Health Disparities Test 2

Methodological Individualism

"Although it is clear that education plays an especially powerful role in the selection of health lifestyle practices, income and occupational status join education as the major components of social class or socioeconomic status (SES).... The three variables are interrelated but not identical or fully overlapping.... So while education, income, and occupational status are characteristics of individuals, collectively they constitute a structural variable whose influence is evident when people express the tastes, distinctions, outlooks, behaviors, and lifestyles common to their class as a whole. Many view smoking as an individual decision, but... ⁃ Cockerham: "Not until smoking was banned in many public places did the prevalence of smoking significantly decline.... Anti-smoking laws, social isolation, and stigma significantly increased smoking cessation 'far beyond the results of purely individualistic approaches.'" Sometimes structure can completely overwhelm personal choice. ⁃ Welsh coal miners in 1930s = high morbidity and mortality rates due to punishing work, poor diets, unremitting childbirth and domestic labor, etc. ⁃ Cockerham: "Assuming people have the freedom to make healthy choices is out of line with what many people experience as real possibilities in their everyday lives."

Updates to the Sick Role

1) Definition of Illness ⁃ Newer research expands Parsons's model to include: ⁃ Contested illness (e.g., chronic fatigue syndrome, back pain). ⁃ Medicalization and demedicalization (e.g., hyperactivity, homosexuality, alcoholism). 2) Politics of Patienthood ⁃ Parsons's definition of patient = almost entirely in terms of relationship with physician. ⁃ BUT much of today's illness experience occurs beyond doctor-patient relationship. ⁃ Main context for health management = one's community (not hospital or doctor's office). ⁃ AND self-management is an important component of the illness experience. 3) Rise of Internet ⁃ Rier: "The Internet arguably constitutes the single greatest change in the experience of illness over the last two decades." ⁃ Extremely powerful tool for accessing information about symptoms, diagnoses, treatments. ⁃ Helps patients bypass physicians (and pressure to explain illness in terms of disease). ⁃ Global in reach and scope (not limited to face-toface support groups). 4) Expansion of Time Parsons's model of time = sick —> seek help —> get better ⁃ The illness experience contains more complicated dimensions of time, such as... A) Trajectories ⁃ Illness experience can include more than three stages for patient and family. ⁃ They can experience illness as interruption, intrusion, immersion, etc. B) Illness States ⁃ For Parsons, sick role commences with onset of physical restrictions. ⁃ Now more emphasis on preemptive or preliminary sick role. ⁃ Ex. patient can be HIV+ without symptoms of AIDS. C) Remission, Liminality, Survival ⁃ Remission = with modern medical advances, we have growing population of patients who are "chronically critical" (some level of remission places them between health and illness). ⁃ Liminality = illness may remove a person from prior life but NOT allow complete return to it (e.g., injury leading to longterm disability). ⁃ Survival = need more research on this; one example is antiretroviral therapy for HIV/AIDS that can lead to Lazarus Syndrome (brought back from brink of death).

Selection

2) SELECTION: People with poor health outcomes end up in the lower class. ⁃ Why? Two possibilities. ⁃ Drift hypothesis: Chronically ill people DRIFT into the lower class. ⁃ Residue hypothesis: Healthy people in the lower class achieve upward mobility and leave a RESIDUE of ill persons at the bottom of the hierarchy.

Class and nationality

Class and Nationality ⁃ Cockerham: "Other studies that explicitly investigate the social gradient in relation to various aspects of health include a comparison of the United States and England in which a steeper social gradient in health was found among Americans than the English." ⁃ Cockerham: "An even more extreme pattern of social disadvantage in health and longevity exists in Latin America, much of Asia, and especially Africa."

Class and Segregation

Class and Segregation ⁃ Research by Mary Shaw = segregation shapes the social gradient in mortality ⁃ Cockerham: "In Britain, where the various classes tend to be spatially segregated by neighborhood.... [researchers] found a social gradient in mortality reflected in housing patterns."

Intersectionality Theory

Based on work of African American feminist scholars (eg., Kimberle Crenshaw, Patricia Hill Collins). Intersectionality Theory: ⁃ From single categories of analysis to simultaneous interactions of social identity. ⁃ Cockerham: "The theory challenges any prioritization because it holds that all social structures are subject to the negative effects of capitalism, patriarchy, racism, and other discriminatory influences.... Since these systems or structures pervade all social relationships, the theory maintains that individual and group characteristics cannot be reduced to single variables (such as class or gender)." Issues with intersectionality theory: 1) Claims to broaden scope of variables, but is actually limited. ⁃ Focus = mainly on gender, race, sexuality. Less attention to class. 2) Almost no attention on disability, immigration status, etc. 3) It is difficult to separate effects of intersecting variables. 4) Cannot explain why statistical analysis shows that more variation in health outcomes is explained by class than by other structural variables. This is NOT to say that structural variables besides class are not important! ⁃ Rather the takeaway = class remains the primary—not the only—determinant of health outcomes (mortality and morbidity). ⁃ If class is so important, then we need to know what it is how to measure it.

Alzheimer's

Both Alzheimer's and mental illness have long been ignored in illness experience literature. ⁃ But that is beginning to change. Alzheimer's ⁃ Rier: "Such Alzheimer's patients occupy a liminal stage in which they remain aware enough to recognize and describe what is happening, and integrated enough into their pre-disease roles, networks, and identities to be able to mourn their losses."

Class and Stress

Class and Stress ⁃ Research by Robert Evans = stress shapes the social gradient in mortality ⁃ Higher the position in social hierarchy = better ability to handle stress (lessening its effects on the body) ⁃ Cockerham: "The level of stress experienced, the amount of resource available to cope with stress, and the degree of control over one's life situation all vary by social class position

Education and Health

Catherine Ross and John Mirowsky's "Why Education Is the Key to Socioeconomic Differentials in Health" What role does education play in creating health? ⁃ Ross and Mirowsky: "Education creates most of the association between higher socioeconomic status and better health because education is a root cause of good health.... Education increases physical functioning and subjective health among adults of all ages and decreases the age-specific rates of morbidity, disability, and mortality." What mechanisms link education and health? ⁃ Work and economic conditions (e.g., status, creativity, autonomy, income, economic hardship) ⁃ Social psychological resources (e.g., sense of personal control, social support) ⁃ Health lifestyle (e.g., smoking, exercise, weight, use of medical services) Could the relationship between education and health be spurious? ⁃ Most research finds education —> health (not the other way around). ⁃ Some economists argue that the education —> health relationship is spurious (because IQ causes BOTH education AND health) ⁃ Ross and Mirowsky: "More realistic lifecourse analyses posit paths in both directions: early childhood conditions, social and genetic, predispose people to better health and higher levels of education, and better childhood health leads to more education. In turn, higher levels of education improve adult health, independent of childhood traits, and also link some of the effect of childhood conditions to adult health." How does education improve health? ⁃ Two possible (but not exclusive) answers: education = 1) human capital or 2) commodity.

