Title: “Not Just a Paycheck” from the California Newsreel Documentary
Series Unnatural Causes: Is Inequality Making us Sick? – A Discussion
Guide for Health Professional Students
(for the discussion facilitator)
Prepared by Olivia Carter-Pokras, Ph.D., Alex Fischer,
Acknowledgements: The authors gratefully acknowledge comments by dental,
medical, and nursing students at the University of Maryland Baltimore, and public
health students at the University of Maryland College Park.
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 social class and
employment status.
3. Evaluate social determinants of health and other underlying factors related
to disparities by social class and employment status.
Session Summary:
This is a 28 minute film segment entitled “Becoming American” 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.
The video explores how a factory closure in Western Michigan undermines the
lives and health of a white, working class community. But the same company
shut down their Swedish plant with hardly a ripple thanks to very different social
policies. The small group case discussion will be facilitated by medical, health
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:
Discussion Questions:
“Not Just a Paycheck”
1. The video says that those workers in Greenville, Michigan that were laid off lost
more than just their jobs. What was meant by that? What else can result from
unemployment?

The effects of unemployment can ripple through whole families and
communities, and it is hard to recover from. Any appearance of job
security is undermined, and as personal finances spiral downward, so does
health. Extra stress may cause us to make choices that are bad in the long
run, including drinking and chronic eating. Job loss can result in increased
risk of depression. There is worry about losing homes, not being able to
afford medicines, not being able to pay bills.
2. The year after closing the regfrigerator manufacturing plant in Greenville,
Michigan, cases of depression, attempted suicide, and domestic abuse treated in
the local hospital tripled. How can we account for this sudden change?

Loss of jobs with little ability to recover the original salary, lack of jobs,
and reliance on unemployment benefits, pensions, and social security can
lead to ambivalence toward the future and feelings of hopelessness.
Additionally, with bills to pay and dwindling money, often medication has
to be cut, and many times the first to go are antidepressants. Such
unemployment stressors also put strain on marriages and family.
3. The video says there is a reasonably direct relationship between unemployment
changes and mortality changes. How can this connection be explained?

Rates of cardiovascular disease along with just about every other cause of
death have been shown to increase as unemployment rates rise. External
life events such as the stress of unemployment and having to deal with
financial issues get under our skin. The stress causes changes in the
workings of our psychology and our bodies. If stress remains high,
excessive levels of cortisol can result, changing the biochemistry of our
bodies, making us much more susceptible to such diseases as
cardiovascular disease.
4. The video states that people who have little of power over their lives have an
increased risk of heart disease, mental illness, absense from work and detriments
from functioning. To combat this, we should should increase the control we have
over our lives, but how can we do this?

It is now no secret that affluence greatly increases the autonomy we have
in our lives, because it gives us much better access to resources, which
translates into social stability and health. But if we are not provided these
opportunities, and do not have the affluence to better access these
resources, we are left with little power to provide for ourselves. We must
look to enact social policy changes that will give us those things that we
need to invest in ourselves to take control of our lives, such as education,
jobs, and community.
5. The video says there is a growing chasm between the “haves” and the “havenots.” How can we account for this phenomenon?

There has been some economic growth in the Greenville, Michigan area as
some large houses and national franchises have been built, even as
workers are losing jobs. Yet in such cases, often the economic growth
favors or directly benefits those at the upper end of the social ladder, and
as a result the gap widens between those with money and those without.
Higher manufacturing productivity does not necessarily benefit the
workers, but those at the top of the ladder.
6. The video talks about the social gradient and its correlation to health. What are
the implications of this trend?

Social status is a great indicator of health. Those who are at the top of the
socioeconomic ladder are healthier than those who are below them, at all
wrungs of the ladder. Affluence buys people the time and resources to
take care of themselves, and as affluence decreases, so does health. Social
policies that will shrink the gap between the poor and the wealthy are
needed, as affluence is clearly a strong determinant of health.
7. In the United States, we live in an individualistic society, in which the majority
feels that individuals are personally responsible for their own fates. How does our
social policy reflect that? What can be done to change this?

Individualism now takes precedence over caring for brothers and sisters.
There is no longer a shared sense of responsibility that there used to be.
As a result our social policy often leans to benefit those who are already in
power. The wealthiest 1% holds 38% of all personal wealth and nearly
one-third of corporate stock, and their taxes are getting lower and lower.
Those that need to benefit from social policy changes are those that do not
have the access to resources needed to provide them with education, jobs,
housing, and health-related services. Social policies need to be enacted to
benefit these groups first.
8. How were the results of unemployment in Sweden different from the United
States? Why was this?

The sudden unemployment in Sweden did not cause the same detrimental
effects on workers as it did in the United States. Those who were laid off
in Sweden were given unemployment benefits at 80% of their salary as
long as they continued school or looked for new work. When the plant
closed in Sweden, the government and union pressured the company to
provide restitution to its workers. The social policy in Sweden is designed
to provide a safety net for the unemployed and a means to get back on
track.
9. Is the social mindset different in Sweden than in the United States, and how does
it reflect in the policy that is made in Sweden? What can we learn from this?

The mindset of policy-making in Sweden can be considered much less
individualistic, and more focused on the benefit of the nation as a whole.
The effects of unemployment have been carefully calculated, and it has
been determined that it is a waste of resources to leave people unemployed
for a long time. Policy rewards entrepreneurs and protects workers.
Taxes need to be high enough to provide its citizen with quality living, yet
knowing the benefits an services provided to them, Swedes are willing to
pay those taxes. As a result of such policy, the average Swede lives 3
years longer than the average American. United States policy can learn
from such examples as Sweden, where the focus is less individualistic,
resulting in a healthier nation.