitable
and
could,
and
There is a growing consensus
Sweden) also demonstrate significant
on the question of the essential role
evidence
played by systematically manifested
of
Netherlands,
and
retaining
and
even
5
differences and differentiation in all
Any way, socio-economic inequities
that concerns the impact of health
violate the principle of social justice.
hazards and risks associated with
In this respect the concept of social
living conditions, when considering
justice could be analyzed.
the reasons underlying the observed
Social justice has no clearly
differences in health. This means that
defined limits. All public ideas of
some groups of society have much
justice
worse chances and opportunities to
layered and not standardized. Even
achieve and realize their full health
within certain groups ir is possible to
potential than others, due to their
come across the combination of
specific
and
different ideas of justice or the
social,
imposition of different ideologies of
socio-economic
justice. Conditionally there are three
life
circumstances:
psychological
factors
physical,
and
conditions of their lives.
Social
multi-
standards of justice:
- justice in services (the "who makes
systematic health disparities in various
more, should get more" neo-liberal
socio-economic groups. This inequity
principle, in which the state must
is socially determined (and, therefore,
restrict access to social services, and
is changeable) and is unfair. Such a
to encourage self-market);
judgment of justice is based on the
- justice in needs (resources are
common principle of human rights.
divided
There are facts showing that there is
prescribed rules for needs);
huge (and still increasing) social
-
inequity in Europe nowadays, at least
inequalities are fair in the medium-
as
term perspective, because ultimately it
as
in
heterogeneous,
is
far
inequity
are
relative
health
criteria
are
concerned. [6].
on
the
functionalist
basis
of
justice
state-
(market
maximizes welfare for all). [15].
The range of socio-economic
Social inequity has existed for
inequities is wide: gender- and age-
the entire comprehensible human
related,
race-ethnic,
history. Even though inequity has
professional, power-related, material-
always been subject to destructive
and property-related, territorial, etc.
criticism
educational,
and
has
never
been
6
approved, yet people through history
esteem, dissatisfaction with their life,
have demonstrated extreme resistance
and substance abuse. ([1], [16]).
to any “ideal” society based on social
The World Health Organization
equity and absence of suppression
has developed an ambitious program
among groups.
Health for All, which targets at a 25 %
There is special concern over
reduction of health inequities both
social inequity when it comes to
inside countries and among them by
children’s health. During that the
the beginning of the XXI century [11].
report on health inequity, including
However, given the results obtained
the issues of qualitative assessment of
from numerous research projects the
gender, age, geographic, and socio-
WHO European Bureau once again
economic factors influencing health
has defined the European targets for
disparities, contains data on the health
health inequity reduction.
status of adolescents aged 11, 13, and
HEALTH-21: European target 1 –
15 in 2005–2006 representing 41
Solidarity for health in the European
countries and the WHO’s European
Region.
region and North America. The
By the year 2020, the present gap in
purpose of the report was to detect the
health status between member states
actual
differences
of the European region should be
health
status,
and
in
youngsters’
provision
of
reduced by at least one third.
information that could be useful for
HEALTH-21: European target 2 –
the development and implementation
Equity in health.
of specific programs, also contributing
By the year 2020, the health gap
to improving young people’s health at
between socioeconomic groups within
large.
countries should be reduced by at least
This
research
has
produced
one fourth in all member states, by
convincing evidence showing that
substantially improving the level of
despite the high health status and
health of disadvantaged groups.
well-being in young people many of
HEALTH-21: European target 3 –
them still have severe issues related to
Multisectoral responsibility for health.
overweight and obesity, low self7
By the year 2020, all sectors should
relative. This is because inequity will
have recognized and accepted their
inevitably
responsibility for health. [6].
societies. Therefore, relative poverty
Prior
dealing
will always be present even if the
prominent health inequity there should
living standards for all the groups of a
be an understanding of its major
society have gone up.
and
health
with
complex
the
causes
to
accompany
inequity
manifestations.
The relation between the death
rate and the income, the likelihood of
Complete
proper
a shorter life expectancy develops due
inequity
to long accumulation of negative
develops – be that in terms of income
impacts from financial hardships and
or health – as well as what factors
the emotional reactions linked to
influence the process, how these
them. An individual’s health status is
inequities are related, and finding
largely determined by the social group
ways to reduce the inequity down to a
this particular person belongs to. A
socially acceptable level – all these
preliminary analysis of the relation
are
the
between health inequity and economic
development of an efficient socio-
status shows that towards various
economic policy. [17].
health indicators there is both inverse
understanding
important
and
of
how
premises
for
The most vulnerable to inequity
(higher status – fewer diseases) and
groups still remain the youth, women,
direct relation. The position held by
retirees,
low-qualification
an individual in the social hierarchy –
workers. Along with poverty and
no matter how it may be defined –
beggary (sometimes referred to as
through job, level of education or
deep
also
income is always the determining
disadvantage. This typically affects
factor both for the health status, and
children,
for the prevalence of behaviors that
and
poverty)
the
there
disabled,
is
retirees,
representatives of another race or
ethnicity, and the chronically poor.
are destructive for health.
