Chapter 2 THE MACROSOCIAL ENVIRONMENT AND HEALTH

1
Chapter 2 THE MACRO-SOCIAL ENVIRONMENT AND
HEALTH

• D.F.Marks, M.Murray, B.Evans, C.Willig,
  C.Woodall
• C.M. Sykes (2005)
• Health Psychology Theory, Research Practice
• (2nd edition). London Sage.
• Starred authors feature in video-clips

2
THE MACRO-SOCIAL ENVIRONMENT AND HEALTH

• Introductionpopulation growth, poverty, and
  longevity
• Inequalities between countries
• Inequalities within countries
• Gender
• Ethnicity
• Disability
• Implications for Health Psychology
• Summary

3
Determinants of global health

• Poverty
• Droughts
• Famines
• Epidemics
• Wars

4
POPULATION GROWTH

• The world population is exploding.
• From about 1 billion in 1800, it is predicted to
  reach 9 billion in 2050 and 11 billion in 2100.
• Of 6.3 billion people alive in 2005,
  approximately 5 billion (81 percent) live in
  developing countries.

5
The Exploding population

• 0.5M -10K years ago
  1 0 Million
• 2000 yrs ago
  300 Million
• 1800 1.0 Billion
• 2005 6.4 Billion
• 2050 9.0 Billion
• 2100 11.0 Billion

6
World population 1950-2050 (U.S. Census Bureau)
.
7
INCREASING LONGEVITY

• Life expectancy has also been increasing almost
  everywhere.
• In developed countries, it is increasing by three
  months every year.
• If this trend continues, life expectancy will
  approach 100 years by about 2060.
• This will place our social security, health and
  pensions systems in a perilous position.

8
POVERTY

• World poverty is on a massive scale. One in six
  people worldwide live on less than 1 a day.
• Poverty is the greatest cause of ill health and
  early mortality.
• Half of the worlds population lacks regular
  access to treatment of common diseases and most
  essential drugs.
• The most common health outcomes are infectious
  diseases, malnutrition and reproductive hazards,
  including HIV/AIDS.

9
INEQUALITIES BETWEEN COUNTRIES

• Globally, the burden of death and disease is much
  heavier for the poor than for the wealthy.
• Economic research suggests that, while the level
  of mass poverty tends to be reduced by economic
  growth, disparities in wealth across a society
  are not reduced by growth.
• Poverty is linked to debt and trade injustice.
  In sub-Saharan Africa, governments spend at least
  four times more on servicing debt repayments than
  on health care.

10
INEQUALITIES BETWEEN COUNTRIES

• If development is to proceed at the kind of pace
  set by the UN Millennium Development Goals, it
  will be necessary for wealthier countries to
  allocate more resources to development of poorer
  countries.
• Following the aims of the post-Jubilee 2000
  movement, the international debt of the poorest
  countries should be cancelled so that they can
  afford to spend more on health care and
  education.
• Fair trade is another way of correcting the
  imbalances between poor and rich countries.

11
INEQUALITIES WITHIN COUNTRIES RICH COUNTRIES

• Inequalities in the form of health gradients are
  a universal feature of the health of populations
  in both rich, developed, and poor, developing
  countries.
• Socio-economic status (SES) and wealth are
  strongly related to health, illness, and
  mortality.
• These gradients may be a consequence of a
  combination of differences in social cohesion,
  stress and personal control.

12
HEALTH GRADIENTS

• The health gradient is illustrated by this plot
  of mortality against social position labeled here
  as A to E. These data are hypothetical, but
  typical of the gradients that persistently occur
  across both space and time. The population is
  divided into 5 groups representing different
  categories of socio-economic status from high (A)
  to low (E)
• When mortality is the outcome measure, a more
  apposite term would be mortality or death
  gradient.

13
SOCIAL INEQUALITY AND HEALTH

• Health inequalities exist between people of
  different socioeconomic status (SES)
• those in the lower social classes tend to have
  lower life expectancies and are at higher risk of
  ill health.
• These inequalities exist throughout the lifespan
  and exist for both men and women.