US Healthcare

Class = strongest and most consistent social predictor of health and longevity in the U.S. and around the world. ⁃ Poorest = worst health outcomes and shortest lives Ex. Coronary heart disease ⁃ Leading cause of mortality in U.S. ⁃ Has declined for all Americans, but greatest decrease for middle and upper classes. ⁃ 50-60 years ago = heart disease associated with affluence (e.g., rich diets, smoking, well-paid but stressful jobs) ⁃ BUT affluent became more knowledgable about heart disease, shifted lifestyle, adopted preventive care, used pharmaceuticals (e.g., lower low-density lipoprotein cholesterol levels). Ex. Mental health ⁃ Lower class = highest overall rates of mental disorders (including schizophrenia). ⁃ Exception to the trend = anxiety and mood disorders more prevalent among upper and middle classes ⁃ Cockerham: "Whether the disparities in mental health are due to genetics or greater stress in coping with the deprivations of lower class living or a combination, or another variable is not known." America has fee-for-service medical care delivery system, which requires cash or insurance. ⁃ Lower classes typically lacked resources to access this health care delivery system. Medicare and Medicaid ⁃ 1965 = passage of two federal health insurance programs: ⁃ Medicare (for over 65) and Medicaid (for lowest incomes) ⁃ Cockerham: "The passage of these two health insurance programs over the strong objection of the American Medical Association, who wanted to keep government out of medicine, signaled a turning point in medical politics: the federal government emerged as a dominant actor in health care delivery for the first time. With these new insurance programs: ⁃ Lower classes started (and continue!) to replace middle class as strata with most physician utilization. ⁃ Lower classes have higher rates of morbidity and see doctors more often—but delay care seeking until health worsens (partly due to lack of treatment facilities in poor neighborhoods). ⁃ Introduced a two-tiered medical system: private and public Public System ⁃ Cockerham: "The public track is a system of welfare medicine supported by Medicare and Medicaid. The urban poor have traditionally been dependent on public —state, county, or municipal—hospitals and clinics, and this situation has not changed. Often these facilities are underfinanced, understaffed, and overcrowded with patients. Few hospitals exist in innercity areas or neighborhoods populated by the poor. The rural poor have problems of access, as doctors and hospitals may not be readily available where they live." Affordable Care Act of 2010 ⁃ Pre-existing conditions no longer used to deny coverage. ⁃ All plans had to provide a minimum level of benefits. ⁃ State insurance exchanges set up to provide competitive plans. ⁃ Businesses with more than 50 workers fined for not providing plans. ⁃ Government subsidies to help low-income persons purchase plans. ⁃ Medicaid expansion to cover more poor people (which could be rejected by states). ⁃ Children could remain on parents's plans until age 26. ⁃ Most Americans required by law to purchase health insurance. ⁃ NOTE: Supreme Court upheld constitutionality of law by 5-4 in 2012.

Class and Biomedicine

Class and Biomedicine ⁃ What about the notion that it's disease alone—not class—that causes people to experience illness? Let's look at two studies for evidence that class —> illness. 1) Research by Lee Hamilton and colleagues contrasted health outcomes of auto plant workers who lost jobs vs. those who did not. ⁃ Cockerham: "Among the workers who lost their jobs, those who were racial minorities and especially of low SES suffered the greatest adverse health consequences. The illness conditions of the workers did not cause the plant closing; rather, the plant closing had caused the illness conditions of the workers." Class and Biomedicine cont. 2) Research by Lutfey and Freese on diabetes ⁃ Cockerham: "Lutfey and Freese (2005) were able to successfully demonstrate how high SES diabetic patients controlled their blood sugar levels significantly better and had better survival prospects than patients from socially disadvantaged backgrounds. Again, in each study, it was not a particular disease causing the different health outcomes, but class position."

Culture

Class can influence health through culture. What is culture? ⁃ Cockerham: "Cultures are ways of living that have been passed on from one generation to the next in the form of abstract ideas, norms, habits, customs, and in the creation of material objects, such as food, dress, housing, art, music, automobiles, and various other items. Culture thus refers to a body of common understandings that represent what groups of people and societies think, feel, and act upon. The knowledge, believes, values, customs, and behaviors shared by people in a particular society reflect the culture of that society." How does culture influence health? ⁃ Culture influences health related behavior (lifestyles). ⁃ Ex. Gender gap in mortality in 2009 = 12.1 years (longer for females) in Russia compared to 5.0 years in U.S. ⁃ Explanation = men's unhealthy lifestyles in Russian culture ⁃ Historically, Russian male agricultural workers binge drank on Sundays and holidays How did a cultural change produce a health change? ⁃ Cockerham: "However, during the Soviet period religion was suppressed and heavy consumption became common any day of the week in both urban and rural areas.... This practice has evolved through socialization and experience to become an established disposition toward drinking reflected in the habitual outlook of many Russian men. It is reproduced over time and in subsequent generations by its continual practice and has become a cultural norm. Moreover, the integration of massive numbers of peasants into an urban working class under communism reinforced this drinking style as a working-class cultural trait that spread throughout society." How do we know that culture rather than stress or gender is at work? ⁃ Stress certainly played some role; but both working-class men and women were stressed. ⁃ Main culprit = Russian men's negative health lifestyles (i.e., heavy drinking and smoking, high-fat diet, lack of exercise). ⁃ Cockerham: "Female drinking and smoking practices are consistent with working-class norms that approve of such behaviors for males and not females." ⁃ THUS... culture is the explanation for the health differences by gender. Why did working-class lifestyles spread but middleclass lifestyles did not (as we've seen in the U.S.)? ⁃ Cockerham: "While the middle-class—primarily the upper-middle class—has been responsible for the expansion of positive health lifestyles in Western society, a similar process has not occurred in Russia. Why? The best answer is that a middle class similar to that of Western countries does not yet exist."

Inequality (Relative Income Theory)3

Class can influence health through inequality. Relative Income Thesis ⁃ Based on work of British scholar Richard Wilkinson ⁃ Focus on health of entire societies (not just individuals) Basic argument: ⁃ Cockerham: "He suggests that a person's position relative to other people in the social hierarchy can be determined by their relative incomes, and that the psychosocial effects of the different social positions have health consequences. In his view, stress, poor social support networks, low self-esteem, depression, anxiety, insecurity, and loss of a sense of control are reduced and social cohesion is enhanced when income levels are more equal." So far so good. But here's where we run into trouble. ⁃ Cockerham: "While it is an established fact that people with low incomes have worse health and shorter lives than those with high incomes, Wilkinson claims that relative levels of income within a society have greater effects on health and mortality than the society's absolute level of wealth." ⁃ No. Actually, Wilkinson does not claim that. His evidence demonstrates that developed nations' per capita incomes are unrelated to health outcomes. This is a bit better. ⁃ Cockerham: "Countries with the most wealth may not have the longest life expectancy; instead, the best health and longevity is to be found in those nations with the smallest differences in income levels and smallest proportion of the total population living in poverty. This is seen in countries like the United States, for example, that have wide disparities in income and lower life expectancy than countries like Sweden, where income is more evenly distributed and life expectancy higher." ⁃ Wilkinson ALSO demonstrates this same relationship between inequality and health within individual states of the U.S. But this is just a mess. ⁃ Cockerham: "But the most recent research does not confirm Wilkinson's results. One problem is that data from developing countries do not show the same pattern.... This situation limits the utility of relative income theory to developed countries." ⁃ Uh... yeah... and Wilkinson goes out of his way to make it clear that the thesis only applies to developed nations. What if the differences between underdeveloped and developed nations require different theories to explain their health outcomes? Who says that one theory must explain both? That's like demanding that physicists explain solar systems using quantum theory. Finally... here's a critique to take seriously. ⁃ Cockerham: "But new studies conducted in countries with high per capita income likewise failed to find a significant association between income inequality and health.... It cannot be proven that reducing income differences will reduce health differences and the likelihood of wealth being redistributed in capitalist countries to test this outcome is virtually nil. Even in Sweden, where social equality in income and living conditions is perhaps the best in the world, the lower class has the poorest health and shortest life spans." ⁃ But note... these findings do not necessarily mean that Wilkinson is incorrect... simply that he has not yet been corroborated by often more conservative researchers. Conclusion on relative income theory: ⁃ Cockerham: "As a fundamental cause of health, we know that class operates through a variety of pathways and income inequality qualifies as only one of these paths." ⁃ Agreed.

