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Advocating for Action Toward a Healthier Society


Hierarchy and health

The most basic factor affecting the health of a population appears to be the range of the hierarchy—the range between the haves and have nots—in a society. Such an idea is counter-intuitive for most of us; we are raised to think that our behaviors most strongly influence our health. Behaviors are important, but studies looking at the bigger picture—health in populations as a whole—suggest that behavior has less effect than do the rules governing the hierarchical structure of society.

Economic equality is best medicine, Stephen Bezruchka, MD (Seattle Post-Intelligencer, June 25, 2006)

Is our society making you sick, Stephen Bezruchka, MD (Newsweek, Feb. 26 2001, p 14 )
Is globalization dangerous to your health, Stephen Besruchka, MD (Western Journal of Medicine)
Globalization proves hazardous to health, Are the rich making us sick, Stephen Bezruchka, MD (Washington Free Press)

Health inequality/Socioeconomic status and health

For at least 30 years, it has been recognized that poor people have poor health and that their poverty is not because of their poor health. Health inequalities is the term used in the United Kingdom and Europe for this observation. In the U.S., it is called socioeocomic status and health. The range of income distribution, or relative deprivation, is probably a key factor in producing this disparity. The reasons for the association between health and poverty are elusive, and not explained by differences in behavioral risk factorssuch as smoking or relative weight, or even by access to medical care. The range of income distribution, or relative deprivation, is probably a key factor in producing this disparity.

Unhealthy Societies: the afflictions of inequality. Wilkinson RG. (1996). London: Routledge.

See a list of other publications on this topic.

General material on social determinants of health

The health status of a population is strongly influenced by the nature of its social relations, considered very generally. We can consider these relations in many ways: social class, economic status, social networks, political systems, social stress, poverty, and environmental relations. It all comes down to the ways in which the rules governing relations in a society are constructed.

The Health of Nations: Why Inequality Is Harmful to Your Health. Kawachi, I. and B. P. Kennedy (2002). New York, New Press. Read Dr. Bezruchka's review of this book on Amazon.

See more publications on this topic.

Overviews, reviews on hierarchy

These scientific papers and books present an overview of factors that affect the health of a population, concentrating on hierarchy, which is perhaps the most significant factor when considering health as measured by life expectancy or infant mortality. See a list of publications on this topic.

Income inequality and health: within country comparisons

These papers were the first to demonstrate the association between income inequality and various measures of health within divisions of a country. They overcome the difficulties of finding consistent data among countries. See a list of publications on this topic.

International comparisons

These papers discuss the studies that first demonstrated the association between income inequality and various measures of health in countries. They are published in public health, medical, or economics journals. Most of them require some familiarity of epidemiology. See a list of publications on this topic.

Economic & Social Data Ranking / Developed countries (OECD)
Compare countries on categories of social determinants.

A central data source and another way to graphically compare nations.

UN Development Program Human Development Report
The annual UNDP Human Development Report listing countries ranked by life expectancy.

Relative deprivation and social problems, especially violence and homicide, and social cohesion

Hierarchy—the range between the haves and have nots, or relative deprivation, in a population—appears to be associated with many social factors. These papers demonstrate some of the factors related to violence, which are linked with measures of community cohesion. See a list of publications on this topic.


Egalitarianism sees equality of condition, outcome, reward, and privilege as a key goal in how a society is organized. Societies that share resources have caring social relationships that are considerably different from those that discourage sharing and in which power relationships elevate some to great status. See a list of publications on this topic.

Psychosocial conditions and health

These papers, dealing with hopelessness, social networks, relative hierarchy, and family conflict, shed light on the aspects of social hierarchy that are measured by income distribution and have health effects. See a list of publications on this topic.

Biological mechanisms to explain the hierarchy/health relationship

How does hierarchy or income inequality in a population translate into mechanisms that affect a population's health? These publications, looking mostly at primate populations, begin to tackle this question. See a list of publications on this topic.

Criticisms of the hierarchy/health relationship

The criticisms of the hypothesis that our health as a population is related to structural factors that determine the range of hierarchy or status differences between the rich and poor, to date, fall generally into two domains. One, put forth mostly by economists, focuses on the limitations of income distribution as a measure of hierarchy. The other questions whether relative deprivation works by limiting what the lower classes can obtain or purchase to produce health or whether it is the psychosocial nature of human relationships in societies that matters more. See a list of publications on this topic.

Research and measurement techniques

Understanding how social relations affect health requires a different way of asking questions and doing research. The typical way is to look at a risk factor, such as diet or tobacco use and see if it affects a disease, or administer a treatment to one group of people and compare the intervention group to anothe group that doesn't get the treatment. In considering social issues, studies must look at large populations, follow them over long periods of time, and try to find measurements that represent social, economic, political, and environmental factors during the course of the study. Although the results of such investigations tend to produce findings that help understand huge discrepancies in health outcomes, they are inherently more difficult to carry out and are very costly. These articles are primarily for academic researchers. See a list of publications on this topic.

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