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The conditions in which people live have a profound influence on their health. Difference in health between individuals and population groups exist in all societies. For example younger age population generally have good health compared to elder population. This kind of health difference cannot be concluded as health inequality because it is natural. So the question is that when the difference in health becomes inequality? According to Graham the difference in health between population groups becomes inequality when it is linked to the inequalities in their position in society (2007: 99). World Health Organisation appointed Committee for the Social Determinates of Health (CSDH) also hold similar view as not all health inequalities are unjust or inequitable. If good health were simply unattainable, this would be unfortunate but not unjust. Where inequalities in health are avoidable, yet are not avoided, they are inequitable (2008: 14). So the differences in health between groups having unequal position in society become an ethical issue.
Evidences of the existence of health inequality are abundant. If we consider life expectancy as an indicator, resent evidences show that there exist significant differences in health between world regions (see Appendix 1). Life expectancy at birth varies between 78.8 years in the higher income OECD countries to 46.1 years in Sub Saharan Africa. Life expectancy improvement over the period 1970-75 to 2000-05 shows that life expectancy has increased all regions in the world except the former Soviet Union countries. It can observe that the increase was not similar in all regions. Life expectancy increased almost 10 years in developing regions over that period while in Sub Saharan Africa the increase was only about 1 year.
Inequalities in health not only exist between countries or regions. Even within the country health inequalities exist. A study in the Scottish city of Glasgow found that life expectancy of men in one of the most deprived area was 54 years while that most affluent area was 82 years (Hanlon, Walsh & Whyte 2006, cited in CSDH 2008). Men with the lowest life expectancy in the United States of America in 1997 2001 had lower life expectancy than that of Pakistan average in 1995 2000 (CSDH 2008).
Studies show that socio-economic status affects health. Differences in life expectancy at birth by social class in England and Wales from 1972 to 2005 shows that it has improved for all classes during the period 1972 -2005 (both males and females). Surprisingly the same difference in life expectancy existed in 1972 between social class was found existed still in 2005 (see Appendix 2 and 3). Even in health behaviour difference exist between socio-economic classes. Percentage males and females smoke in England and Wales during 2001-07 period shows that smoking rate is comparatively higher among lower occupational classes (see Appendix 4). Whitehall II study which investigates the health of British civil servants between the age 20 and 64 found that mortality rate is high among low occupational classes (see Appendix 5).
How material conditions affect health? The Black Report published in 1980 by the expert committee into health inequality chaired by Sir Douglas Black was the first attempt to examine the relationship between economic inequality and health inequality. The main responsibilities of the committee were to bring together available information about the difference is health status among the social classes, examine the contributing factors, and to analyse the collected information for casual relationships. The committee found that there was strong relation between social class and mortality-morbidity rates. It also found that people in lower class experience worse health and working class population underutilise NHS (Morall, 2001).
The committee examined four possible explanations for the inequality. The artefact explanation suggests that the class inequality in health do not really exist. They only appear to exist because of the way class is constructed. The social selection explanation argues that people who experience bad health tend to find difficult to get good job. There for they either move into or remain in lower class occupations. This means, people are in lower social class because of their poor health, rather than their class causing poor health. The behavioural/cultural explanation suggests that ill-health is due to not following a healthy life style. Lower class people are unhealthy because they smoke and drink too much, eat wrong kind of food and do not exercise. Finally the structural/material explanation view the material situation in which people live is the most important factor that determine health (Kirby, 2000).
Based on the Ottawa Charter for Health Promotion number of models of the determinants of health has been developed. The model by Dahlgren and Whitehead (1991) is particularly important. This model identified that individual characteristics of age, sex and genetic makeup are core determinant of health. Other influences are represented by concentric layers each of which interfaces with the other factors. They suggest that the inner circle represented by the fixed characteristics of the individual cannot be modified but outer circles can be influenced by behavioural or other life changes (see Appendix 6).
There are many theories that try to explain health inequality. Behavioural and cultural explanations suggest that individual behavioural choices are responsible for health outcome. The lower the income status, the person is more likely to engage in less health promoting form of behaviour. It is also found that those with more years of schooling, and with more qualification, are found to have healthier diets, to smoke less and do more exercise (Bartley 2004).
The psycho-social model argues that the health difference between people in more and less advantaged social positions cannot be explained purely by material factors (Marmot 1989). Psycho-social model focus on how feeling that arises because of inequality, domination, or subordination may directly affect biological process by altering body chemistry. This model argues that availability of social support, control and autonomy at work, the balance between home and work, the balance between efforts and rewards etc. can affect health (Bartley 2004).
The materialist framework sees the objective living conditions people living in explain relation between poverty and health. Material condition of life associated with poverty lead to greater likelihood of physical problems, developmental problems, educational problems and social problems (Blane et al. 1998). Neo-materialist model explains the relationship between population health and income inequality. It looks beyond individual level and gives more attention to whole societies and how they differ. It is argued that absolute income is not the determinant rather its distribution is the matter (Wilkinson 1996; Wilkinson and Pickett 2009).
Basic premise of life course approach is that persons past social experiences affect the physiology and pathology of their body. So this model argues that health in later adult life may be a result of complex combinations of circumstances taking place over time and the cumulative effects of circumstances can affect the health negatively in future (Davy Smith et al. 2002). The major purpose of the life course researchers is to see whether the difference in health between people in different groups is due to past adverse life circumstances (Bartley 2004)
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