Obesity

Class can influence health through obesity. ⁃ Cockerham: "The lower an individual's income, the more likely they are to be obese and this is especially true for blacks and to a lesser extent for Hispanics in the United States." ⁃ Obesity = both unhealthy and stigmatized But don't genetics determine bodyweight? ⁃ Cockerham: "While the causes of obesity are complex, involving a variety of factors, including genetics, we find that once again class position from high to low inversely matches the distribution of a negative health condition from much less (at the top) to much more (at the bottom)." What are the social factors associated with obesity? ⁃ Highest rates of obesity = lowest incomes and least education (esp. among women and ethnic minority groups) ⁃ Obesity = linked specifically to poor diets What mechanisms link class and obesity? ⁃ Cockerham: "Barry Glassner suggests that poor Americans are disproportionately overweight because during the decades their rates of obesity increased, so did their economic hardships and financial insecurity. He suggests that higher stress levels resulting from this situation cause the body to produce less of a growth hormone that reduces fat and increases the body's metabolism that provokes cravings for soothing comfort foods like glazed donuts and chocolate fudge ice cream. What mechanisms link class and obesity? cont. ⁃ Cockerham: "Glassner further suggests that poverty promotes binge eating, in that when low-income persons have enough money they indulge in calorie-rich foods. Over time, the body adapts to this situation by storing more fat. Other factors, like the decline in the family meal, fast-foods, drinking sodas as snacks in schools, and a lack of exercise also contribute to obesity among poor children and adults." What mechanisms do NOT appear to link class and obesity? ⁃ Obesity = not linked to fast-food proximity ⁃ Obesity = not linked to limited access to affordable healthy foods (in Great Britain) ⁃ Cockerham: "Food preferences and eating habits along class lines appear to be powerful influences on food selection."

Smoking

Class can influence stress through smoking. Choice to smoke = an exercise of agency (personal choice)—but not independent of structure. ⁃ Cockerham: "Structure intervenes in this decision as distinct difference persist between classes, suggesting that decisions about smoking are not entirely an individual matter. In the United States, for instance, the Center for Health Statistics reported in 2010 that adults with high school education are twice as likely to smoke as those with a bachelor's degree and nearly five times more likely to smoke as those with a graduate degree." Viewing smoking as ONLY an act of agency —> victim blaming ⁃ Cockerham: The reasoning is that if people choose to smoke, what happens to them physiologically is no one else's fault but their own. This approach (blaming the victim)... is not helpful, since it fails to account for the underlying reasons why socially disadvantaged people are attracted to smoking and the nature of the social conditions that reinforce this behavior." ⁃ Social factors that induce smoking = adverse economic conditions, deprivation, stressful circumstances, growing up with smoking parents, having a smoking spouse, socializing with smokers ⁃ Of course... people with higher SES do sometimes smoke (but probably due mainly to stress).

Critical Illness

Critical Illness ⁃ Most illness experience literature focuses on chronic—not acute and critical illness. What's the difference? ⁃ Chronic illness typically involves struggle to integrate illness into daily routine. ⁃ Critical illness typically is likelier to replace one's existing daily routines. Why the lack of research on critical illness? ⁃ Rier: "A major reason for the lack of focus on the ICU patient experience is the significant methodological difficulty in studying these patients. ICUs have high mortality rates, many survivors are too weak to be interviewed, and many remember very little of their experiences, particularly given the heavy sedation they often receive." One solution = ICU diaries = daily summaries completed by nurses and family members on behalf of patients ⁃ Most of this work is done by clinicians with little reference to resources of medical sociology.

Class Structure (Current Med Soc)

Current medical sociology = five classes 1) Upper class (extremely wealthy top corporate execs and professionals) 2) Upper-middle class (affluent, well-educated, professionals, high level managers) 3) Lower-middle class (office and sales workers, small store owners, teachers, nurses) 4) Working class (skilled and semi-skilled workers, lower-level clerical workers) 5) Lower class (semi-skilled and unskilled workers, unemployed)

Illness Experience

David Rier on "The Patient's Experience of Illness" Major questions: ⁃ What is it like to be sick? ⁃ What happens when someone gets sick? To answer these, we must know the difference between disease and illness. Disease vs. Illness DISEASE = physiological, clinical entity approached by physicians in objective, empirical way. ILLNESS = subjective, lived experience of patients (and families, social networks). ⁃ Can include fear, suffering, hope, stigma, support, shame, etc. ⁃ Physicians often use techniques such as interruptions to guide patients away from speaking of illness and toward describing disease in the framework of biomedicine. Most research on illness experience on chronic illness. ⁃ Ex. focus on coping with daily regimens (e.g., medication, exercise, therapy). ⁃ First major statement on illness experience = Sick Role

Health as an Achievement

Defining Health ⁃ Health used to be thought of as a given (i.e., either you turned out to be healthy or you did not). ⁃ Three more current approaches: health = normality, absence of disease, ability to function ⁃ Thus today health is often seen as an achievement (i.e., people must work to enhance or protect it) How did health move from a given to an achievement? 1) Disease Patterns 2) Modernity 3) Social Identities

Class Structure (Early Med Soc)

Early medical sociology = three classes 1) Upper class 2) Middle class 3) Lower class

Education as Human Capital

Education improves health by providing benefits beyond economics. ⁃ Ex. creative work, sense of personal control, health lifestyles ⁃ Ross and Mirowsky: "The concept of human capital implies that education improves health because it increases effective agency on the part of individuals, that is, education develops habits, skills, resources, and abilities that enable people to achieve a better life.... Human capital theory posts an effect of education on health over and above the good jobs that pay well and provide health insurance and the other economic benefits that stem from education." Health Lifestyles ⁃ Education makes people more effective users of information... ⁃ Which enables educated people merge unrelated habits into a coherent healthy lifestyle. Sense of Personal Control ⁃ Education increases people's sense of agency and personal control... ⁃ Which motivates educated people to design their own lifestyles, including health lifestyles. Creative Work ⁃ Education minimizes people's need to trade freedom (autonomous self-expression) for money (paid work)... ⁃ Which enables people to use their time and energy in health-promoting ways. Stress (not commodity) is the link between education and health. ⁃ Ross and Mirowsky: "Economic well-being forms a link between education and health, but mostly not in support of the commodity perspective. Individuals and societies cannot get healthier buying more or better medical interventions. However, poverty and economic hardship are stressful in themselves and they bring a sense of powerlessness, helplessness, and failure.... The sense of helplessness undermines the motivation to find and adopt healthy lifestyles.... Economic hardship directly undermines health. Household income also boosts the sense of personal control, which is associated with a healthy lifestyle, and in turn with good health. Thus, education increases the sense of personal control directly and indirectly by way of household income." What are the models for this approach? ⁃ High education —> high income —> much personal control —> healthy lifestyle —> good health ⁃ Low education —> low income —> stressful powerlessness —> unhealthy lifestyle —> poor health So is poor health due to "structural disadvantage" or "individual responsibility?" Yes! ⁃ Ross and Mirowsky: "In the theory of learned effectiveness, a low sense of personal control, smoking, being overweight, and a sedentary lifestyle are not explanatory alternatives to structural disadvantage. A low sense of personal control and an unhealthy lifestyle form the mechanism of structural disadvantage connecting low education to poor health." How does age affect the influence of education on health? ⁃ Health disadvantages of the poorly educated increase as their age advances. What is the overall conclusion reached by the authors? ⁃ Ross and Mirowsky: "Educational attainment is a root cause of good health. Education gives people the resources to control and shape their own lives in a way that protects and fosters health. Apart from the benefits to their own health, well-educated parents transmit resources to their children, including habits such as walking regularly and not smoking, which ultimately improve adult health status. Yet health policy makers typically do not view improved access to education as a way to improve the health of the U.S. population. Instead they usually view improved access to medical care as they way to decrease inequality in health, despite the fact that countries with universal access to medical care have large social inequalities in health. Perhaps policy makers should invest in educators and schools, not just doctors and hospitals, for better health."

