Think
the health disparities between rich and poor are simply a matter of
unequal access to health care? Think again.
Health
disparities exist in the United Kingdom and other countries with universal
health coverage that should flatten differences. Disparities exist even in
the upper brackets, with Americans who make $500,000 a year enjoying fewer
health problems and longer lives than those making a still-hefty $100,000
a year.
"As
you move up the socioeconomic status hierarchy, your health prospects
continue to improve," says psychologist Norman B. Anderson, PhD, a
professor of health and social behavior at Harvard University's School of
Public Health and former director of the Office of Behavioral and Social
Sciences Research at the National Institutes of Health (NIH). "Why
that happens is the $100,000 question."
Now
psychologists are working to find the answer. Using new methodological
strategies, they're trying to figure out how a constellation of economic,
social and work factors--together known as socioeconomic status--affects
health. They're exploring ways to mitigate low status's negative effects.
And they're hoping to convince policy-makers and others that low status is
not only an economic problem but a health risk, too.
Linking
Status and Health
Epidemiological
studies have confirmed the relationship between income, education and
occupation on the one hand and health outcomes on the other. The
decade-long Whitehall study of 17,350 British civil servants, for example,
found that relative risk of death increased significantly as rank
decreased. The message is simple: The lower your socioeconomic status, the
greater your risk of both physical and psychological health problems.
Now
psychologists are trying to find out why. Behavioral and environmental
differences clearly play a role, since those at the lower end of the
socioeconomic spectrum tend to smoke more, eat worse and live in
unhealthier environments. But something more seems to be at work as well.
The hypothesis? Inequality itself contributes to health disparities.
"One
of the greatest advances of the last few years has been that
socio-economic status is now viewed as a determinant of health rather than
a mere correlate," says Anderson.
Instead
of controlling for socioeconomic status, researchers are beginning to
study it as an etiologic factor in its own right. Nancy E. Adler, PhD, for
instance, has developed a new measure of subjective social status. Adler,
a professor of medical psychology at the department of psychiatry and the
Center for Health and Community at the University of California at San
Francisco, asks people to identify their place on a socioeconomic ladder.
Not
surprisingly, says Adler, people's self-reported status turns out to be
correlated to objective indicators such as income and education. But, she
says, their self-reported status is even more highly correlated with
biological and psychological health outcomes.
In one
study, for example, Adler collected objective data about women's
socioeconomic status and then asked them on which rung of the
socioeconomic ladder they felt they belonged. She found that the women's
subjective assessments were more consistently and strongly related to
health factors, such as self-rated health, heart rate, sleep quality, body
fat distribution and cortisol habituation to repeated stress, than the
objective assessments.
Sheldon
Cohen, PhD, a professor of psychology at Carnegie Mellon University in
Pittsburgh, has used the socioeconomic ladder concept to study the impact
socioeconomic status has on the immune system's ability to ward off
infections.
Cohen's
interest grew out of a study of stress and susceptibility to
upper-respiratory infection among monkeys. Although stress had no effect
on the monkeys' susceptibility to the virus researchers exposed them to,
it turned out that their position in the monkey hierarchy did. The more
subordinate the monkey, the more likely it was to succumb to the virus.
Intrigued,
Cohen began studying the relationship between humans' perceived social
status and their susceptibility to infection. Participants in these
studies mark a rung on a picture of a ladder to show where they think they
are in terms of their community and their country. People who put
themselves on a low status rung were at very high risk of developing
infections.
"One
of the reasons we use the ladder is because standard measures of
socioeconomic status, such as education, income and occupation, miss a
lot," Cohen explains. "Think of someone who doesn't have much
education, much income or a good job but is a deacon in a church. That
person may have fairly high status in the community even though he would
come out as low status through traditional measures."
Cohen
has also taken a closer look at specific markers of social status. In one
study, for instance, he found that people who were underemployed or
unemployed were four and a half times more likely than other participants
to get sick when exposed to the cold virus.