People employed in areas with
A society may eliminate absolute
lower status and low income more
poverty, yet there is always some
often demonstrate stress symptoms.
8
Stress can act as an effect modifier.
this number of infarction occurrences
This means that in case of comparable
goes down as long as the subjective
levels of harmful impacts those
economic status goes up ([10], [23] -
experiencing
[26]).
stress
are
more
susceptible to diseases and accidents.
The dependence of health from
We should also keep in view the extra
the objective economic status is also
effects
an illustration of the type of health
of
behavioral
manifestations,
such
as
stress
smoking,
alcohol abuse or violence.
An
empirical
issues.
First,
shows
a
higher
of
concentration of people with low
interrelation between health inequity
income among those with high or very
and income inequity is, for instance,
high likelihood of health loss: groups
the data on differentiation of the
of those unable to maintain self-care
medium number of health deviations
and suffering from limited physical
in
subjective
capacity include the elderly. In other
economic status. The highest number
words, inverse relation between the
of health issues has been registered in
objective economic status and the
the groups with the lowest economic
health status is mostly typical of the
status, and the number will decrease
elderly and the oldest groups of the
as the status of the group grows.
population,
Russian authors' works confirm the
hypothesis concerning the fact that the
influence of social aspect on health.
development of a stable negative
([18] - [22]).
relation between health and economic
various
groups
illustration
it
of
which
supports
the
A similar relation between health
status is largely subject to the factor of
and the objective economic status can
accumulating the negative impact
be seen in case of some specific
from financial hardships and their
diseases, blood circulation issues in
consequences over a long time.
particular. The highest concentration
Second,
of those who suffered myocardial
between chronic diseases and the
infarction can be seen among the
economic status. A complementary
population with the lowest status, and
analysis of the relation in view of the
there
is
direct
relation
9
age factor among people with various
institutions. Among the well-off this
incomes also shows that the poor have
index
a higher share of those suffering from
compared to the disadvantaged, both
diagnosed chronic diseases in all age
in general, and within specific age and
groups, if compared with similar age
level-of-education groups ([22], [27] –
groups with the maximum income. As
[29]).
for acute communicable diseases both
is
significantly
higher,
if
Thus, there has been both direct
the poor and the rich are equally
and
inverse
relation
identified
vulnerable to them, with the middle
between health and the objective and
class demonstrating a lower level of
subjective economic status. On the
vulnerability.
one hand, the higher economic status
The distribution of the different
the more often people visit medical
age population suffering from health
institutions for preventive purposes
issues in the groups of the subjective
and the higher the number of those
economic status also suggests that in
with chronic diseases detected. On the
the young age (or in the first part of
other hand, the higher economic status
life) the share of people with detected
the lower (on average) the number of
(diagnosed) issues is growing along
people with health issues, the lower
with the subjective economic status
the share of people with severe heart
growth. Yet, there is a tendency seen
diseases (myocardial infarction), and
in those approaching the end of their
the lower the share of those with
age: the higher subjective economic
significant and stable loss of health. In
status the higher concentration of
general the individual findings on
people with health issues.
health support the conclusions and
People who are rather well-off
assumptions concerning the prolonged
have significant material possibilities
and ongoing impact of income on
to get the medical assistance needed
health, which were done based on the
and to take care of, and maintain their
analysis of socio-economic inequity
own health. This could be seen, in
and territorial differences in people’s
particular,
of
health status. There we can see both
medical
cumulative effect where “the quantity
preventive
in
the
visits
prevalence
to
10
(of money) shall transfer into quality
data obtained suggesting that mental
(of health)” after a certain period of
disturbances are more common for the
time, and the stimulating role of
lower social class. [30]. Employment
higher income on the ongoing health
status was the main factor explaining
monitoring and timely response to its
differences in the prevalence of all
disturbances.
mental
First of all, economic status - is
disorders
Unemployment
among
also
adults.
significantly
only one of many social structural and
increased the odds ratio of developing
behavioral factors that affect health. It
mental disorders in comparison with
is more appropriate to consider age as
the reference group. Chances of
one
developing
of
the
most
important
drug
addiction
have
almost
four-fold
after
determinants of health - a direct
increased
indicator of the degree of "exhaustion"
adjusting for other socio-demographic
of biological resource of health given
indicators, phobias and functional
to man by nature. On average, the
psychosis - almost tripled, depressive
younger the person, the higher the
episodes, generalized anxiety disorder
biological resource, the older, the
and obsessive-compulsive disorders -
poorer the resource.