Disease Patterns

Epidemiological transition = from acute to chronic illness (e.g., heart disease, cancer, stroke, diabetes) as major source of human mortality in most areas of world. ⁃ Chronic illness cannot be cured by medical treatment, but can be influenced by lifestyle (e.g., smoking, alcohol, drugs, diet, unprotected sex). ⁃ Cockerham: "The result has been greater public awareness that medicine is not the automatic answer to all health situations.... [This realization] carries with it the revelation that the responsibility for one's health ultimately falls on oneself through healthy living."

Class Structure (Cockerham)

Explanation of class by Cockerham: ⁃ CLASS:"A social class is a category or group of people who have approximately the same amount of wealth, status, and power in a society." ⁃ STRATIFICATION: "The various classes are arranged in a hierarchical pattern from top to bottom and constitute a layered system of social stratification." ⁃ RESOURCES: "The pattern is one of inequality in which classes at the top have superior living conditions and greater access to quality goods and services while those at the very bottom have none of these things." ⁃ OPPORTUNITIES: "The relevance of social inequality in the daily lives of most individuals is that it determines their personal opportunities and life experiences in very powerful ways." ⁃ POVERTY: "To be poor by definition means having more of the bad things in life and fewer of the good things, including health."

Gene Environment Interaction (Perrin and Lee)

Five criteria for evaluating measures of environmental effects in behavioral genetics: Andrew Perrin and Hedwig Lee (2007) 1) It cannot simply assume that environment constrains genetic expression. Particular environments may very well be the "natural" or (particularly in humans) the strategic production of actors or groups. 2) Similarly, environment must be conceptualized as potentially enabling as well as constraining. 3) Both environments and genetic potentials must be understood as nested and cross-cutting in potentially complex ways. That is, environments interact with, and exist within, other environments. 4) Because genetic and environmental influences may iterate overtime, small differences may matter—that is, small and even immeasurable environmental influences may have substantial influences on outcomes, particularly over multiple iterations. 5) Because evolutionary time is very slow, change observed within historical time must be (mostly) the result of environmental change. ⁃ Each of these points can be understood as increasing the level of uncertainty in the measurement and interpretation of genetic and environmental data. Although we maintain no general preference for uncertainty, the sociological research strongly supports more uncertainty than is generally expressed in behavioral genetic research.

Four examples of geneticization

Four examples of geneticization: 1) Genetic reductionism = causation of all human differences is limited (or reduced) to genes 2) Genetic determinism = genes inevitably cause (or determine) human traits and behaviors 3) Genetic essentialism = genetics as dominant (or essential) way to discuss fundamental life issues (e.g., responsibility, power, intellect, emotion) 4) Genetic fatalism = once expressed, genetically caused traits and behaviors are fixed and unchangeable (or fated)

Life Choices (Agency)

From where does agency come? ⁃ Primary socialization, secondary socialization, and socialization experience provide the CAPACITY for life choices (or agency). How does agency matter for health lifestyles? ⁃ Cockerham: "Life choices are a process of agency by which individuals critically evaluate and choose their course of action."

Class and Medical Care

Gradient in health and mortality = universal and enduring ⁃ This raises possibility = introducing quality medical care to those lower in the hierarchy could change the social gradient in health and mortality. ⁃ We have a natural experiment with this very concept = National Health System in Great Britain in 1948 ⁃ Why is this important? NHS evened the playing field concerning medical services but left respective social circumstances the same. Black Report (1980) = proof that health care alone cannot eliminate or reduce class differences in health ⁃ Yes, health and life expectancy of entire nation improved. (Good news!) ⁃ BUT gap between upper and lower classes WIDENED! ⁃ Lower class = highest rates of illness, disability, infant mortality and lowest life expectancy, use of prenatal and preventive care ⁃ Cockerham: "Although medical treatment was equalized and subsequently utilized more often by the poor, their use of services was directed largely toward treatment rather than prevention." What caused class differences to persist? ⁃ According to Black Report = socioeconomic environment (e.g., smoking, work accidents, overcrowding, poor living conditions, overexposure to cold and dampness). ⁃ Update to Black Report a decade later (1990) = found same conditions persisted. What are the conclusions of the Black Report? 1) DEATH = Cockerham: "Those at the bottom of the social scale have much higher death rates than those at the top." 2) DISEASE = Cockerham: "Neither is it just a few specific conditions that account for these higher death rates. All the major killer diseases now affect the poor more than the rich." 3) EMPLOYMENT = Cockerham: "The unemployed and their families have considerably worse physical and mental health than those in work." MEDICINE ALONE CANNOT SOLVE HEALTH DISPARITIES. ⁃ Cockerham: "Whereas improved access to quality medical care by the lower class has undoubtedly assisted many of the poor in having better health relative to people in the classes above them, the fact remains that medicine alone has not been able to reduce the disparity in health between the British social classes. This is because living conditions and negative lifestyles could not be equalized as well." Medicine alone cannot solve health disparities BECAUSE IT DOES NOT RESHAPE ENVIRONMENTS. ⁃ Cockerham: "After the poor are treated by physicians for their ailments, they return to their usual social environments featuring dwellings that are damp, inadequately heated, and perhaps moldy and infested with lice and mites, in which colds, bronchitis, skin diseases, allergies, and other ailments are commonplace." Medicine alone cannot solve health disparities because it does not reshape environments AND HEALTH LIFESTYLES. ⁃ Cockerham: "They still consume the same less-healthy diets lacking fresh fruits and vegetables and featuring high-fat meats and fried cheap foods, lack exercise, and either smoke and heavily consume alcohol or live where exposure to the smoking of others or the adverse consequences of drunkenness like accidents and violence are likely. In circumstances such as these, the capability of medicine to intervene to produce good health is significantly undermined."

Health Behaviors

Health behavior is the activity undertaken by people for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image." ⁃ Health behaviors are the opposite of risk behaviors (e.g., good nutrition vs. bad nutrition). ⁃ Health behaviors are related, such that people who behave unhealthily in one area are more likely to do so in another. ⁃ Self-care = individual health behaviors

British Healthcare

Health record keeping = started in 1851 with first Registrar-General's Occupational Analysis ⁃ Class differences observed in this data have persisted through 21st century. ⁃ Life expectancy of entire population has risen. ⁃ BUT social gradient in mortality, morbidity, and injury by class across all ages has persisted. ⁃ Black Report (1980) = gap in mortality is widening between top and bottom earners. What causes the differences between classes? ⁃ Cockerham: "The reasons for this development were social and due to differences in living conditions and class-based health lifestyles with respect to alcohol use, smoking, diet, and exercise—especially leisuretime exercise unaccompanied by the stress and strain of manual labor and deadlines, quotas, demands, and schedules for physical outputs mandated by others. More judicious use of physician services, particularly preventive care by the affluent, was also important." National Health System in 1948 ⁃ Brits introduce socialized medicine, giving everyone equal access to health care. ⁃ Why didn't that equalize health outcomes by class? ⁃ Cockerham: "All classes experienced an improvement in health, but class differences remained. The adverse effects of unhealthy living conditions and lifestyles could not be overcome by medical care alone."