14
SOCIAL INEQUALITY AND HEALTH

• Health inequalities can be viewed from an
  ecological perspective or systems theory
  approach.
• This approach presents developmental influences
  as four nested systems -
• Microsystems
• Mesosystems
• Exosystems
• Macrosystems
• These systems are reflected in the onion or
  rainbow framework of Dahlgren and Whitehead.

15
EXPLANATIONS FOR SOCIAL INEQUALITIES IN HEALTH

• There are several scientific explanations for
  social inequalities in health
• Psychosocial
• Neo-material
• Statistical artifact
• Health selection

16
EXPLANATIONS FOR SOCIAL INEQUALITIES IN HEALTH

• Lay explanations of social inequalities in health
  include peoples immediate social and physical
  environment.
• Inequalities found in terms of class, race and
  gender are linked with issues of social and
  material exploitation such as institutional
  racism, gender discrimination, corporate
  globalization, degradation of the environment,
  destruction of the public sector, etc.

17
EXPLANATIONS FOR SOCIAL INEQUALITIES IN HEALTH

• The persons living/working environments are also
  significant determinants of health.
• There is a growing interest in the role of social
  capital in explaining the social variations in
  health.
• Social capital refers to the degree of civic
  engagement, levels of interpersonal trust and
• norms of reciprocity within the society.

18
INEQUALITIES WITHIN POOR COUNTIRES

• Possible mechanisms
• Better health and social services
• Better education and literacy
• Cleaner environment, improved sanitation and
  water supplies
• Economic growth and employment opportunities
• Redistribution of wealth

19
Human Development Report, 2000

• As in earlier times, advances in the
• 21st century will be won by human struggle
  against divisive values and against the
  opposition of entrenched economic and political
  interests.

20
Aghion et al (1999)

• The question of how inequality is generated and
  how it reproduces over time has been a major
  concern of social scientists for over a century.
  Yet the relationship between inequality and the
  process of economic development is far from being
  well understood. (p.1615)

21
Study of growth and inequity in 21 developing
countries 1950-1985 (Lal and Myint, 1996)

• It might be expected that economic growth should
  lead to increasing prosperity for all and even to
  a reduction of inequalities.
• Lal and Myint found that, in all 21 countries
  studied, growth in income per capita led to the
  alleviation of mass structural poverty.

22
Inequity and growth

• Lal and Myint (1996) found that
• 1) Growth does trickle down, but that when
  growth collapses there is increasing poverty.
• 2)There is no clear connection between changes
  in inequality and growth performance.
• 3) Economic growth and inequality appear to be
  independent economic variables that are not
  causally related.

23
The impacts of poverty on health are caused by
the absence of

• safe water environmental sanitation
  adequate diet secure housing basic
  education income generating opportunities
• access to health care

24
World population increasing by 74 million per year

• It is estimated by the U.S. Census Bureau that
  from July 1 2004 July 1 2005 the world
  population is increasing from 6,377,641,642 to
  6,450,219,806, a 74-million increase. This is an
  average daily increase of around 200,000 people,
  the population of Southampton.

25
Two indices relevant to health inequalities

• The availability of clean drinking water
• The presence of sanitation

26
The expected population increase

• of approximately 50 in the next 50 years
• will reduce the supply of drinking water by
  33

27
Water, water everywhere, nor any drop to drink
Coleridge, Rime of the Ancient Mariner

• Natural supplies of water globally are
  distributed as follows
• Saltwater 97.5
• Freshwater 2.5
• of which
• 68.9 is locked in glaciers
• 30.8 is groundwater
• 0.3 is in lakes in rivers

28
World water shortage

• Water-borne diseases already kill one child every
  eight seconds
• Two-fifths of the world's people already face
  serious shortages, and water-borne diseases fill
  half its hospital beds.
• People in rich Northern countries use 10 times
  more water than those in poor Southern ones.

