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John Cameron Jnr.
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Date Posted: 22:52:28 06/08/04 Tue
In reply to:
Montlhly Review
's message, "desigualdades fazem mal à saúde segundo Vicente Navarro" on 21:33:12 06/08/04 Tue
>Inequalities Are Unhealthy
>by Vicente Navarro
>
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>-------------------------------------------------------
>-------------------------
>
>Vicente Navarro is Professor of Public Policy,
>Sociology, and Policy Studies at the Johns Hopkins
>Bloomberg School of Public Health and Professor of
>Political and Social Science at Pompeii Fabra
>University. He is editor-in-chief of the International
>Journal of Health Services,and author of The Politics
>of Health Policy (Blackwell, 1994) and Dangerous to
>Your Health: Capitalism in Health Care (Monthly
>Review, 1993).
>
>This essay was an address to the 2003 graduating class
>of the Johns Hopkins Medical School.
>
>-------------------------------------------------------
>-------------------------
> The growing inequalities we are witnessing in the
>world today are having a very negative impact on the
>health and quality of life of its populations. It is
>true, as many conservatives and neoliberal authors
>continue to stress, that health indicators are
>improving in many parts of the world, including in
>many underdeveloped countries. But what these authors
>are not saying is that the rate of improvements in
>these indicators have slowed down in most countries
>that have experienced a growth of inequalities, and in
>many of them, including the United States, these
>indicators have even reversed. According to the last
>report of the National Center for Health and Vital
>Statistics, infant mortality in the United Staes has
>increased, reversing the decline that had occurred
>since 1953.1 The growth of inequalities is thus bad
>for people’s health. But why?
>
>One answer, which is only partially true, is that the
>growth of inequalities is usually accompanied by the
>growth of poverty. When inequalities increase, some
>people’s standard of living becomes much better, while
>other’s becomes worse. It is within these latter
>groups that health indicators deteriorate. But
>although there is an element of truth in this
>explanation, it is not the whole truth. As a matter of
>fact, it is a very small part of the whole truth.
>
>What is the truth then? The answer is that inequality
>is in itself bad, i.e., the distance among social
>groups and individuals and the lack of social cohesion
>that this distance creates is bad for people’s health
>and quality of life. Studies performed among civil
>servants in Great Britain have shown, for example,
>that life expectancy (the years that people can expect
>to live) among the top civil servants, grade 32, is
>longer than the life expectancy of civil servants of
>grade 31, who have longer life expectancy than civil
>servants of grade 30, and so on, reaching the lowest
>life expectancy at grade 1. There is no poverty among
>British civil servants, but there are significant
>differences in their life expectancies. The same
>finding has been replicated in other countries. In
>Spain, for example, we performed a similar study,
>looking at life expectancy by social class, and we
>found that the members of the bourgeoisie (the
>European term to define the corporate class) live an
>average of two years longer than the petit bourgeoisie
>(the term to define the upper middle class), who live
>two years longer than the middle class, who live two
>years longer than the skilled working class, who live
>two years longer than the members of the unskilled
>working class, who live two years longer than the
>unskilled working class that has been chronically
>unemployed. The difference between the two poles—the
>corporate class and the chronically unemployed—is ten
>years. This average distance in the European Union is
>seven years. In the United States, it is 14 years.2
>
>Why these differences in life expectancy? A lot of
>research has been done in the attempt to answer that
>question. And we have enough evidence to provide an
>answer: social distance and how that distance is
>perceived by people, in addition to the lack of social
>cohesion that it produces, is at the root of the
>problem. This situation appears clearly when we
>compare the life expectancy of a poor person in the
>United States (who makes $12,000 a year) with the life
>expectancy of a middle-class person in Ghana. The poor
>person in the United States is likely to have more
>material resources than the middle-class person of
>Ghana (who makes the equivalent of $9,000). The U.S.
>resident may have a car, a TV set, a larger apartment
>and other amenities that the middle-class person in
>Ghana does not. As a matter of fact, if the world were
>considered a single society, then the poor in the
>United States would be a member of the worldwide
>middle class and the middle-class person of Ghana
>would be part of the worldwide poor—certainly poorer
>than the poor in the United States. And yet, I repeat,
>the poor citizen of the United States (although of the
>worldwide middle class) has a shorter life expectancy
>than the middle-class person (although of the
>worldwide poor) in Ghana (two years less, to be
>precise).
>
>Why? The answer is simple. It is more difficult to be
>a poor person in the United States than a middle-class
>person in Ghana. For the poor person in the United
>States, the worst component of his or her existence is
>not primarily the absence of material resources, but
>rather his or her social distance from the rest of
>society. He or she feels frustrated, a failure, unable
>to fulfill the expectation of becoming a successful
>member of the “mainstream” and attaining its standard
>of living, which incidentally, for those depicted in
>the media as mainstream (and very much in particular
>in the broadcast industry), is higher than the
>national average. Indeed, the image of the
>“mainstream” does not correspond with the reality of
>the average person in our society. Most TV program
>characters, for example, are professionals in the
>upper middle class. Very rarely are blue-collar
>workers, nurse’s aides, carpenters, or taxi drivers,
>for example, the main characters in TV programs. The
>establishment’s media has, in general, a wrong view of
>how average U.S. citizens live and work. In the United
>States, the “American Dream” imparts an idealized
>vision of what Americans really are. The frustrations
>of those who do not see themselves a part of that
>mainstream in America are indeed a source of
>pathology. It is very difficult—emotionally as well as
>materially—to be outside of what the U.S.