Socialization Experience

How are people socialized? 1) Primary socialization = imposition of society's norms and values on an individual by significant others (e.g., parents). 2) Secondary socialization = later training in life (reinforces and/or updates norms and values learned as a child) 3) Socialization experience = practical, learned outcome of day-to-day activities that arise through social interaction and exercise of agency

Education

How does education influence health outcomes? ⁃ Cockerham: "Education provides individuals with critical thinking useful in producing health and that the more educated are more likely to adopt and use new medical technologies and drugs, [which means that we need] future research to determine more precisely the pathways by which education influences health." But aren't more people becoming educated in developed nations? ⁃ Yes. Example = 9% of UK had university degree in 1960s vs. 40% today. ⁃ But this has NOT led to disappearance of class differentials in health outcomes. Why isn't the expansion of education equalizing health outcomes? ⁃ Children of all classes have participated in the expansion of education. ⁃ BUT there is still a strong connection between class origins and relative probabilities of attaining higher education. Main exception to this rule = Sweden (and somewhat in Netherlands and Germany). ⁃ Cockerham: "Therefore, the children of upper- and upper-middle class parents in almost all countries are still significantly more likely to acquire a university-level education, while children from less advantaged classes remain less likely to seek and obtain ambitious educational credentials." Does gender figure into this trend? ⁃ Yes! Since the 1970s, women have equalled or surpassed men in educational attainment in developed nations. ⁃ Cockerham: "So the expansion of education has not meant the children from less advantaged families are catching up with the children from more advantaged backgrounds in their average levels of education, but rather that daughters in families across the class structure are rapidly catching up with sons." What is the significance of persisting class differentials in education? ⁃ Class differentials in education —> class differentials in health ⁃ Highly educated people (esp. university) = better health, better info about merits of healthy lifestyle (e.g., exercise, not smoking, moderate drinking, healthy diet, preventive care), and better jobs (e.g., well-paying, personally satisfying) Does the relationship between education and health change over time? ⁃ Yes! Cockerham: "This relationship, in fact, gets stronger over the life course—producing a cumulative effect—as less educated persons have increasingly more sickness and die sooner than the well-educated."

Class Structure (Marx)

How many classes are there? Karl Marx = three classes 1) Bourgeoisie (owners, managers) 2) Petit bourgeoisie (merchants, traders) 3) Proletariat (workers)

International Comparison

International comparison of health care systems can reveal the connections between class and health. ⁃ Ex. Great Britain and the U.S. have different health care systems. ⁃ BUT class influences health similarly in both nations. What will we discover when we compare these societies? ⁃ There are multiple pathways between class and health outcomes (e.g., stress, culture). ⁃ People do have individual choice (agency) when it comes to health lifestyles (e.g., smoking, diet). ⁃ BUT according to Cockerham: "Class provides some individuals more options than others making it difficult if not impossible to avoid the structural constraints and enablements associated with social hierarchies."

Lifestyle and Class

Lifestyle and class: ⁃ Whereas Thorsten Veblen portrayed lifestyles as modes of leisure adopted by upper classes, ALL classes have a lifestyle. ⁃ Giddens: "The notion of lifestyles sounds somewhat trivial because it is so often thought of solely in terms of superficial consumerism: lifestyles as suggested by glossy magazines and advertising images. But there is something much more fundamental going on than such a conception suggests:... Giddens: "In conditions of high modernity, we all not only follow lifestyles, but in an important sense are forced to do so—we have no choice but to choose. A lifestyle can be defined as a more or less integrated set of practices which an individual embraces, not only because such practices fulfill utilitarian needs, but because they give material form to a particular narrative of self-identity."

Age

People tend to take better care of their health as they age. ⁃ How? Greater care about food selection, more rest and relaxation, less alcohol and smoking. ⁃ BUT also less exercise. ⁃ Health lifestyles reflect intersection of age and class. ⁃ Ex. significantly more smoking among lower SES teens. ⁃ Which means that class produces differences WITHIN age cohorts.

Class Structure (Weber)

Max Weber = four classes 1) Greatly privileged (by property or education) 2) Highly educated but less propertied (intellectuals, white collar, civil servants) 3) Lower-middle class 4) Working class

Class vs. SES

Max Weber = stratification is multidimensional ⁃ Class (economic), status (honor), party (power) What has been Weber's influence on the study of stratification in the U.S.? ⁃ Cockerham: "Weber's influence on modern studies of social stratification is seen in the widespread use of socioeconomic status (SES) in American sociology to determine a person's position in society. SES typically consists of measures of income, occupational prestige, and levels of education. The advantage of using this scheme in quantitative studies is that the income, occupation (through the use of scales ranking occupational prestige), and years of education of an individual or head of household can all be assigned numbers with values that can be used What is the basic difference between class and SES? ⁃ Class is segmented. SES is continuous. ⁃ Class is a categorical variable. SES is a continuous variable. Which component of SES is the most influential? ⁃ Cockerham: "While income and occupational rank are important, American studies often show that education is the strongest single SES predictor of good health." ⁃ BUT note that high education does NOT operate alone.

Mental Illness

Mental Illness ⁃ Rier: "Despite such studies, we still know comparably little about the experience even of such common conditions as schizophrenia and phobia. Additionally research is needed to examine more fully such questions as: How does society label and stigmatize the mentally ill? How do they manage their disease across its particular trajectory? Do they attempt to resist their diagnosis and its attendant stigma? If so, how successfully? How do these patterns vary by gender, class, and ethnicity?"

Practices (Action)

Practices can be based on calculation, intuition, or— most often—habit. ⁃ Health practices are often integrated into routine behavioral repertories. What are the most commonly measured practices? ⁃ Alcohol use, smoking, diet, exercise (seen in box 7). ⁃ Others include getting checkups, wearing seat belts, etc.

Weber and Lifestyles

Provides insight into how behaviors aggregate into lifestyles. ⁃ Status groups are stratified by their consumption. ⁃ Status groups arise as people with similar life chances adopt similar lifestyles. ⁃ Thus lifestyles are not individual but aggregate The dialectical relationship between life choices (agency, voluntary) and life chances (structure, esp. class position) produce behavioral outcomes (including decisions about diet, exercise, smoking, alcohol, drugs, preventive checkups). ⁃ Cockerham: "Health lifestyles are a form of consumption in that the health that is produced is used for something, such as a longer life, work, or enhanced enjoyment of one's physical being."

Geneticization

Sara Shostak and Jeremy Freese's "Gene-Environment Interaction and Medical Sociology" How much human variation is caused by genetics alone? ⁃ Problem = genetics can be seen as a rival explanation to SES as a fundamental cause of health outcomes. ⁃ Example = Shostak and Freese: "The notion that lung cancers were invariably genetically determined—and so any relationship between smoking and lung cancer had to reflect a common genetic cause—was the main alternative to justify doubt that smoking causes cancer." Solution = focus on gene-environment interaction ⁃ Shostak and Freese: "Whether a genetic predisposition actually makes a person sick depends on the interaction between genes and the environment What is geneticization? ⁃ Lippman: Geneticization = "an ongoing process by which differences between individuals are reduced to their DNA codes, with most disorders, behaviours, and physiological variations defined, at least in part, as genetic in origin." ⁃ Similar medicalization = ever more conditions explained by reference to genetics

Agency vs. Structure

Schemas = transferable rules or procedures applied to social life ⁃ Resources = can be human (e.g., physical strength, mental knowledge) or non-human (e.g., natural, manufactured) What is the balance of agency and structure in determining individual behaviors? ⁃ Cockerham: "Individual choices in all circumstances are confined by two sets of constraints: (1) choosing from among what is available and (2) social roles or codes telling the individual the rank order and appropriateness of preferences. People do have the capability to act independently of the social structures in their lives, but the occasions on which they do so appear to be rare. Cockerham: "While agency is important, it will be argued that social structural conditions can act back on individuals and configure their lifestyle patterns in particular ways. Agency allows them to reject or modify these patterns, but structure limits the options that are available. This is not to say that considerations of agency should be minimized, but agency is not the whole story. In many situations it is not dominant and can even be passive

Questioning Class

Should we stop using class as a variable? ⁃ Some believe class = outmoded 19th century concept becoming less relevant as we proceed into late modernity. ⁃ BUT empirical evidence = class position has important influence on health outcomes. Whitehall Studies = evidence that mortality has a social gradient ⁃ Michael Marmot's Whitehall Study (1984) of mortality rates of 18,000 British male civil servant employees ⁃ Cockerham: "Regardless of the cause of death, those with the highest occupational rank had the lowest percentage of deaths, and the percentages increased the lower the rank, with the lowest-ranked occupations having the highest percentage of deceased civil servants." ⁃ Marmot repeated the Whitehall Study (1991), including women = found same social gradient. Whitehall Studies = evidence for relative (rather than absolute) deprivation ⁃ Cockerham: "An intriguing aspect of this research is the finding of a social gradient linked to differences in hierarchy rather than [absolute] deprivation. As noted, all of the these persons had stable, secure, and hazard-free jobs. They were all white-collar workers, most were Anglo-Saxon, many wore the same dark suits and had similar haircuts, and almost everyone was middle class." ⁃ This trend is found in the wider society, with each class living longer and having better overall health than the ones below. Whitehall Studies = evidence that environment is the social mechanism causing the gradient ⁃ Cockerham: "The social gradient is caused by people in different social groups being exposed to different social and economic conditions and 'it is these differences in the social environment that are responsible for the gradient.' Group differences are depicted as outweighing individual differences in producing health outcomes, but such differences are not produced just by a person's material circumstances. Rather, a host of other factors are also identified as contributing to the gradient, such as self-esteem, status differences, self-direction in work, control over one's environment, social capital, and sense of social support—all variables which decline in strength as one descends the social ladder."