29
(No Transcript)
30
Water shortages currently exist in most places in
the South

• Cuba, Gujarat, China, Thailand, Pakistan,
  Mexico, Darfur, Ghana, Kampala, Fiji, Yemen,
  Trinidad and Tobago, etc

31
Global access to water and sanitation(SourceWHO)

• 18 (1.1 bn) have no improved water supplies
• 40.0 (2.4 bn) without basic sanitation
• Water-borne diseases (typhoid, cholera) are
  responsible for 80 of illnesses and deaths in
  developing world
• 2.1 mn people dies every year from diarrhoeal
  diseases (include cholera) associated with
  inadequate water supply, sanitation and hygiene

32
Study of the relationship between infant
mortality and asset wealth
Marks (2004) carried out secondary analyses of
data collected in a World Bank (2002)survey of
Demographic and Health variations across 44 poor
countries. Source Marks (2004) Chapter 4 of M.
Murray (ed.) Critical Health Psychology.
LondonPalgrave
33
Re-analysis of World Bank data

• Data from the Demographic and Health Surveys
  (DHS) programme of the World Bank (2002) were
  re-analysed.
• The DHS collect data on a large number of health,
  nutrition, population and health service
  utilization measures, as well as on the
  respondents demographic, social and economic
  characteristics.

34
DHS dataset

• The DHS are large-scale household surveys
  carried out periodically in 44 countries across
  Asia, Africa, the Middle East, Latin America and
  the former Soviet Union. The DHS use a standard
  set of questionnaires to collect individual,
  household and community level data.

35
SES/asset scores

• Socio-economic status is evaluated in terms of
  data concerning assets gathered through the DHS
  questionnaire that is typically answered by the
  head of each household. The asset score is
  generated from the households ownership of a
  number of consumer items ranging from a fan to a
  television and car dwelling characteristics such
  as flooring material type of drinking water
  source and toilet facilities used and other
  characteristics that are related to wealth status.

36
Scoring method

• Each household asset is assigned a weight or
  factor score generated through principal
  components analysis.
• The resulting asset scores are standardized and
  then used to define wealth quintiles.
• Each household is assigned a standardized score
  for each asset, where the score differed
  depending on whether or not the household owned
  that asset (or, in the case of sleeping
  arrangements, the number of people per room).

37
Quintiles formed

• Scores are summed for each household, and
  individuals are ranked according to the total
  score of the household in which they reside.
• The sample is then divided into population asset
  wealth quintiles -- five groups with the same
  number of individuals in each.

38
INEQUALITIES WITHIN COUNTRIES POOR COUNTRIES
Under 5 mortality rates in 22 countries in
sub-Saharan Africa across wealth quintiles (1
richest 5 poorest) (Source Marks, 2004).
39
Correlates of U5MR in 44 countries

• female illiteracy rates (0.69, plt.0001)
• the proportion of households having piped
  domestic water (-0.65, p lt.0001)
• the proportion of households using bush, field or
  traditional pit latrines (0.60, p lt.0001)
• the number of doctors per 100,000 people (-0.51,
  plt.0001)
• the number of nurses per 100,000 people (-0.35, p
  lt. 01)
• national health service expenditure (-0.33, p lt
  .01)
• immunization rates (0.27, p lt.05 )

40
Education and environmental factors strongest
predictors of infant health

• The 3 strongest predictors of low infant
  mortality rates are
• High literacy among females
• Widespread access to domestic water supplies
• Access to sanitation

41
Health service variablesare important but less
so than education, water and sanitation

• high numbers of doctors and nurses
• high immunization rates
• high health service expenditure
• are all associated with lower mortality
  rates

42
Mechanisms

• Better health and social services YES
• Better education and literacy YES
• Better sanitation and cleaner water supplies YES
• Redistribution of funds???
• Would any government dare, on the scale
  required to influence inequalities in health ?

43
A 3-step plan to eliminate global poverty

• Rich countries release poor countries from 100
  of their debt
• Trade justice
• Rich countries cut expenditure on defense by 50
  and transfer the freed-up military resources to
  improve water supplies, sanitation, and education
  in poor countries.

44
21 OECD countries in 1998 spent

• 0.24 GDP in official development assistance
  (ODA) US55.05 bn
• USA gave 0.10
• 2.2 of GDP on defence US504.65 bn

45
The War on Poverty is the real War on Terror

• Transferring 50 of military resources to ODA
  would enable world water shortages and sanitation
  issues to be solved (180 bn) and leave 70 bn
  for education and literacy programmes.
• Health inequalities would be significantly
  reduced if ODA could be raised by 1.0GDP and
  ring fenced for water and sanitation projects.
• Terrorism and wars are fuelled by poverty. The
  War on Poverty is the real War on Terror.

