HEALTH INEQUALITIES (ESSAY)
Over past decades most
countries around the world have seen widespread disparity in the society,
wealth, race and gender. These disparities have affected the health status
of the countries badly. Those countries which succeeded to keep the
disparity under control eventually succeeded in improving the health of
people. Some countries despite their huge economic growth failed to
improve health and registered higher mortality in their population because
of widened socioeconomic gap. Whilst some European countries have taken
positive measures to reduce the inequality in their population, Pakistan
has a very long way to go. Pakistan’s socio-cultural practice, religious
influence, growing population and market driven policies to elevate its
dooming economy have made a huge gap between rich and poor. It is the time
for Pakistani government to take a holistic approach with inter-sector
collaboration to curb this gap.
Health Inequalities in
Pakistan is an important issue. There are several factors responsible for
the inequalities in health, for example, social, economic, gender and age
related factors. Social inequalities in health are health gap
in the population because of wealth, education, occupation, racial group,
ethnicity, gender and rural or urban locality (Braveman, Starfield and
Geiger, 2001). Persistence of communicable diseases in less developed
countries and emergence of multi risk factorial non communicable chronic
diseases in developed countries are mainly due to the inequalities in the
health care access and system.
Socioeconomic factors top
the reasons of health inequalities. It has been said that higher the
socioeconomic status (SES), better the health. In this term, every high
SES has better life expectancy than its next SES and poor are the worst
sufferers. Studies carried out in Great Britain among the civil servants
suggested that those who worked as grade 32 civil servants had better life
expectancy than the grade 31 civil servants, who had better life
expectancy than grade 30 workers (Navarro, 2004).
Similar results were found in a study in Spain. According to
Navarro (2004), researchers in Britain
found that the most significant increase in life expectancy of British
people was noted during Second World War. The most important factor for
this surprising result was the reduction in the social gap between people.
People from all the social classes united during the war and this in fact
led to increase in the life expectancy. Although, this research did not
clarify whether they considered the death of thousands of soldiers during
war into account or not, those who survived lived longer. Navarro (2004)
also suggests that after change of Britain’s policies that were more
liberalizing caused reduction in the pace of increasing life expectancy of
its people which strongly suggest the positive correlation between
socioeconomic gap and health inequality.
Therefore, for a country
to have good health, it is important that there should be minimum gap
between rich and poor. Pakistan has very high religious and cultural
influence on its people. According to the religious and cultural
practices, people are divided into multilayer social status. In this
multilayer social status system, higher status gets better treatment; by
all the sectors including health. Sometimes, the privilege also goes to
the religious groups. Pakistan has its majority of population living in
rural areas. Most health care services and funding are often directed
towards urban areas ignoring large chunk of rural population.
An age adjusted study
carried out in Texas, United States to review the mortality of rural and
urban population between 1990 and 2000 according to race, ethnicity and
gender suggested that rural population suffered from most diseases
including cancer, heart disease, diabetes, stroke, and respiratory
diseases more than the urban population (McGehee,
2004). The study also suggested that black people suffered more
death rates in metropolitan area, while Hispanic people had higher
mortality in non metropolitan areas.
A cross-sectional survey
carried out in Geneva, Switzerland between 1993 and 2000 suggests that
many risk factors and chronic diseases like obesity, smoking, physical
inactivity and high blood pressure are more prevalent among the low SES
people as compared to high SES (Galobardes et al, 2003). If WHO capital
(Geneva) hasn’t done up to the mark to remove gap of SES, no wonder
Pakistan has long way to go. However, to wait until the developed
countries come up with some strategy would be a wrong justification.