Social Identities

Social Identities Primary locus of social identity = shifted from work to consumer habits. ⁃ Previous era = occupation largely determine social class and way of life. ⁃ 2nd half of 20th century: lifestyle consumer habits have become primary source of social identity. ⁃ Ex. Distinctions within the working class are determined more by consumption patterns than by relationship to the means of production.

Class

Social class (or SES) = strongest predictor of health, disease causation, and longevity ⁃ Ex. mortality rates have universal social gradient (e.g., morality rates increase as income decreases). Aren't age, gender, race/ethnicity important determiners of health outcomes? ⁃ Yes. But the influence of these variables often diminish when controlling for class. ⁃ Cockerham: "The advantages or disadvantages that accrue to differences in age, gender, and race are magnified one way or another by class position." Let's take age for an example: ⁃ As people age, they tend to adjust food intake. ⁃ Higher SES = tend to have better diets to begin with and make positive changes as they age. ⁃ Lower SES = tend to have worse diets to begin with and make negative changes (or ignore diet altogether) as they age. Why? Health lifestyles (e.g., food choice) get locked in over the life course along class lines. BUT not everyone agrees that class overrides other structural variables in determining health. ⁃ Ex. = intersectionality theory

Stress

Stress studies = evidence for causal role of class position in poor health outcomes What is stress? ⁃ Heightened mind-body reaction to stimuli from threatening or burdensome situations causing fear or anxiety. ⁃ Perception of stressor —> physiological and/or emotional arousal in autonomic nervous system (e.g., heart rate, blood pressure, gastrointestinal functions) and neuroendocrine adaptations. What are the effects of stress? ⁃ When stressors persist over time —> weakening of body's defense against disease AND damaging of body's organic systems ⁃ Pearlin and colleagues: "Continuous and repeated stressors, moreover, are likely to have a cumulative effort on the allostatic load, which refers to the burden placed on the organism and its biological functions in responding to hardship and demand." What are the types of stress? 1) Life events (e.g., spouse's death, divorce, weddings, job loss, changes in finances or residence, vacations) 2) Chronic strains = persistent demands requiring adjustments over prolonged period (e.g., coping with poverty) 3) Daily hassles = short-term demands requiring small adjustments (e.g., traffic jams, long lines) What do we know about stress and class? ⁃ Negative life events & chronic strains = occur in all classes ⁃ BUT preponderance of both is higher among lower classes. ⁃ Cockerham: The unequal distribution of stress in general populations promotes inequality in physical and psychological well-being with low SES persons being penalized most. Recent research has confirmed the significant impact of stressful life events on the lower class." ⁃ People in poverty also stressed by living environments, and long-term poverty is more stressful than intermittent poverty. What is structural amplification? ⁃ Cockerham: "Mirowsky and Ross came to a similar conclusion when they used the term 'structural amplification' to refer to situations where well-educated individuals accumulate advantages and poorly educated persons amass disadvantages that are bundled over time into 'cascading sequences' impacting either positively or negatively on health. They describe how structural amplification concentrates poor health in those persons with multiple disadvantages." What role do resources play in coping with stress? ⁃ Both social and economic resources = particularly helpful for coping with stress. ⁃ BUT resources possessed with low-SES people = outweighed by much greater exposure to stress. ⁃ AND lacking resources is itself a stressor that promotes sense of fatalism and powerlessness. But don't people in other classes get stressed? ⁃ Working and lower-middle class people face particular stressors that produce physical and mental health problems. ⁃ Ex. economic recessions, factory closings What is the consensus in the literature on class, stress, and health? ⁃ Cockerham: "These studies support a social causation explanation of poor health by showing that people in the lower class are in poorer health because they are subjected to greater stress and adversity by way of a deprived life situation. Although much of the social causation thesis in the stress literature is found in studies of mental health, there is strong evidence showing it can be applied to physical health." How much choice (agency) do lower-SES people actually have when it comes to health? ⁃ Cockerham: "Some stresses cannot be changed by an individual simply changing his or her behavior, such as a lower-class diabetic deciding to eat a healthier diet, since that person's stresses resulting from class situations are beyond that individual's control. Life events and strains embedded in class hierarchies can create stressful circumstances in which people are forced to respond to conditions not of their own choosing and these circumstances can have adverse effects on physical and mental health

Living Conditions

Structural variable, not just personal possession. ⁃ Includes housing quality, access to basic utilities (e.g., electricity, gas, heating, sewers, indoor plumbing, safe piped water, hot water), neighborhood facilities (e.g., grocery stores, parks, recreation), and personal safety. More research needed on influence of living conditions on health lifestyles. ⁃ BUT overall health lifestyles were most

Sick Role

Talcott Parson's Sick Role (1951) Sick person has duties and privileges: ⁃ Duties = recognize that it's bad to be sick, must seek competent help (e.g., physician), and must comply with treatment. ⁃ Privileges = excused from normal obligations (e.g., family, community, job) and from blame for being ill. Model criticized for... ⁃ Ignoring self-management. ⁃ Paternalism (esp. control by physicians). ⁃ Simplistic conception of time (sick—> seek help —> get well). ⁃ Simplistic view of how illness is determined (e.g., some patients struggle for diagnosis). ⁃ Absence of patient's perspective (which is often overlooked in medicine also).

Health Lifestyles (Reproduction)

The aggregation of health practices produces a health lifestyle. • Cockerham: "Action (or inaction) with respect to a particular health practice leads to its reproduction, modification, or nullification by the habitus through a feedback process.... This is consistent with Bourdieu's assertion that when dispositions are acted upon they tend to produce or modify the habitus from which they are derived. As conceptualized by Bourdieu, the habitus is the centerpiece of the health lifestyle model."

Lifestyle

The primary mechanisms through which health is socially manufactured is through lifestyles. Lifestyles are integrated sets of practices fulfilling utilitarian needs and giving material form to the expression of a particular social identity." Aggregate or collective pattern of health practices available to people according to their life chances (which are determined by SES, class position, age, gender, race, ethnicity, etc.

Life Chances (Structure)

The structural variables in Box 1 determine life chances (structure). What are life chances? ⁃ ADVANTAGES and DISADVANTAGES of relative class situations. ⁃ Weber: They are the "crystallized probability of finding satisfaction for interests, wants and needs, thus the probability of the occurrence of events which bring about such satisfaction." ⁃ The higher the position in the class hierarchy, the better the life chances.

Causation vs. Selection

What does the evidence suggest is the better approach? ⁃ Cockerham: "When the question is whether class position determines health (social causation) or health causes class position (social selection), the strongest argument of social causation.... But the explanations are not mutually exclusive.... There are undoubtably situations where sickness locks a person into the lower class or causes downward movement in society. Nevertheless, class position and the various factors associated with it are the most powerful social determinant of health."

