Social Class

Not only do the poor have less money, but they also have much worse health, as the news story that began this chapter illustrated. There is growing recognition in the government and in medical and academic communities that social class makes a huge difference when it comes to health and illness (Centers for Disease Control and Prevention, 2011).

Many types of health indicators illustrate the social class–health link in the United States. In an annual survey conducted by the government, people are asked to indicate the quality of their health. As Figure 13.5 “Family Income and Self-Reported Health (Percentage of People 18 or Over Saying Health Is Only Fair or Poor), 2009” shows, poor people are much more likely than those with higher incomes to say their health is only fair or poor. These self-reports of health are subjective indicators, and it is possible that not everyone interprets “fair” or “poor” health in the same way. But objective indicators of actual health also indicate a strong social class–health link (National Center for Health Statistics, 2011).

For example, poor adults are also at much greater risk for many health problems, including heart disease, diabetes, arthritis, and some types of cancer. Rates of high blood pressure, serious heart conditions, and diabetes are at least twice as high for middle-aged adults with family incomes below the poverty level than for those with incomes at least twice the poverty level. All these social class differences in health contribute to a striking difference in life expectancy, with Americans whose family incomes are more than four times the federal poverty level expected to live 6.5 years longer than those living in poverty (Kaplan, 2009).

Several reasons account for the social class–health link (Pampel, Krueger, & Denney, 2010). One reason is stress, which, as Chapter 2 “Poverty” explained, is higher for people with low incomes because of unemployment, problems in paying for the necessities of life, and a sense of little control over what happens to them. Stress in turn damages health because it impairs the immune system and other bodily processes.

A second reason is that poor people live in conditions, including crowded, dilapidated housing with poor sanitation, that are bad for their health and especially that of their children. Although these conditions have improved markedly in the United States over the last few decades, they continue for many of the poor.

Another reason for the poor’s worse health is their lack of access to adequate health care. As is well known, many poor people lack medical insurance and in other respects have inadequate health care. These problems make it more likely they will become ill in the first place and more difficult for them to become well because they cannot afford to visit a physician or to receive other health care. Still, social class disparities in health exist even in countries that provide free national health care, a fact that underscores the importance of the other reasons discussed here for the social class–health link (Elo, 2009).

Many people who are poor or near poor lack medical insurance and in other ways have inadequate health care. These problems make it more likely they will become ill and, once ill, less likely they will become well.

Truthout.org – Money Behind Health Care – CC BY-NC-SA 2.0.

A fourth reason is a lack of education, which, in ways not yet well understood, leads poor people to be unaware or unconcerned about risk factors for health and to have a fatalistic attitude that promotes unhealthy behaviors and reluctance to heed medical advice (Elo, 2009). In one study of whether smokers quit smoking after a heart attack, only 10 percent of heart attack patients without a high school degree quit smoking, compared to almost 90 percent of those with a college degree (Wray, Herzog, Willis, & Wallace, 1998).

A final reason for the poor health of poor people is unhealthy lifestyles, as just implied. Although it might sound like a stereotype, poor people are more likely to smoke, to eat high-fat food, to avoid exercise, to be overweight, and, more generally, not to do what they need to do (or to do what they should not be doing) to be healthy (Pampel et al., 2010). Scholars continue to debate whether unhealthy lifestyles are more important in explaining poor people’s poor health than the other factors just discussed. Regardless of the proper mix of reasons, the fact remains that the poor have worse health.

Race and Ethnicity

Health differences also exist when we examine the effects of race and ethnicity, and they are literally a matter of life and death. We can see this when we compare life expectancies for whites and African Americans born in 2006 (Table 13.2 “US Life Expectancy at Birth for People Born in 2007”). When we do not take gender into account, African Americans can expect to live about five fewer years than whites. Among men, they can expect to live almost six fewer years, and among women, four fewer years.

At the beginning of the life course, infant mortality also varies by race and ethnicity (Table 13.3 “Mother’s Race/Ethnicity and US Infant Mortality, 2006 (Number of Infant Deaths per 1,000 Live Births)”), with African American infants more than twice as likely as white infants to die before their first birthday. Infant mortality among Native Americans is almost 1.5 times the white rate, while that for Latinos is about the same (although the Puerto Rican rate is also higher, at 8.0), and Asians a bit lower. In a related indicator, maternal mortality (from complications of pregnancy or childbirth) stands at 8.1 maternal deaths for every 100,000 live births for non-Latina white women, 7.2 for Latina women, and a troubling 23.8 for African American women. Maternal mortality for African American women is thus about three times greater than that for the other two groups.