Pakistan is one of the
poorest countries in the world. Many people live below the poverty line
and can not access or afford the health care system. Rather, approaching
health care comes at the bottom of their priorities way after food, house,
and family and so on. An attempt by government to boost its dying economy
led to changes which would adopt American markets. There is no doubt that
this change has improved Pakistan’s economy, but rich have become richer
and poor, poorer. This attempt has led to increase in the gap between rich
and poor people. Many tertiary hospitals are built but only a few people
can afford to access those services. There are many risk factors directly
related to the poor economic conditions, like under-nutrition, poor
housing conditions, poor sanitation, poor drinking water, difficult access
to health care services, etc. All these lead to a multiple diseases like
Tuberculosis, water born diseases, communicable diseases. Poor SES also
leads to higher crime rate, homicide, suicide among youngsters causing a
number of potential life years lost.
Economic disparity not
only threatens public health, it also slows the economic growth.
Mackenbach (2002) suggest that many
economists consider economic gap in society as an indicator of poor
health. He cites the Harvard graduate Kennedy and Kawachi who interpreted
that the income inequality that occurred in U.S. in 80s and 90s led to
long working hours, less time with family, increased crime rate, and
eventually worsening the health and economic conditions of U.S.
Gender influence is
another factor for health inequalities and mortality. Some of the diseases
and health problems are confined to one particular sex. Pakistan has deep
rooted religious practices and rituals which prevent the women to avail
the access of many health services. Women are highly dependent on their
husbands and family-in-laws for the health status. They should be
accompanied by one male member of their families to go to the clinics;
moreover critical decisions of total number of children in the family,
family planning and termination of pregnancy are taken by their
family-in-laws.
A high infant mortality
and child death rates in Pakistan indicate health inequalities with age as
factor. High infant mortality rate is a huge burden on health because it
is responsible for maximum life year lost. This is not the case with only
Pakistan. United States despite its economic boom in last two decades had
rather widened the gap between rich and poor. This led to increase in the
infant mortality rates in past two decades (Navarro,
2004).
The influence of
socioeconomic and gender on health status of a person has been observed
over years. W.H.O. in its Solid Facts (Marmot and
Wilkinson, 2003) describes that higher socioeconomic gradient is
one of the most important factors in a country’s and hence, a person’s
health status. Whilst the government controlled health care system
countries are working towards minimizing the socioeconomic gradient,
market driven individualistic countries like US are also concerned about
the importance of this gradient.
There are enough evidences
which suggest that income inequalities are directly related to higher
mortality; hence, only the economic growth of a country is not necessarily
related to the improvement of a country’s health (Pearce
and Smith, 2003). Many countries with higher gross domestic product
(GDP) and gross national product (GNP) have a poor health conditions than
some of the poor countries or states that have successfully minimized the
socioeconomic gap. Countries like China and India state Kerala do not have
the best of economies and yet, they have their health status quite
comparable with the developed countries and have higher life expectancy (Pearce
and Smith, 2003).
Nonetheless, for
implementing a strong policy for equitable health services, growing
economy of a country is vital. When most countries were successfully
adopting policies to reduce inequalities in Europe, Finland could not
implement its policy because of the recession in early 1990s (Mackenback
and Bakker, 2003). Less developed countries like Pakistan need a
holistic approach by its all government sectors to combat the inequalities
and promote a policy for equitable health services.
The developed countries
have started making policies which would reduce the socioeconomic
gradients. Many European countries have started developing strategies to
shorten the gap of SES to reduce the health inequalities in past one
decade (Mackenbach and Bakker, 2003).
Sweden, France and The Netherlands have adopted multiple policies which
are targeted against the health inequalities. Improve child education,
organize annual health checkups, improve employment opportunities are the
part of these policies (Mackenback and Bakker,
2003). While European countries are trying to develop policies to
reduce the socioeconomic gap between different classes, U.S. does not have
any class layer system and its policies are targeted at reducing the
income gap between different race and ethnicity (Rathore and Krumholz,
2004).