46
INEQUALITIES WITHIN COUNTRIES POOR COUNTRIES

• Poverty and ill-health are a vicious circle
• Ill-health causes Poverty
• and
• Poverty causes Ill-health

47
INEQUALITIES WITHIN COUNTRIES POOR COUNTRIES

• One major consequence of inequality is conflict,
  including full-scale war and terrorism.
• In the future, global warming may exacerbate the
  incidence of infectious diseases and shortages of
  food and water.
• One climate change scenario in Africa has
  predicted that there will be an additional 55 to
  65 million people at risk of hunger by the
  2080s.
• Currently, the number of people affected by water
  shortages is about 1.7 billion.

48
GENDER

• Gender differences in health, illness and
  mortality are significant and show striking
  interactions with culture, history and SES.

49
ETHNICITY

• The health of minority ethnic groups is generally
  poorer than that of the majority of the
  population.
• Possible explanations include racial
  discrimination, ethnocentrism, SES, behavioural,
  personality, and cultural differences, etc.
• Discrimination in the health-care system could
  exacerbate the impacts of social discrimination
  by virtue of reduced access to the system, poorer
  levels of communication and poorer compliance.

50
ETHNICITY

• Ethnocentrism in health services and health
  promotion marginalizes minority groups leading to
  lower adherence and response rates in comparison
  to the majority of the population.
• Differences in culture, language, lifestyle,
  health-protective and health-seeking behaviours
  are likely to compound the problems of racism and
  ethnocentrism.
• Health status differences related to race and
  culture appear to be partly mediated by
  difference in SES.

51
DISABILITY

• The experiences of people with disabilities are
  in many ways similar to experiences of other
  disadvantaged groups.
• The psychological effects of discrimination,
  prejudice and physical and social exclusion are
  likely to affect health outcomes negatively, over
  and above the affects of the disability itself or
  SES and poverty related factors.

52
SUMMARY

• The world population is exploding. It is
  predicted to reach 9 billion in 2050 and 11
  billion in 2100. Of 6.3 billion people alive in
  2005, approximately 5 billion (81 percent) live
  in developing countries.
• As the global population climbs to 9 billion by
  2050 the amount of drinkable water per person
  will fall by 33. The increased shortage will
  affect mainly the poor where the water shortage
  is already most acute. More than a billion
  people already lack portable water, and nearly 3
  billion lack even minimal sanitation.
• The greatest influence on health for the
  majority of people is poverty. Half of the
  worlds population lacks regular access to
  treatment of common diseases and most essential
  drugs. Globally, the burden of death and disease
  is much heavier for the poor than for the
  wealthy.
• In developed countries life expectancy is
  increasing by three months every year. If this
  trend continues, life expectancy will approach
  100 years by about 2060. If life expectancy
  increases in the 21st century to 85, 90 or even
  100, this will place our social security, health
  and pensions systems in a perilous position.
• Economic research suggests that the level of
  mass poverty tends to be reduced by economic
  growth but disparities in wealth are not.

53
SUMMARY (continued)

• 6 Health gradients are a universal feature of
  population health in both rich, developed and
  poor, developing countries.
• 7 If development is to proceed at the pace set by
  the UN Millennium Development Goals, wealthier
  countries must allocate more resources to
  development of poorer countries. Following the
  aims of the post-Jubilee 2000 movement, the
  international debts of the poorest countries
  ideally should be cancelled so that they can
  afford to spend more on health care and
  education.
• 8 Gender differences in health, illness and
  mortality are significant and show striking
  interactions with culture, history and SES.
• The health of minority ethnic groups is generally
  poorer than that of the majority of the
  population. Possible explanations include racial
  discrimination, ethnocentrism, SES differences,
  behavioural and personality differences, cultural
  differences and other factors. Discrimination in
  the health-care system could exacerbate the
  impacts of social discrimination .
• Ethnocentrism marginalizes minority groups
  leading to lower adherence and response rates.
  Differences in culture, language, lifestyle,
  health-protective and health-seeking behaviours
  compound the problems of racism and
  ethnocentrism. A critical approach to Health
  Psychology argues for a transformation of Health
  Psychology to encompass an agenda that is
  relevant to the struggle for justice of
  yesterday, today, and tomorrow.