To most medical students, social determinants of health have a very specific denotation. They refer to the absolute differences in material resources that can lead to manifestations of poor health. Most students can rattle off examples that fit this definition, such as the lack of food in certain geographic locations that gives rise to food deserts, or the lack of health insurance that has historically plagued minority populations and the poor. An excerpt from U.S. News “Best Graduate Schools 2016” suggests as much when highlighting how advancements in the training of doctors involves providing students clinical experience in resource-poor areas.
As future physicians, understanding the consequences of how absolute resource levels impact health is critical. A physician who advises a better diet to somebody without the ability to act on that advice is of little more use than the physician who prescribes an imaginary medication. However, institutes of medical education do a disservice to their students by keeping the conversation so narrow. Medical schools must begin to more fully teach how relative inequality impacts health.
This brings up an important question: what is relative inequality as a social determinant of health, and how is it different from absolute resource deprivation? Simply put, it is the idea that one’s relative position in a social hierarchy, regardless of whether one is above or below the critical threshold of resources necessary for good health, can intrinsically cause differences in health status.
Consider the following example to help better understand the difference between absolute and relative inequality. According to data compiled by the CIA in its World Factbook, the Gini coefficient for the United States ranks 100 out of 141 countries. The Gini coefficient is a measure that quantifies the income inequality among a country’s population, and the United States is in the bottom 30th percentile, which is close to where a country like Kenya ranks. The United States is far richer than Kenya by almost any economic metric, and even the poor in America tend to have a greater absolute level of resources than the average Kenyan citizen. However, while the average U.S. household may have more resources than the average household in Kenya, the level of relative inequality, the differences in wealth between the haves and have-nots, is remarkably similar.
This existence of inequality is most assuredly not a shocking revelation. However, how many understand why relative inequality is important for health? This issue is critical and woefully under-addressed in current medical school curricula.
Of course, the answer to that question cannot be adequately addressed in one article, hence there is a need for a greater curricular focus. As an overview, work done in the past several decades has elucidated the impact that relative inequality has on health independent of absolute resource access. Take, for example, the representative work of Richard Wilkinson, which has connected economic inequality to health, quality of life and even societal values. The studies of Sir Michael Marmot showed that one’s position in a social gradient correlates with disease and death even in a country with a robust social safety net. More recently, specific changes in the body have been found to correlate with relative social status. Social inequalities, not just absolute access to resources, find a way to get into the body to cause physiological damage via hormonal changes and other biological processes.
Considering this last study, mounting works are going beyond epidemiological research to explore the mechanisms by which relative inequality impacts health. For example, the aforementioned study explores the concept of an allostatic load, or cumulative damage from a heightened stress response, that is generated by relative social inequality and can lead to multiple diseases. Allostatic load, this extra wear and tear on the body due to a dysregulated stress response, is found to be higher in those who are poor and part of certain minority groups, which has been postulated to be due to internalizations of relative inequality and group disadvantage.
The human brain has an incredible ability to compare, whether it is a high school student comparing his shoes to a classmate’s or an adult comparing her car to her peer’s. Therein lies the danger, as Dr. Robert Sapolsky explains in his book “Why Zebras Don’t Get Ulcers”: social hierarchies leave those on the bottom with a consistent and damaging stress response. In this way, the brain tricks itself — the perception of disadvantage is enough to damage health.
An unequal society — even one in which some are simply perceived to be born into privilege — causes poor health the same way a pathogen might. Frighteningly, this occurs despite the fact that many possess the absolute levels of resources necessary for a healthy life.
There is this cornucopia of evidence showing that relative inequality both exists in the United States and impacts health, but why must it be taught to medical students? Physicians are being increasingly called upon to heal not only individual patients, but to improve population health as well. The sentiment that those claiming to practice medicine should recognize their obligation to society is not novel. In the 1800s Virchow famously claimed that “medicine is a social science and politics is nothing else but medicine on a large scale.” However, to practice medicine on a large scale, more future physicians must understand the more nuanced view that health disparities manifest from more than just absolute resource differences.
More consistent teaching of the impacts of relative inequality on health can have important implications for health decisions. Concerning the patient, it would underscore the importance of being empathetic to perceptions, as even perceptions of unequal conditions are powerful enough to have an impact on health. With regard to policy, it informs why future physicians must fight against a growing gap between the one percent and the 99 percent.
Of course, in a neoliberal society, there is going to be competition. Fighting against relative inequality in the name of health is in conflict with a capitalist culture. Some will always win and be relatively better off than others. But, an understanding of the implications of relative inequality can help tilt the balance between the formation of elites and, in turn, benefit society.
Perhaps there should be private incentives for those born with privilege to relinquish some voluntarily to benefit others, lest neoliberalism feed the growth of inequalities. Perhaps this is a task that should be undertaken by government. Even capitalist Adam Smith conceded that government had a role in maintaining certain institutions that were vital to continued flourishing of society as a whole. Forming the policies capable of striking the proper balance between health-saving and competition-promoting policies will be difficult, and it requires educated physicians.
Crafting such policies is “medicine on a large scale,” and it is arguably the most complex practice a physician can join. Yet despite this fact, the average neurosurgeon will receive a decade of training, while intricacies of health disparities are currently brushed over in only a couple of hours.
In a country of relative wealth, a shift to teaching the role of relative inequality in health formation within medical school curricula can be a powerful move towards reducing health disparities.
Contributing Writer
Cleveland Clinic Lerner College of Medicine
Alexander Chaitoff completed his undergraduate work at The Ohio State University and his Master of Public Health at the University of Sheffield. Interested in the nexus of health and society, he has worked in numerous research settings, including for the Ohio State University College of Public Health and Cleveland Clinic, as well as in multiple policy settings, including the United States Department of Health and Human Services and the National Health Service. In 2010, he co-founded the 501(c)3 nonprofit organization the Pure Water Access Project, Inc., a group for which he still serves as a member of the Board of Trustees. Alex is currently a second year medical student at the Cleveland Clinic Lerner College of Medicine.