Getting
'Under the Skin'
Other
researchers have zeroed in on the fact that members of ethnic and racial
minorities are more likely than whites to have low socioeconomic status.
To take just one indicator of socioeconomic status, the U.S. Census Bureau
reports that 1999 poverty rates were 26 percent for American Indians and
Alaska Natives, 24 percent for African Americans, 23 percent for Hispanics
and 11 percent for Asians and Pacific Islanders, compared to just 8
percent for whites.
Hector
F. Myers, PhD, a professor of psychology at the University of California
at Los Angeles, believes that racism increases the vulnerability of those
already struggling with low socioeconomic status. Myers has studied the
ways that racism-related stress gets "under the skin" to affect
the health of racial and ethnic minorities.
"We've
often chosen to focus on either ethnicity or class rather than on the
interaction between the two," says Myers. "We've become a lot
more sophisticated in our thinking recently."
According
to Myers, racism affects people's health through both psychological and
biological pathways. From a psychological standpoint, he says, racism has
a demoralizing effect that can undermine health and well- being. And it's
not just overt racism that renders people vulnerable, he says. Even more
debilitating are ambiguous incidents that leave people wondering what
really happened.
These
psychological effects then interact with biological processes, says Myers,
noting that anger, self-doubt and other emotions may result in hemodynamic,
endocrinological, immunological and other changes that lead to disease.
"I'm
not suggesting that exposure to a racist event necessarily leads to
hypertension," Myers explains, noting that the process is much more
insidious. "Instead it builds on existing biological vulnerabilities
people might have."
A
person with a family history of high blood pressure is already at risk of
developing hypertension, Myers points out. The stress of racism may add to
what Myers calls "cumulative vulnerability" and that person's
chances of succumbing to disease. Myers is planning to investigate whether
chronic exposure to racism even contributes to genetic mutations that
increase vulnerability.
Treating
'Socioeconomic Stress'
Other
psychologists are exploring ways to treat people suffering from
status-related stressors that may ultimately lead to physical problems.
Lauren E. Storck, PhD, a private practitioner in Belmont, Mass., and a
clinical instructor in the psychiatry department at Harvard Medical
School, is exploring ways to treat what she calls "socioeconomic
stress syndrome."
"This
is a psychosocial syndrome that combines features of depression and
anxiety along with a dissociative-like process," she says, explaining
that her theory is based on narrative data she and other researchers have
collected. "It's due to socioeconomic insults or injuries that have
not had a chance to be exposed, digested or talked about in a healing
place."
In our
supposedly classless society, Storck says, people find it difficult to
talk about class. As a result, people at both ends of the socioeconomic
spectrum can express class-related traumas only through psychological or
psychomedical complaints. Whether it's a new immigrant facing poverty and
discrimination or a recent widow facing a plummeting income, says Storck,
people need to be able to talk about these emotional wounds. It is crucial
not to blame the individual and to recognize this is a complex societal
issue.
Storck
is trying to help people do just that. In addition to teaching and working
with patients, she is planning research that uses small and large group
dynamics to help participants overcome socioeconomic stress.
On a
broader scale, NIH has issued a call to eliminate health disparities. This
NIH-wide initiative requires every NIH institute and center to come up
with a plan for addressing disparities.
For
Norman Anderson of Harvard, the NIH initiative is a hopeful sign. The next
step is to convince policy-makers and others that Head Start, job-training
programs and other interventions designed to increase socioeconomic status
are really health interventions. Debates about minimum wage and other
economic issues should factor health costs into their analyses, say other
psychologists.
"If
biomedical researchers found a pathophysiological process that was
predictive of every single health outcome under the aegis of NIH, there
would be an incredible, spare-no-expense effort launched to change that
pathophysiological process," says Anderson. "With socioeconomic
status, we have a social variable that's indeed predictive to all causes
of death. Shouldn't we be interested in ways to change socioeconomic
status in hopes of improving health outcomes?"
