The health gap: the challenge of an unequal world
2016; Association of College and Research Libraries; Volume: 53; Issue: 08 Linguagem: Inglês
10.5860/choice.195387
ISSN1943-5975
Autores Tópico(s)Child and Adolescent Psychosocial and Emotional Development
ResumoIn Aldous Huxley’s dystopia, Brave New World, there were fi ve castes. The Alphas and Betas were allowed to develop normally. The Gammas, Deltas, and Epsilons were treated with chemicals to arrest their development intellectually and physically, progressively more aff ected from Gamma to Epsilon. The result: a neatly stratifi ed society with intellectual function, and physical development, correlated with caste. That was satire, wasn’t it? We would never, surely, tolerate a state of aff airs that stratifi ed people, then made it harder for the lower orders, but helped the higher orders, to reach their full potential. Were we to fi nd a chemical in the water, or in food, that was damaging children’s growth and their brains worldwide, and thus their intellectual development and control of emotions, we would clamour for immediate action. Remove the chemical and allow all our children to fl ourish, not only the Alphas and Betas. Stop the injustice now. Yet, unwittingly perhaps, we do tolerate such an unjust state of aff airs with seemingly little clamour for change. The pollutant is called social disadvantage and it has profound eff ects on developing brains and limits children’s intellectual and social development. Note, the pollutant is not only poverty, but also social disadvantage. There is a clear social gradient in intellectual, social, and emotional development—the higher the social position of families the more do children fl ourish and the better they score on all development measures. This stratifi cation in early child development, from Alpha to Epsilon, arises from inequality in social circumstances. Emphasising social circumstances and the social gradient is not to say that all diff erences in early child development can be linked to the social environment. Were the conditions under which children grew and developed to be equalised there would still be diff erences between individuals in cognition and social and emotional development. Twin studies show substantial heritability of cognitive ability, for example. That said, the Flynn eff ect refers to the substantial increases in IQ scores that have occurred over time that are due to the environment, broadly conceived. The evidence shows clearly that social conditions infl uencing parenting aff ect children’s ability to reach their potential and are the major determinants of the social gradient in early child development. This social gradient, in its turn, has a profound eff ect on children’s subsequent life chances. We see a social gradient in school performance and adolescent health; a gradient in the likelihood of being a 20 year old not in employment, education, or training; a gradient in stressful working conditions that damage mental and physical health; a gradient in the quality of communities where people live and work; in social conditions that aff ect older people; and, central to my concern, a social gradient in adult health. A causal thread runs through these stages of the life course from early childhood, through adulthood to older age and to inequalities in health. The best time to start addressing inequalities in health is with equity from the start. But intervention at any stage of the life course can make a diff erence. Relieving adult poverty, paying a living wage, reduction in fuel poverty, improving working conditions, improving neighbourhoods, and taking steps to reduce social isolation in elderly people can save lives. The health gradient to which these life course infl uences give rise is dramatic. There is a cottage industry, taking subway rides in various cities and showing how life expectancy drops a year for each stop. The gap at the ends of the gradient is truly large. In the London Borough of Westminster, UK, there is an 18 year gap in male life expectancy between the most and least salubrious parts of the borough. Similarly, in the US city of Baltimore there is a 20 year gap at the ends of the gradient. 20 years is huge—it is the gap in life expectancy between women in India and in the USA. Health inequalities are perhaps the most damning indictments of social and economic inequalities. These subway rides used social characteristics of area of residence. We see similar social gradients in health if we classify people by education, wealth, income, or occupational status. All societies have social and economic inequalities and all societies have social gradients in health, but the magnitude varies. At the UCL Institute of Health Equity, London, UK, we led a review of social determinants and health inequalities for the European Commission. As part of that review we examined life expectancy at 25 years by level of education. In each country there is a gradient in life expectancy—the higher the level of education, the longer the life expectancy. Three striking fi ndings emerged from the comparison. First, average life expectancy is lower in the countries of central and eastern Europe than in Sweden, Italy, and Norway. In other words we must add to our concern health inequalities between countries as well as those within countries. If we extend beyond Europe we see diff erences in life expectancy of 40 years and more. Second, the gradient is steeper in the east than in the west. Third, and linked to the steeper gradient, the country diff erences in life expectancy are much greater for people with little education than they are for people with tertiary education. The health risks associated with being low status vary greatly. The variation in health inequalities gives grounds for optimism. The data show shallower socioeconomic gradients are possible. Further, Estonia, Romania, and Hungary are able to achieve good health. They do it for people with tertiary education. The challenge is to bring the health level of the more disadvantaged up to the level Lancet 2015; 386: 2442–44
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