In other indicators, African Americans are more likely than whites to die from heart disease, although the white rate of such deaths is higher than the rates of Asians, Latinos, and Native Americans. African Americans are also more likely than whites to be overweight and to suffer from asthma, diabetes, high blood pressure, and several types of cancer. Latinos and Native Americans have higher rates than whites of several illnesses and conditions, including diabetes.

Commenting on all these disparities in health, a former head of the US Department of Health and Human Services said a decade ago, “We have been—and remain—two nations: one majority, one minority—separated by the quality of our health” (Penn et al., 2000, p. 102). The examples just discussed certainly indicate that her statement is still true today.

Why do such large racial and ethnic disparities in health exist? To a large degree, they reflect the high poverty rates for African Americans, Latinos, and Native Americans compared to those for whites. In addition, inadequate medical care is perhaps a special problem for people of color, thanks to unconscious racial bias among health-care professionals that affects the quality of care that people of color receive (see discussion later in this chapter).

An additional reason for racial disparities in health is diet. Many of the foods that have long been part of African American culture are high in fat. Partly as a result, African Americans are much more likely than whites to have heart disease and high blood pressure and to die from these conditions (Parra-Medina et al., 2010). In contrast, first-generation Latinos tend to have diets consisting of beans, grains, and other low-fat foods, preventing health problems stemming from their poverty from being even worse. But as the years go by and they adopt the typical American’s eating habits, their diets tend to worsen, and their health worsens as well (Pérez-Escamilla, 2009).

In a significant finding, African Americans tend to have worse health than whites even among those with the same incomes. Several reasons explain this racial gap. One is the extra stress that African Americans of all incomes face because they live in a society that is still racially prejudiced and discriminatory (Bratter & Gorman, 2011). In this regard, studies find that African Americans and Latinos who have experienced the most racial discrimination in their daily lives tend to have worse physical health (Lee & Ferraro, 2009). Some middle-class African Americans may also have grown up in poor families and incurred health problems in childhood that continue to affect them. As a former US surgeon general once explained, “You’re never dealing with a person just today. You’re dealing with everything they’ve been exposed to throughout their lives. Does it ever end? Our hypothesis is that it never ends” (Meckler, 1998, p. 4A).

African Americans have worse health than whites, even when people with the same incomes are compared. One reason for this racial gap is the continuing racial discrimination that African Americans experience and the stress that accompanies this experience.

Pixabay – CC0 Public Domain.

To some degree, racial differences in health may also have a biological basis. For example, African American men appear to have higher levels of a certain growth protein that may promote prostate cancer; African American smokers may absorb more nicotine than white smokers; and differences in the ways African Americans’ blood vessels react may render them more susceptible to hypertension and heart disease (Meckler, 1998; Ricker & Bird, 2005). Because alleged biological differences have been used as the basis for racism, and because race is best thought of as a social construction rather than a biological concept (see Chapter 3 “Racial and Ethnic Inequality”), we must be very careful in acknowledging such differences (Frank, 2007). However, if they do indeed exist, they may help explain at least some of the racial gap in health.

A final factor contributing to racial differences in health is physical location: poor people of color are more likely to live in urban areas and in other locations that are unhealthy places because of air and water pollution, hazardous waste, and other environmental problems (Walker, 2011). This problem is termed environmental racism (Michney, 2011). One example of this problem is found in the so-called Cancer Alley on a long stretch of the Mississippi River in Louisiana populated mostly by African Americans; 80 percent of these residents live within three miles of a polluting industrial facility (Cernansky, 2011).

Gender

The evidence on gender and health is both complex and fascinating. Women outlive men by more than six years, and, as Table 13.2 “US Life Expectancy at Birth for People Born in 2007” showed, the gender difference in longevity persists across racial categories. At the same time, women have worse health than men in many areas. For example, they are more likely to suffer from migraine headaches, osteoporosis, and immune diseases such as lupus and rheumatoid arthritis. Women thus have more health problems than men do even though they outlive men—a situation commonly known as the morbidity paradox (Gorman & Read, 2006). Why, then, do women outlive men? Conversely, why do men die earlier than women? The obvious answer is that men have more life-threatening diseases, such as heart disease and emphysema, than women, but that raises the question of why this is so.

Several reasons explain the gender gap in longevity. One might be biological, as women’s estrogen and other sex-linked biological differences may make them less susceptible to heart disease and other life-threatening illnesses, even as they render them more vulnerable to some of the health problems already listed (Kuller, 2010). A second reason is that men lead more unhealthy lifestyles than women because of differences in gender socialization. For example, men are more likely than women to smoke, to drink heavily, and to drive recklessly. All such behaviors make men more vulnerable than women to life-threatening illnesses and injuries. Men are also more likely than women to hold jobs in workplaces filled with environmental and safety hazards that kill thousands of people—most of them men—annually.

