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?
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?
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?
3b. Did the experiments which proved this prediction surprise you
and do you think the results are valid?
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?
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?
6. What is it about chronic stress that makes us more susceptible to
disease?
7. What are the lifelong consequences of childhood poverty? To catch
the problem at its root, what can be done to limit childhood poverty?
8. What role does hunger play in behavioral issues, violence and
truancy?
9. The video states that 83,000 excess deaths occur annually in the
black community. How can we account for such staggering
numbers?
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?
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?)
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?
12. What sorts of innovative initiatives are shown in the video that favor
community empowerment and social change? Could a similar
initiative flourish here?
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?
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?
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?
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]
2.
3.
4.
5.
b. The Sanctuary Model: http://www.sanctuaryweb.com/ [Resources
and information about skills training]
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.
“Teach Back” Approach
a. Institute of Medicine. Health Literacy: A Prescription to End
National Academies Press. Washington, DC. 2004.
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.
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.