Interplay of Chances and Choices

There is a dialectical relationship between life chances and life choices. ⁃ Cockerham: "This interaction is Weber's most important contribution to conceptualizing lifestyle construction." How does this interplay work? ⁃ Cockerham: "Choices and chances operate in tandem to determine a distinctive lifestyle for individuals, groups, and classes. Life chances (structure) either constrain or enable choices (agency); agency is not passive in this process.... Unrealistic choices are not likely to succeed or to be selected, while realistic choices are based upon what is structurally possible." ⁃ Including agency here keeps the health lifestyles model from having too much downward conflation.

Modernity

Transition into a new social form in the late modern period = cultural globalization capitalism, collapse of state socialism, Western deindustrialization, information technology, rise of China as economic powerhouse, multiculturalization of U.S. and Europe, gender politics, new family forms, changing pattern of stratification, etc. Three influence on health lifestyles: 1) Decline in status and and professional authority of physicians (e.g., as compared to insurers and HMOs). 2) Movement toward mutual participation model of patient-physician relationship (e.g., patient shares in decision making). 3) Rise of Internet medicine and diffusion of medical knowledge to the public.

Race/Ethnicity

We lack comprehensive data on influence of race/ ethnicity on health lifestyles. ⁃ Compared to blacks, whites in the U.S. have HIGHER rates of alcohol use, smoking, exercise, and weight control practices. Exercise ⁃ As age increases, exercise declines more steeply for blacks than for whites (perhaps because of more functional health problems and less safe neighborhoods). ⁃ Whites disproportionately favor facility-based exercise (e.g., swimming, tennis, golf) Blacks favor team sports (e.g., basketball) and fitness activities (e.g., walking, running). ⁃ Hispanics favor team sports (e.g., soccer). ⁃ Because 1) recreational facilities are often absent in lowincome neighborhoods and 2) team sport ability declines earlier than facility-based exercise, whites have advantage in exercise as they age.

Causation

What explains the connection between class and health? 1) CAUSATION: Being in the lower class causes poor health outcomes. ⁃ Why? Because poorer people have more adversity and stress and fewer resources to deal with them.

Education as Commodity

What is a commodity? ⁃ A material resource that can be bought and sold. Education improves by health by providing economic benefits. ⁃ Ex. increased household income, access to medical care, and insurance coverage. ⁃ Ross and Mirowsky: "Commodity theories focus on material assets. Education is a credential that employers use in allocating good jobs. Degrees, especially college degrees, are markers that employers use to hire.... Commodity theories focus on earnings, income, wealth, and health insurance." Are education and income interchangeable indicators of SES? ⁃ Nope. Education and income influence health in separate but overlapping ways. ⁃ BUT commodity theories focus on the ways that education improves income, which in turn improves health. How much does income influence health? ⁃ Ross and Mirowsky: "Household income... has a diminishing positive association with health, that is, the size of the improvement in health with each additional step up in level of income gets smaller and smaller. The biggest improvements are on the low end, moving up from the bottom of the economic ladder to the middle. Beyond forty thousand dollars, the differences in average health with increased level of income gets small, and beyond sixty thousand dollars they nearly vanish." ⁃ So improving a nation's overall health would benefit more from raising low incomes than average incomes. How does income influence health? ⁃ Economic hardship can effect health through material deprivation (e.g., food, clothing, shelter, utilities, sanitation). ⁃ Ross and Mirowsky: "Clearly, some households suffer from material deprivations that a wealthy society need not accept. Nevertheless, material privation probably does not account for most of the impact on health of low income and economic hardship in the United States.... People exposed to economic hardship probably experience frequent, intense, and prolonged activation of the physiological stress response, with consequences for their health." Can income improve health through access to health care? ⁃ Ross and Mirowsky: "Money can indeed buy access to medical care, but it is questionable whether buying more access improves health.... The differences in health across levels of income apparently do not result from differences in access to medical care.... The rise of modern life expectancy cannot be attributed to the medical and surgical treatment of disease, because most of the declines in mortality rates preceded the advent of effective medical treatments for the declining causes of death.... In the United States, most of the mortality decline may be attributed to clean water." Can income improve health through access to health care? cont. ⁃ Mortality differentials by SES have stabilized or are widening in the U.S. and in countries with national (socialized) health systems. ⁃ People with low SES use health services more—but still have worse health outcomes (mainly because they have more problems to begin with). Can income improve health through access to health insurance? ⁃ Ross and Mirowsky: "The substantial association between income and medical insurance coverage gives the impression that lack of coverage accounts for much of the poor health in lowincome households, and that government programs soften some of that deleterious effect. Our analyses show that this cannot be true, for two reasons: private medical insurance does not improve adult health, and public insurance seems to make it worse." Wait a minute. What? ⁃ The authors soften their conclusion by reminding us to consider what types of people select into private and public health insurance policies. ⁃ Ex. poor people use Medicaid; retirees use Medicare; young healthy people opt out of insurance. ⁃ Ross and Mirowsky: "Adjusting for factors that select people into different categories of insurance is crucial: those adjustments reduce the apparent negative effects of public insurance, but they also reduce the apparent positive effect of private insurance." So what is the conclusion on health insurance? ⁃ Ross and Mirowsky: "Medical insurance cannot account for any appreciable part of the socioeconomic differences in health.... Private medical insurance shows no sign of preserving or improving health. The better health seen among individuals with private medical insurance results entirely from their high levels of education, employment, marriage, and economic well-being that preserve and improve health directly and also increase the likelihood of having private medical insurance.... Public insurance has no effect on subsequent changes in physical impairment, but it increases the accumulation of chronic conditions and decreases subjective health over time.... The lower rates of medical insurance cannot explain the high levels of health problems found among persons with low socioeconomic standing."

Issues of Geneticization

What are the possible issues with geneticization? ⁃ Shostak and Freese: "Sociologists have been especially concerned about the possibility that such dynamics will contribute to the individualization of health and illness, with social, political, and economic etiological explanations relegated to secondary status discredited altogether." ⁃ Shostak and Freese: "Extensive public sector investment in genetic research will disproportionately and negatively impact blacks by diverting attention and resources away from social environmental factors that contribute to increasing rates of lung cancer and cardiovascular disease in the African American population." ⁃ Geneticization may increase stigmatization of mental health patients and their families. But don't some genetics researchers include environment in their thinking? ⁃ "Enlightened geneticization" = approach that mentions the environment while still prioritizing genetics. ⁃ Epigenetics = approach that highlights how cellular environments modify gene expression ⁃ Shostak and Freese: "The complexities involved in defining, operationalizing, and measuring environmental influences on health may enhance 'the allure of specificity' of genetic explanations." Can genetic information prompt social action? ⁃ Biosociality = process by which biological knowledge produces new forms of collective identity. ⁃ Ex. Learning genetic information can prompt a reworking of racial and ethnic identity. ⁃ Ex. Individuals can make use of genetic information to protect health, maximize quality of life, optimize life chances, etc.

