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CARDIOLOGY CASEBOOK |
Gross inequities in health and longevity are worldwide and continue at undesirable levels despite advances in disease control and treatment. Through communication, modern medicine can improve these statistics. A series of questions and discussions of the answers are presented in order to illustrate these worldwide health inequities and their consequences.
QUESTIONS
ANSWERS
1. g. all of the above
The World Health Organization (WHO) has set up an independent Commission on Social Determinants of Health in order to understand the determinants of health, their function, and how health can be improved and inequities reduced. If determinants of health are social, so too must be the remedies. Action on the social determinants of health is necessary to improve health and to indicate that society has moved toward meeting human needs. Major factors of social determinants include levels of perceived stress, early life experience, social exclusion, work, unemployment, social support, addiction, transportation, food, and the social gradient. Where material or physical deprivation is severe, a social gradient in mortality can arise from the degree of absolute deprivation.
Where material deprivation is relative, physical as well as spiritual needs become important to the health gradient. Advising people to reduce risk factors is not enough to effectively change the health problem; the cause must be examined—that is, the social conditions that give rise to the prevailing health problem. The circumstances in which people live and work are as important for communicable as for noncommunicable diseases. Social conditions project a powerful influence on the onset and response to medical treatment, which become critical in the face of potentially fatal communicable diseases. Other forms of social determinants that affect health status include prevailing taxes, tax credits, pensions, health insurance, illness, maternity and child care, and unemployment benefits. Also included are housing policies and access to healthcare facilities.1
2. a. true
Gross inequities in health status and life expectancy continue to persist between and within the countries of the world, challenging the best of international social and governmental groups. Social determinants, similar to communicable and noncommunicable diseases, are thought to be a factor if not the root of many of these avoidable inequities.1
There is no apparent biological reason for life expectancy to be 34 years in one country and 82 years in another. Not surprisingly, the first response is to control major lethal diseases and to improve the healthcare systems (provide clean water, ensure adequate nutrition [increase caloric intake], and improve medical care); the second response is dealing with poverty. What is not realized is that the simple relief of material deprivation is inadequate. Recipients of these resources are often determined by social status. Relief from the health effects of poverty requires an understanding of the role of social and economic policies. A third and more recent theory being investigated is the action taken on the social determinants of health. The spectrum of this goal would not only be to relieve poverty and disease, but also to determine the circumstances in which people live and work that lead to poor health and a shortened life span.1
3. c. income loss
Inequities in health status are generally related to inequality and poverty; however, given the social determinants, poverty takes different forms and generates different health consequences. Income poverty is an incomplete explanation of varying mortality rates among countries or regions. Not only income level but income fluctuation and income loss have been characterized as powerful determinants of mortality both on the lower end and beyond the median, yet the impact of income on mortality may not be the same for all social groups (female versus male, black versus white).2 One study suggests that the psychological effects of income loss are more devastating than a stable low income level. Inability to maintain consumption patterns and the distress caused by lifestyle changes may lead to compromised health.2
4. b. false
The nature of poverty has changed, and poverty is more complex than simply a lack of money. Countries with a high gross national product (GNP) per person provide little correlation between poverty and life expectancy. Where a US male citizen has a life expectancy of 75.1 years and a GNP of $34 000, Cuba’s GNP is less than $10000, yet the life expectancy for a Cuban male is 76.5 years. Female life expectancy is 80.5 years in the United States and 80.1 years in Cuba.3 China and Kerala, India, are additional examples where populations are uniformly poor, yet health is maintained. The United States spends more on healthcare ($5711 per capita) than any other country, yet ranks 29th in the world in life expectancy.3,4 As the health of a population suffers, there is usually a set of underlying social circumstances that require change.1 The social circumstances are those features of society that meet basic human needs, but at a pervasive, incongruent level that depends on socioeconomic position or degree of social exclusion.
Adult mortality rates contrast greatly between countries. Although mortality in African nations increased from chronic disease and violence, it declined in the world as a whole.1 In some countries, adult mortality varies inversely with the level of education. In Sweden, those with a doctor’s degree in philosophy had a lower mortality than did their counterparts with a master’s degree, who in turn had lower mortality than did those with a bachelor’s degree. Material deprivation does not explain this hierarchy of relationships.
5. a. higher social position ensures better health
b. status is determined by one’s accomplishments, as well as one’s possessions and by what can be accomplished with them
d. the degree of control over life and job is important to the well-being of the individual
It is an accepted fact that the poor have inadequate healthcare due to a lack of basic necessities; however, in affluent countries, as in the United States, early mortality does not result from famine or lack of sanitary facilities. The socioeconomic differences do not result in poor health and a higher mortality in those at the bottom of the ladder and better health and longevity for those at the top. Social gradients in mortality occur everywhere, whether due to communicable or noncommunicable diseases.
A notable study, the Whitehall study of British Civil Servants, provides evidence of a social gradient, or occupational hierarchy, that appears to influence health and survival. In this early study, the level of a man’s employment was a stronger predictor of CVD risk than any other major coronary risk factor.5 The higher the social position, the better the individual’s health, with a significant difference in survival spread within this hierarchy. This finding is known as the "status syndrome."4 Status may be defined not only by the number of possessions owned, but also by what has been accomplished with these assets. It is not the individual’s place in the hierarchy that determines the social gradient, but what the position in the hierarchy allows within a given society.