A final reason is men’s reluctance to discuss and seek help for their medical problems, owing to their masculine socialization into being “strong, silent types.” Just as men do not like to ask for directions, as the common wisdom goes, so do they not like to ask for medical help. As one physician put it, “I’ve often said men don’t come in for checkups because they have a big S tattooed on their chests; they think they’re Superman” (Guttman, 1999, p. 10).

Studies find that men are less likely than women to tell anyone when they have a health problem and to seek help from a health-care professional (Emmers-Sommer et al., 2009). When both sexes do visit a physician, men ask fewer questions than women do. In one study, the average man asked no more than two questions, while the average woman asked at least six. Because patients who ask more questions get more information and recover their health more quickly, men’s silence in the exam room may contribute to their shorter longevity (Foreman, 1999). Interestingly, the development of erectile dysfunction drugs like Viagra may have helped improve men’s health, as men have had to see a physician to obtain prescriptions for these drugs when otherwise they would not have seen a physician (Guttman, 1999).

We have just discussed why men die sooner than women, which is one of the two gender differences that constitute the morbidity paradox. The other gender difference concerns why women have more nonfatal health problems than men. Several reasons explain this difference (Read & Gorman, 2010).

Women more than men tend to have more health problems that are not life threatening. Two reasons for this gender difference are gender inequality in the larger society and the stress accompanying women’s traditional caregiving role in the family.

Francisco Osorio – CL Society 287: Waiting for a doctor – CC BY 2.0.

One reason arises from the fact that women outlive men. Because women are thus more likely than men to be in their senior years, they are also more likely to develop the many health problems associated with old age. This suggests that studies that control for age (by comparing older women with older men, middle-aged women with middle-aged men, and so forth) should report fewer gender differences in health than those that do not control for age, and this is indeed true.

However, women still tend to have worse health than men even when age is taken into account. Medical sociologists attribute this gender difference to the gender inequality in the larger society (Read & Gorman, 2010). For example, women are poorer overall than men, as they are more likely to work only part-time and in low-paying jobs even if they work full time. As discussed earlier in this chapter, poverty is a risk factor for health problems. Women’s worse health, then, is partly due to their greater likelihood of living in poverty or near poverty. Because of their gender, women also are more likely than men to experience stressful events in their everyday lives, such as caring for a child or an aging parent. Their increased stress impairs the immune systems and thus worsens their health. It also is an important cause of their greater likelihood of depression and the various physical health problems (weakened immune systems, higher blood pressure, lack of exercise) that depression often causes. Finally, women experience discrimination in their everyday lives because of our society’s sexism, and (as is also true for people of color) this discrimination is thought to produce stress and thus poorer physical health (Landry & Mercurio, 2009).

Social Class

First, social class affects the incidence of mental illness. To be more specific, poor people exhibit more mental health problems than richer people: They are more likely to suffer from schizophrenia, serious depression, and other problems. A major reason for this link is the stress of living in poverty and the many living conditions associated with it. One interesting causal question here is whether poverty leads to mental illness or mental illness leads to poverty. Although there is evidence of both causal paths, most scholars believe that poverty contributes to mental illness more than the reverse (Warren, 2009).

Women are more likely than men to be seriously depressed. Sociologists attribute this gender difference partly to gender socialization that leads women to keep problems inside themselves while encouraging men to express their problems outwardly.

Jessica B – Week Five – Face of depression… – CC BY-NC-ND 2.0.

Race and Ethnicity

Second, there is no clear connection between race/ethnicity and mental illness, as evidence on this issue is mixed: Although many studies find higher rates of mental disorder among people of color, some studies find similar rates to whites’ rates (Mossakowski, 2008). These mixed results are somewhat surprising because several racial/ethnic groups are poorer than whites and more likely to experience everyday discrimination, and for these reasons should exhibit more frequent symptoms of mental and emotional problems. Despite the mixed results, a fair conclusion from the most recent research is that African Americans and Latinos are more likely than whites to exhibit signs of mental distress (Jang, Chiriboga, Kim, & Phillips, 2008; Mossakowski, 2008).

Gender

Third, gender is related to mental illness but in complex ways, as the nature of this relationship depends on the type of mental disorder. Women have higher rates of manic-depressive disorders than men and are more likely to be seriously depressed, but men have higher rates of antisocial personality disorders that lead them to be a threat to others (Kort-Butler, 2009). Although some medical researchers trace these differences to sex-linked biological differences, sociologists attribute them to differences in gender socialization that lead women to keep problems inside themselves while encouraging men to express their problems outwardly, as through violence. To the extent that women have higher levels of depression and other mental health problems, the factors that account for their poorer physical health, including their higher rates of poverty and stress and rates of everyday discrimination, are thought to also account for their poorer mental health (Read & Gorman, 2010).