Ruger (2004) suggests that
for a successful policy towards combating inequalities, the policy should
not only emphasize socioeconomic determinants, but should take a holistic
approach. First of all, the factors responsible for the increased
socioeconomic gap should be determined and then the policy should be
targeted to each of them. According to Ruger (2004), the orthodox health
policies should be changed. Moreover, all the policies which affect the
health policies indirectly or directly, including social and economic
policies should be changed altogether. While some people suggest
abolishing the multilayer hierarchy in the society simultaneously, others
do not agree to this idea and suggest understanding the factors and
political structure of a society and then working on them objectively
(Ruger, 2004).
However, to make such
solid policies, enough data and political will are essential. There are
not enough data provided in Pakistan which would point at one particular
disease mortality to the population inequality as its root cause.
Frequently changing governments are the hindrance in making one solid
policy. The influence of religion and religious practitioners is more on
people than the politicians, which prevents the governments to take some
strong actions against the rich and so-called influential people. Less
developed countries like Pakistan highly rely on W.H.O. for the guidelines
and policies of health and it is surprising the WHO itself is not very
conscious for the issue of health inequalities. In the world health report
2000 the issue of population inequality in health is completely ignored.
According to Braveman, Starfield and Geiger (2001) the world health report
2000 hasn’t measured the socioeconomic factors and other inequality issues
within countries and hasn’t given any specific guidelines to make national
policies.
Pakistan government has to
take holistic approach to lessen the gap between rich and poor. The
social, economic and health departments have to work together along with
all the departments which indirectly affect the health of people. Policies
should be made which would educate people and reduce the religious
influence on people. Government should also make policies which guarantees
employment to the most people. Moreover, rather than dragging towards
Americanized market driven society, redistribution of wealth should be
done to facilitate similar income range among all people. Women
empowerment is an important thing in Pakistan. Removing inequalities from
Pakistan would eventually push each government department into action for
a holistic collaboration among them.
In the end, socioeconomic
and gender inequalities are main disparities which affect the health of
people. Some European countries have taken the initiatives and policies to
reduce the inequality despite strong influence by liberal policies of U.S.
Pakistan, which also adopts the liberal policies of U.S. to improve its
economy has further widened its already big socioeconomic gap. A holistic
and inter-sector approach to combat the ever rising inequality is needed
for the betterment of health of people.
References:
Braveman, P., Starfield,
B. and Geiger, J. (2001) World Health Report 2000: how it removes equity
from the agenda for public health monitoring and policy. BMJ; 323:
678-681.
Galobardes,
B.,
Costanza, M.,
Bernstein, M.,
Delhumeau, C.
and
Morabia,
A. (2003)
Trends in risk factors
for lifestyle-related diseases by socioeconomic position in Geneva,
Switzerland, 1993-2000: Health inequalities persist. American Journal of
Public Health; 93 (8): 1302.
Mackenbac, J. (2002) Inequality, health
and the economy. The Lancet; 360 (9347): 1794.
Mackenbach, J. and Bakker,
M. (2003) Tackling
socioeconomic inequalities in health: Analysis of European experiences.
The Lancet; 362 (9393): 1409.
McGehee, M., Hall, S. and
Murdock, S. (2004)
Rural and Urban Death
Rates by Race/Ethnicity and Gender, Texas: 1990 and 2000.
Journal of
Multicultural Nursing & Health. 10 (2): 13-23.
Marmot, M. and Wilkinson, R. (ED) (2003)
Social determinants of health. The solid facts. (2nd
Ed). World Health Organization: Europe.
Navarro, V. (2004)
Inequalities are Unhealthy. Monthly Review; 56 (2): 26-30.
Pearce, N. and Smith, G.
(2003) Is social capital the key
to inequalities in health? American Journal of Public Health; 93 (1):
122-129.
Rathore, S. and Krumholz,
H. (2004)
Differences,
Disparities, and Biases: Clarifying Racial Variations in Health Care Use.
Annals of Internal Medicine; 141 (8): 635-638.
Ruger, J. (2004) Ethics of the social
determinants of health. The Lancet; 364 (9439): 1092-1097.