The traditional view of health is a biomedical one – stop people from getting ill by preventing infection and treating disease. But a growing body of research showing that health is the result of social conditions has now gathered enough momentum to prompt a rethink about how social policy is made.
The largest and longest-running study on maternal crack cocaine use, for instance, surprised everyone earlier this year when it showed that poverty - not cocaine use during pregnancy - was more detrimental to the long-term development of children.
This isn’t the only research to show the insidious impact of social status on social, mental, and physical well-being.
Social standing and anxiety
In his book The Status Syndrome, Michael Marmot argues that social status powerfully influences health outcomes through personal autonomy and social participation.
Marmot was the principal author of a series of longitudinal studies of the health of public servants in Whitehall in the 1970s. His studies showed a significant gradient in mortality and other health outcomes between those working in the upper echelons and those in the lower pecking orders of the British public service.
The higher we climb the status ladder, the more autonomy we have and the more comfortable we are participating in social activities and relationships.
Conversely, the lower down the pecking order, the greater are the stresses associated with everyday living, as people do what the system requires rather than enjoy the sense that they are in charge of their lives.
A similar relationship with ill health is clear with poverty.
What is poverty anyway?
Poverty is a relative concept that is used to categorise people who can’t afford things that most other people in the same society take for granted.
It’s often defined by financial “poverty lines”: the financial income level below which it is agreed that someone is likely to struggle to afford rent, food and clothing. A commonly used poverty line is 50% of the median income.
In 2010, it was estimated that 12.8% of the Australian population were living below this poverty line (after taking housing cost into account). It was also estimated that 17.3% of Australian children were living in poverty.
There is now a large body of research that shows a very consistent gradient for life expectancy with those in the upper echelons living longer and experiencing less illness than those in each of the socioeconomic strata below them.
These gradients have been consistently shown in country after country including Australia.
Not what you think
Most of us feel we understand intuitively why those in poverty have worse public health outcomes.
Poor people have less disposable income for nutrition, health care, safe housing and are less able to avoid risk. Poverty is often associated with single parenthood and dependence on junk food, alcohol, tobacco and illicit drugs. Homelessnes is also more common among people in this group.
What is less clear is how to deal with the health consequences of poverty.
The gap between Australia’s rich and poor is now increasing substantially. And the burden of ill health for those in poverty persists across the nation, especially among indigenous communities.
Would that burden diminish appreciably simply by moving everyone above the financial poverty line or do we need to make more fundamental changes?
The social determinants of health
A public health approach to the health consequences of poverty requires an understanding of cultural and social participation, which begins with education.
According to Richard Wilkinson and Kate Pickett, authors of The Spirit Level, education could have positive social and health ramifications right across the social gradient.
Their approach is known as the “social determinants of health” and requires stepping beyond the conventional biomedical understanding of disease causation by factors such as diet, exercise, genetic factors, and exposure to toxic products.
Rather, it asks about the factors that perpetuate status differences and exclude those in the lower echelons of society from feeling worthwhile and being able to control.
A social-determinants approach recognises the multifocal nature of human stress and its frequent social origin in the status syndrome; the more helpless we feel when facing a difficult situation, the more toxic will be the stress from conventional health risks.
This approach modifies public health thinking and action. It means that we need to pay attention not only to the income, tax and targeted benefits for those currently below the poverty line but should also pay particular attention to education, child care, employment, housing, mobility and transport.
It changes the aim of public policy to fostering autonomy and the capacity to participate meaningfully in a range of social and community activities. These result in benefits that run counter to conventional thinking about the causal mechanisms of disease.