>establishment defines as “mainstream,” which, I
>repeat, has a much higher than average pattern and
>standard of living. Moreover, the massive poverty that
>exists in terms of political and collective resources
>available to defend the interests of the majority of
>working people in the United States explains their
>enormous feeling of powerlessness and lack of social
>cohesion, both of which give rise to disease.
>
>In fact, we have found that countries with strong
>labor movements, with social democratic and socialist
>parties that have governed for long periods of time,
>and with strong unions (Sweden, for example), have
>developed stronger redistribution policies and
>inequality-reducing measures of a universalistic type
>(meaning that they affect all people) rather than
>antipoverty, means-tested, assistence types of
>programs. These worker-friendly countries consequently
>have better health indicators than those countries
>where labor movements are very weak, as is the case in
>the United States, a corporate-class-friendly country.
>The reason for this difference is that the sense of
>social cohesion is larger in the worker-friendly
>countries, the sense of power and participation is
>higher, and the feeling of social distance is smaller
>than in the corporate-class-friendly countries. The
>evidence for this conclusion is plainly overwhelming.3
>However, you would not know it by reading the
>scientific medical literature in the United States,
>which focuses on the biological, genetic, and
>behavioral aspects of health but rarely on the social
>and political determinants, thus revealing the
>ideological bias of most scientific, medical, and even
>public health research at our U.S. institutions.
>
>This neglect of the social and political determinants
>of health persists despite the fact, known for some
>time, that social distance is bad for your health.
>Researchers in the UK, for example, have found that
>the period in the 20th century during which the most
>significant increases in life expectancy occurred in
>the UK was, paradoxically, the years of the Second
>World War. And although improvements in nutrition (due
>to government rationing of food) contributed to this
>situation, the fact is, the most important factor was
>the reduction of social distances that occurred as a
>result of people of all classes committing themselves
>to the same project (the war to defeat Nazism) and
>making sacrifices in the pursuit of a cause the
>majority of people believed in. Those who lived during
>that period in Great Britain will tell you that never
>before had people felt so much camaraderie toward one
>another. Complimenting this sense of togetherness were
>the public policies that curtailed some of the
>privileges of the establishment, policies that were
>developed to garner popular support for the war
>effort, and which reduced the inequalities that
>existed in that country. Needless to say, classes and
>class differentials still existed, but the social
>distances were significantly reduced, resulting in the
>improvement in life expectancy for the majority of
>classes.
>
>As an example of the other extreme in social
>cohesiveness, we can look at Great Britain during the
>Thatcher years—when neoliberal policies were
>implemented, resulting in significantly higher social
>inequalities in that country—and see how the rate of
>decline in mortality that had occurred during the
>previous 20 years slowed down for all ages and for the
>majority of classes. The increased lack of social
>cohesion, the sense of insecurity and the Darwinian
>competition that the Thatcher policies created
>negatively affected the health of the majority of the
>British population.
>
>It is likely that the same thing happened during the
>same period of time, the 1980s, in the United States.
>Unfortunately, however, the United States does not
>collect or tabulate mortality statistics by social
>class. The United States is one of the very few
>countries that do not include class in its national
>health and vital statistics. It collects health and
>vital statistics by race and gender but not by class,
>even though, as I have shown, class mortality
>differentials are far larger than race or gender
>differentials.4 Class discrimination is the most
>frequent and least spoken of type of discrimination in
>the United States. The U.S. establishment (including
>the scientific establishment) does not document the
>existence of classes, even though class is the most
>important variable in predicting ways of living and
>dying in this country. Still, although we do not
>publish mortality statistics by class, we can see how
>the enormous inequalities we are experiencing in the
>United States are affecting our population’s health
>indicators. Infant mortality, for the first time since
>1953, has increased, and this is not only the result
>of increased poverty but is also caused by the
>increase of inequalities, with the subsequent growth
>in sense of distance and lack of cohesion that leads
>to ill health. This is the reality behind mortality
>statistics of which you should be aware, and yet, you
>are not. The most effective public intervention in
>reducing mortality in the United States would be to
>reduce the social inequalities among our people. The
>scientific evidence shows this. But in this case the
>science is ignored.
>
>Notes
>
>1. Infant Mortality Tables 1946–2002, National Center
>for Health Statistics, U.S. Department of Health and
>Human Resources, Washington, D.C., 2004.
>
>2. Vicente Navarro, ed., The Political Economy of
>Social Inequalities: Consequences for Health and
>Quality of Life (Amityville, N.Y.: Baywood, 2002).
>
>3. Vicente Navarro, ed., The Political and Social
>Context of Health (Amityville, N.Y.: Baywood, 2004).
>
>4. Vicente Navarro, “Race or Class versus Race and
>Class: Mortality Differentials in the U.S.,” Lancet
>336 (1990): 1238–1240.
>
>For further reading on inequalities and health see
>Vicente Navarro, ed., The Political and Social Context
>of Health (Amityville, N.Y.: Baywood, 2004); and
>Vicente Navarro & Carles Muntaner, eds., Political and
>Economic Determinants of Population Health and
>Well-Being: Controversies and Developments
>(Amityville, N.Y.: Baywood, 2004).
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