US Class

What are the trends in class structure in the U.S.? 1) Shifting sources of wealth = Source of wealth for richest segment has shifted from industry to finance, real estate, and information technology. 2) Expanding income inequality = For every $1 increase in wages/salaries for bottom 90%, the top 0.1% gained an extra $18,000. 3) Changing class sizes = Increases in size of upper and upper-middle class (due to mobility) and lower class, but decrease in size of working class (due to loss of manufacturing jobs)

British Class

What do we know about class in Great Britain? ⁃ Class distinctions = much sharper in G.B. than U.S. (due to feudal history of land ownership). ⁃ Cockerham: "At the top of British society today is a small upper class of wealthy families, many of them members of the nobility, and a new elite of top professional in financial and legal services and corporate managers that have emerged in particular strength since the 1960s. The upper strata is followed by a small uppermiddle class of professionals and managers, a large lower-middle class of white-collar workers, and a very large working class. At the bottom is the lower class, many of whom live in poverty or on the edge of it." Most common class system used in British research = National Statistics Socio-Economic Classification (NS-SEC) ⁃ Based on differences in 1) employment relationships (e.g., autonomy, job security) and 2) work conditions (e.g., promotion opportunities, work planning). ⁃ Seven-class model = higher managerial, lower managerial, intermediate occupations, small employers/ self-employed, lower technical, semi-routine, routine Most common class system used in European Union research = European Socioeconomic Classification (ESeC) ⁃ Nine class categories = higher managers/ professionals, lower managers/professionals, intermediate occupations, small employers non-agricultural, small employers agricultural, lower supervisory/technicians, lower service/ sales/clerical, lower technical, routine

Public View on Geneticization

What do we know about the public's views on genetics? ⁃ African Americans and Hispanics = more eager than whites to utilize prenatal and adult genetic testing. ⁃ 90% of all Americans = believe genetics at least somewhat important for physical illness. ⁃ 2/3 of all Americans = believe genetics at least somewhat important for success in life. ⁃ BUT American public does not rule out importance of environment and individual behavior in health outcomes. How much emphasis is placed on genetic by the public? ⁃ Shostak and Freese: "What outcomes are regarded as 'more genetic' may be influenced by a cultural schema, at least in the United States, in which individual characteristics perceived as closer to the body are seen as more strongly caused by genetics." ⁃ Descending genetic influence = physical health, mental health, personality, success in life. ⁃ Shostak and Freese: "In addition, many people have a strong notion of individual will as a causal force independent from either genetics or environment, which could be seen as more important for social outcomes."

Disposition to Act (Habitus)

What is a habitus? ⁃ A durable internal disposition that guides behavior and is shaped mainly by class. ⁃ Cockerham: "The habitus serves as a cognitive map or set of perceptions in the mind that routinely guides and evaluates a person's choices and options. It provides enduring dispositions toward acting deemed appropriate by a person in particular social situations and settings. Included are dispositions that can be carried out even without giving them a great deal of thought in advance. They are simply habitual ways of acting when performing routine tasks." How does habitus influence health lifestyles? ⁃ Cockerham: "Individuals who internalize similar life chances share the same habitus.... As a result, there is a high degree of infinity in health lifestyle choices among members of the same class. Bourdieu maintains that while they may depart from class standards, personal styles are never more than a deviation from a style of a class that relates back to the common style by its difference." Is this simply more downward conflation? ⁃ Bourdieu does emphasize structure over agency... but does allow for the influence of agency. What is a field? ⁃ Lifestyle practices 1) originate in the habitus and 2) are carried out in the field. ⁃ Fields = networks or configurations of objective relations (e.g., domination, subordination) between social positions. ⁃ Fields = social arenas where people and institutions use economic, social, and cultural capital to maneuver for advantage in the hierarchy relative to others in the field. What do fields have to do with health lifestyles? ⁃ Cockerham: "Healthy lifestyles can be viewed as the habitual practices of groups that dominate social fields where healthy living is considered important. The opposite could be the case in fields with different power dynamics."

Gene Environment Interaction (PKU)

What is an example of gene-environment interaction? ⁃ PKU = phenylketonuria (lacking enzyme to break down amino acid phenylalanine) ⁃ PKU = favorite example for demonstrating role of environment in gene expression ⁃ Shostak and Freese: "For decades, it has been known that if someone with PKU adheres to a diet low in phenylalanine, the accumulation can be avoided and the negative consequences of the condition can be minimized. In other words, PKU is a genetically determined condition whose consequences medical science has transformed to being largely environmentally determined." Couldn't we reduce inequality by simply finding treatments for conditions such as PKU? ⁃ Mothers with lower education levels have difficulty adhering to PKU diets for their children. ⁃ SO drug treatments for PKU could reduce inequality by making dietary adherence less important. ⁃ BUT they could also increase inequality by being utilized primarily by already advantaged groups (e.g., mothers with better education).

Class Circumstances

What is the most powerful influence on health lifestyles? ⁃ Class circumstances! Where does this idea originate? ⁃ Pierre Bourdieu's Distinction = seminal study in detailing class as most decisive variable in determining health lifestyles ⁃ Survey of differences in sports preferences and eating habits between French professionals (upper-middle class) and working class. ⁃ Working class = attentive to strength of male body; favored cheap but nutritious food; enjoys rugged team sports such as soccer. ⁃ Professionals = attentive to shape of male body; favored food that is tasty, healthy, light, low calories; enjoys sailing, skiing, golf, tennis, horseback riding What produced differences in classes? ⁃ Working class faces economic barriers and social barriers (e.g., hidden entry requirements of family tradition, obligatory dress and behavior, and early socialization). ⁃ Cockerham: "Thus Bourdieu formulated the notion of 'distance from necessity' that emerges as a key explanation of class differences in lifestyles. He points out that the more distant a person is from having to forage for economic necessity, the greater the freedom and time that person has to develop and refine personal tastes in line with a more privileged class status." How does this relate to health lifestyles? ⁃ Cockerham: "The greater the social distance from struggling to obtain necessities, the greater the refinement of lifestyle practices. The relevance of the distance from necessity concept is seen in health lifestyles where classes higher on the social scale have the time and resources to adopt the healthiest practices." ⁃ In general, lower SES people view health mainly as means to an end (to be able to work), and higher SES people view health as an end in itself (vitality). Are we saying that lower SES people always have unhealthy lifestyles and higher SES people always have healthy ones? ⁃ Not necessarily. We all know exceptions to the basic trend. ⁃ But in aggregate, socioeconomic circumstances and living environment determine the extent to which health lifestyles are practiced effectively. Can the middle class serve help the health of the overall population? ⁃ Yes. It serves as a carrier of positive health lifestyles in society (esp. upper-middle class). ⁃ Why? Distance from necessity allows leisure time, knowledge, and resources to learn about and adopt health behaviors as a public model for other classes. Is capitalism good or bad for health? ⁃ Paradox of capitalism and health: ⁃ It creates massive inequality (and low SES is a fundamental cause of disease). ⁃ It is compatible with major improvement in overall health standards. Examples of health advancement within capitalism: ⁃ Indicators such life expectancy, infant mortality = never been better. ⁃ Eradication or major curtailment of communicable disease (e.g., smallpox, polio). ⁃ Advances in medical procedures (e.g., organ transplant, fertility treatment, replacement surgery) Recap on the paradox of capitalism: ⁃ Michael Bury: "General health improvement can therefore occur alongside persistent and even widening inequalities." ⁃ Cockerham: "When it comes to health lifestyles, the advantage likewise accrues to higher social strata."

Agency vs. Structure (cont.)

⁃ Cockerham: "Structure invariably has a role in lifestyle outcomes and it is usually the interaction between agency and structure that is decisive. Yet when it comes to health, lifestyle is 'predominantly understood as an individual rather than structural variable."... This needs to change because structure has a significant role in the production of health by individuals."

Collectivities

⁃ Collections of actors linked through social relationships (e.g., kinship, work, religion, politics). How do collectivities matter for health lifestyles? ⁃ Cockerham: "Their shared norms, values, ideals, and social perspectives constitute intersubjective 'thought communities' beyond individual subjectivity that reflect a particular collective world view.... While people may accept, reject, or ignore the normative guidance rendered, collective views are nevertheless likely to be taken into account when choosing a course of action. What are some examples? ⁃ RELIGION: Highly religious people tend to have healthier lifestyles (e.g., better nutrition, exercise, personal hygiene; less alcohol and smoking). ⁃ KINSHIP: Parental influence = most important and persistent influence on children's preventive health beliefs.

Gender

⁃ In general women = healthier lifestyles (e.g., more health food, less smoking and alcohol, more doctor visits for prevention, wear seat belts more often—BUT exercise less). ⁃ As with age, gender intersects with class in shaping health lifestyles (such that women at the top have much healthier lifestyles than women at the bottom).