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Social Inequality Harms Health, Sociologist Says

By Susan M. Persons

On the Front Page...
When the rich get richer and the poor get poorer, consequences to public health are grave.

"Socioeconomic differentials are arguably the most important public health problem facing our nation," reported Dr. James S. House, the featured speaker at a recent NIH Office of Behavioral and Social Sciences Research seminar and scientist at the Institute for Social Research in Ann Arbor, Mich.


The University of Michigan's Dr. James House (c), who gave a recent seminar on social inequality and health, is flanked by hosts Dr. Norman Anderson (l), director of the Office of Behavioral and Social Sciences Research, and NICHD's Dr. Norman Krasnegor.

Although advances in medical science and practice have been important to human health and wellbeing, a mounting body of evidence indicates that behavioral, psychosocial, and environmental factors are the major determinants of health and the way health changes with age, according to House. "It has been widely assumed in the pages of Science and elsewhere that advances in medical science and practice were the principal causes of the rapid increase in human life expectancy of the past several centuries," he said, "but studies now show that improved nutrition and better living conditions are the critical factors that have improved health in human populations."

Consistent with this conclusion, House continued, is evidence that the United States spends more money than any other nation in the world on medical care and research, yet levels of population health in terms of life expectancy -- at all but the oldest ages -- lag increasingly behind the most developed countries of Europe and Asia, and even some less developed ones. Greece, Spain, the United Kingdom and Denmark, he said, spend one-half to one-third as much on health, and yet all have the same or better population life expectancy both for males and females at age 60 and at birth.

While improving the inequalities of access to medical care in the U.S. would help make a significant difference, social inequalities in health are not due primarily to a lack of health care. "People of lower socioeconomic status by education and income have a multitude of psychosocial risk factors that health care alone will not be able to overcome including smoking, lack of exercise, immoderate eating and drinking, and high fat/low fiber diets," House said.

These individuals also experience more chronic and acute stress, higher rates of ill health and death among family and friends, lower levels of social support and personal efficacy, and higher levels of depression and hostility, and typically live and work in environments that are hazardous to health.

Why persons of low socioeconomic status (SES) are vulnerable to virtually all psychosocial and environmental risk factors is not fully understood, although science has discovered much about how socioeconomic factors can get "under the skin." Further, improving risk factors is not enough. "We need to improve the socioeconomic context which generates and sustains these risk factors," House recommended.

While investing in science and improving access to health care are important and would improve the health of lower SES populations, research findings suggest that doing so would likely have only a limited impact on population health unless these gains are accompanied by policies and conditions that mitigate current levels of deprivation and inequality.

"To have a substantial impact on public health," House said, "there would need to be a decrease both in absolute and relative deprivation and inequality of the lower 30 to 50 percent of the socioeconomic distribution."

Investments in biomedical research should continue at the current levels and higher, in House's opinion, but "a broader psychosocial perspective must be considered very seriously as we plan our science, practice, and policy for health and aging in the 21st century. Greater emphasis," he said, "has to be placed on the role that social factors and social policy play in the development of future health science and health policy, and should be seen not as an alternative, but as a necessary complement."

House, who is professor of sociology and director of the survey research center in the Institute for Social Research at the University of Michigan, received funding for his work on social factors from the National Institute on Aging, and earlier at the National Institute of Mental Health and the National Heart, Lung, and Blood Institute.

Dr. Redford Williams, a researcher at Duke University Medical Center, will continue the examination of social inequality and health at the next OBSSR seminar on Monday, Sept. 15 from 10 to 11 a.m. at Wilson Hall, Bldg. 1. His presentation will address "Excess Illness in Low SES Populations: A Psychobiological Theory of Why."

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