more than doubled, and mixed anxiety
The relation between the social
status and various aspects of mental
and depressive disorder - more than
two-thirds.
issues has been of interest for both
At the same time, lately there
doctors and researchers since long
have been discovered other channels
ago; the findings from a lot of
of the significant impact that inequity
research
the
has on health. In particular, it has been
meaningfulness of social status in
shown that chronic stresses related to
understanding mental diseases and
the dissatisfaction with one’s socio-
disability.
economic status may result in neuro-
have
The
demonstrated
epidemiological
research projects conducted all over
endocrine
and
psychological
the world have shown an inverse
functional
relation between mental issues and the
contributing to the disease likelihood.
social class. There has been consistent
It has already become a common
alterations
thus
11
opinion that a longer feeling of fear,
are connected. Higher indices of
uncertainty, low self-esteem, social
vulnerability
isolation, inability to make decisions
individuals with lower levels of
and be in charge of the situation both
education and social achievements.
are
detected
among
at home and at work impact health
There was also a suggestion that
seriously: this may cause depression,
belonging to a particular social class
increase
will
susceptibility
to
influence
the
nature
of
communicable diseases, diabetes, high
psychopathological
blood cholesterol, and cardio-vascular
in depression. Patients demonstrating
issues. Low socio-economic position,
symptoms of somatized and anxiety
therefore,
directly
disorders more often belong to a lower
through deprivation and financial
social class. At the same time
hardships, and through the subjective
cognitive symptoms were more often
vision of one’s “unequal” position in
detected in patients from a higher
the society and the related judgment,
class. The severity of depression in
relations, experiences. When studying
adults, related to financial issues, may
the influence that the socio-economic
depend on age. Mirowsky и Ross [32]
status has on health focus should be
found that it goes down as the age
kept on both the objective and
goes up. Financial troubles and poor
subjective
status.
marital relationships are significant
Therefore, there is an undoubted
factors contributing to the risk of
connection
financial
depression onset and its chronic
status and health, which can be seen
course [33]. Just like depression,
both from the scientific-theoretical
poverty is typically chronic in its
viewpoint, and at the level of common
nature, so it usually needs focus both
sense. ([27] – [29]).
from caregivers and from decision
impacts
health
socio-economic
between
the
Many researchers state that low
socio-economic status is associated
with
high
prevalence
of
symptomatology
makers.
If compared to the general
mood
population people who attempt suicide
disorders [31]. Socioeconomic status
more often belong to the social groups
and vulnerability in mood disorders
12
where social instability and poverty
The social class is a risk factor of
are typical.
death due to alcohol abuse, which is
Gunnell et al. [34] nvestigated
the
relation
parasuicidal
between
behavior,
suicide,
factors
as
poverty,
disadvantage
socio-
position and the social class. The rate
economic issues. They identified a
of alcohol-induced death is higher
connection
and
among men involved in physical labor
parasuicidal behavior, while negative
than among clerks, yet the relative
socio-economic factor offered nearly
index will depend on the age. Men
complete explanation.
aged 25-39 and involved in common
between
and
also related to such structural social
suicide
Besides, these murders and
non-qualified
physical
labor
suicides more often happen in densely
demonstrate a death rate 10-20 times
populated poor areas [35]. Crawford и
higher than representatives of the
Prince
these
middle class, while among those aged
findings. They noticed an increase in
55-64 the same index is only 2,5–4
the
young
times higher if compared to those who
unemployed men living under severe
are involved in a type of labor
social deprivation. It also true that the
requiring special skills [38].
[36]
suicide
frequency
of
also
rate
support
among
cocaine
or
opiate
Thus,
consideration
of
of
the
overdose cases is associated with
influence
socio-economic
poverty [37].
determinants of health on vulnerable
Alcohol and drug addiction
groups is an important element in the
corresponds to the general tendency,
implementation of effective social
with the highest indices in the social
policies to reduce inequalities in
class V. Both unemployed men and
health.
women demonstrate a higher level of
alcohol or substance dependency in
case they belong to the unemployed.
References
13
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ВОЗ.
стратегии
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Европейское
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inequality in health. As the most
important
Summary:
factors
are
considered
poverty, ecological trouble, lack of
The article describes the state of the
education.
problem of inequality in health in the
residents largely confined to socio
world. The main causes of increasing
economic factors that do not depend
inequality in health. The authors refer
directly on the person.
to them economic differentiation of
Summary:
society, the transition from health to
inequity,
the
health, public health and health care.
health
of
clinical
medicine,
Shown
that
Keywords:
social
lifestyle
health
determinants
of
unequal access to health services.
Analyzed the influence of socioeconomic determinants that shape
17