6. a. the stress load becomes overwhelming
b. the adaptive process can become mal-adaptive
Profound lifestyle changes in modern society have resulted in an increase in the incidence of CVD. Optimum body weight, diet, and exercise have been neglected, and as a result elevations in blood pressure and metabolic alterations may lead to atherothrombotic disease.6 The perception of stress activates the central nervous system by triggering behavioral and physiological response patterns; defense and defeat patterns result from catecholamine release, vagal withdrawal, cortisol secretion, and activation of the renin-angiotensin system. The physiological responses to stress are initially beneficial for survival, but become detrimental when stress is chronic or frequent. When stress is frequent and physiological adaptive responses are lacking or inadequate, the stress load becomes overwhelming and the adaptive processes may become maladaptive. It has been postulated that there is a behavioral or psychosocial component of neuroendocrine activation and that stress is involved in the pathophysiology of CVD and the metabolic syndrome.6,7
7. a. the sympatho-adreno-medullary axis
b. the hypothalamic-pituitary-adrenal axis
Metabolic syndrome is a cluster of neuroendocrine risk factors that can lead to atherogenic disease. Common features are central obesity, insulin resistance, hypertension, and dyslipidemia. Although a common neurohormonal thread has been suggested, no clear relationship between these entities has been demonstrated. There is a strong inverse relationship between socioeconomic status and the risk of CVD.7 The Whitehall II findings have shown a close relationship between a lower social position (adverse psychosocial conditions) and an increased probability of having the metabolic syndrome, increased inflammatory variables, and CVD. Low social position has been linked to activity of the 2 main biological stress pathways, the sympatho-adreno-medullary axis and the hypothalamic-pituitary-adrenal axis. Using normetanephrine excretion and heart rate variability (HRV) as indicators of sympathetic tone, the Whitehall II study reported psychosocial-related elevations of normetanephrine excretion and decreased HRV in individuals in the lower levels of civil service than in those at the higher levels.4 Low control at work and low social position were linked to low HRV and raised cortisol levels.
Although the Whitehall II study offers clues, the exact mechanism of how psychosocial factors relate to neuroendocrine activation and the metabolic syndrome is not clear.6 The Whitehall II study explained that the lower the individual is on the social hierarchy, the less likely that fundamental human needs for autonomy are being met. Failure to meet these needs results in chronic stress, leading to metabolic and endocrine changes that in turn increase disease risk.4 Metabolic syndrome may be the transition point between long-term psychosocial stress and CVD.7
8. e. all of the above
The effects of poverty and social inequality on health and survival are documented. Survival trends in progressive and affluent countries such as Japan are better than in poorer countries like Kazakhstan or Bangladesh.4,8 It is also not uncommon to find great variations in health status and survival within a specific locale. For example, in Washington, DC, and New York City, there is a 20-year gap between male life expectancies within a 12- to 15-mile radius of a single region.4,8 Whereas the low life expectancy in a poor country may be due to infected water, poor sanitation, or starvation, the low life expectancy in a poor area within an affluent country is often due to violence, HIV infection, and CVD.
What role does social environment have in generating contrasting health differences between residential areas? It has been postulated that both the socioeconomic characteristics of the community and the characteristics of the individual are related to the incidence of ill health. Psychosocial factors may parlay into health inequities in disadvantaged communities when ill health results from lack of access to positive lifestyle constituents (meaningful work and income, healthy foods, educational opportunities for children, opportunities for exercise, medical services) and exposure to negative factors such as crime and violence, fear, lack of social support, and psychological effects of being in the low socioeconomic level.
Median household incomes being the same, there is evidence that affluent blacks in black neighborhoods had better health than poor whites who were on the lower end of their white neighborhood scale. Thus, not only deprivation may portend ill health since even those in a lower income bracket in a rich society can have higher rates of disease.8 Questions have been raised in attempts to explain this finding. Is health related to the equality of medical care? Even universal provision of health-care may be subject to differences in access and utilization. Is health a determinant of social position or is the reverse true?
The usual explanation for inequalities in health is lifestyle, yet controlling risk factors appear to have little effect on the socioeconomic differences in illness. A recent hypothesis suggests that there is a psychological component of disease and survival. The mind may affect disease-related behaviors by affecting neuroendocrine or immune mechanisms. A psychosocial characteristic (low control) by which the individual perceives little control over his or her work, role in the family, or role in life is a predictor of CVD and depression.8
CONCLUSION
Reducing social inequalities in health and meeting human needs are issues in social justice. Two interventions that are starting points for reducing social inequities in health involve enhancing social and psychological resources and improving the quality of neighborhoods and communal life.8
ACKNOWLEDGMENTS
Supported in part by a grant from the Applebaum Foundation, in loving memory of Joseph Applebaum.
Reprint requests: Louis Lemberg, MD, University of Miami Miller School of Medicine, Division of Cardiology (D-39), PO Box 016960, Miami, FL 33101.
None reported.
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