Social Inequality and Health: A Commentary

Abstract

Medical anthropologists have had a long interest in the subject of social inequality and health. Critical medical anthropologists (Farmer 1999; Singer 1986) and biocultural anthropologists (Goodman and Leatherman 1998; Thomas 1998) have all argued for the systematic study of structured economic and social inequality in communities and their impact on health. In this issue of MAQ, Ricardo Godoy and his colleagues add a new dimension to the anthropological study of this subject. My aim here is to provide a bit more background, to better contextualize their study. Although anthropologists have a deep interest in the subject of inequality and health, we have contributed proportionately little to the debate. The inverse association between socioeconomic status (SES) and health, and the related positive association between social integration and health, are probably the most widely replicated of any associations observed between social variables and health outcomes. And, the SES–health relationship is certainly the most often replicated association of these two relationships. Social epidemiology is the field that has contributed the most to this literature (Berkman and Kawachi 2000). This of course will be familiar to the many medical anthropologists who are acquainted with the literature in epidemiology. Regardless of who is doing the research, however, the question remains: why? What is it about social inequality that leads to ill health? This may seem like a silly question when you consider the grinding poverty (or absolute material deprivation) under which some people live as described in the ethnographic literature by, for example, Nancy Scheper-Hughes (1992). Her careful ethnographic description of the desolate poverty experienced by many living in a Brazilian favela (or “shantytown”) makes it clear that some people are sicker because they are poor, oppressed, and exploited. On the other hand, it is not such a crazy question when you look at the socioeconomic gradient in health found in Michael Marmot’s Whitehall study (Marmot 1994). Whitehall, of course, refers generally to the British civil service. From the housekeeping staff to the titled ministers, the inverse gradient in health can be seen. Granted, the differences in health may not be as great as those between the poorest Brazilians and Brazilian members of the international elite, but the gradient, nevertheless, is there. And, these British civil servants are fortunate to live in a society with a national health care service and with the economic wherewithal