Deconstructing Health Inequity A Perceptual Control Theory Perspective 1St Edition Timothy A Carey Full Chapter
Deconstructing Health Inequity A Perceptual Control Theory Perspective 1St Edition Timothy A Carey Full Chapter
Deconstructing Health Inequity A Perceptual Control Theory Perspective 1St Edition Timothy A Carey Full Chapter
Timothy A. Carey
Sara J. Tai
Robert Griffiths
Deconstructing
Health Inequity
A Perceptual Control Theory Perspective
Timothy A. Carey Sara J. Tai
Institute of Global Health Equity University of Manchester
Research Manchester, UK
University of Global Health Equity
Kigali, Rwanda
Robert Griffiths
University of Manchester
Manchester, UK
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Foreword
v
vi FOREWORD
level the analysis draws attention to the classic issue concerning the impact
of structure and agency on human behaviour. From a structural perspec-
tive, individual outcomes are seen to be governed by abstract forces (e.g.
class, institutionalised racism, economic inequality) emanating from the
social structure; from the perspective of agency, outcomes are seen as
more influenced by subjective responses to the environmental context in
which one exists.
Carey, Tai, and Griffiths’ analysis underscores the extent to which the
abstract forces of structural theory dominate the explanation of health
inequities. Seeking to clarify the theoretical basis for the prevailing expla-
nation of health inequities, they ask the logical question: What is the
causal link between economic inequality and adverse health outcomes?
According to Richard Wilkinson and Kate Pickett’s widely cited research,
the standard answer is that income inequality generates psychological
stress, which is empirically shown to have deleterious effects on physical
and mental health. Really, ask Carey, Tai, and Griffiths: “Are we really that
fickle as a species that we can become psychologically and socially debili-
tated, as well as seriously compromised by life-threatening physical health
conditions, at the idea of people doing better than us?” And how does
this causal line of reasoning square with Wilkinson and Pickett’s finding
that people tend to compare themselves with others who were similar to
them, not those considerably higher on the economic ladder or the reality
that most people do not know the degree of inequality in their country,
how much it is changing and where they place in the income distribution.
Stress may cause illness, but there is no empirical evidence that inequality
(not abject poverty) causes stress.
This persuasive analysis of the implausible line of reasoning in the
economic-inequality-health-inequities chain of causality is followed by
the authors’ painstaking examination of the empirical evidence, which
reveals a body of research racked by methodological weakness, statistical
anomalies, contradictory findings, and a general absence of conceptual
clarity. Indeed, their findings lend detailed substantive verification to an
earlier review of 98 studies that reports “little support for the idea that
income inequality is a major, generalizable determinant of population
health differences within or between rich countries”.1
1 Lynch, J., Smith, G. D., Harper, S., Hillemeier, M., Ross, N., Kaplan, G. A., et al.
(2004). Is income inequality a determinant of population health: part 1. A systematic
review. Milbank Quarterly, 82(1), 5–99.
FOREWORD vii
Neil Gilbert is the Milton and Gertrude Chernin Professor of Social Welfare at
the University of California, Berkeley.
Preface
We hadn’t originally planned a Preface for this book, however, some very
useful suggestions by two anonymous reviewers encouraged us to see the
value in pre-empting what you might be about to encounter.
There is a Congolese saying that:
No matter how hard you throw a dead fish in the water, it still won’t swim.1
We think this wisdom is a fitting way to set the context for the Preface. In
many ways, this short introduction is a warning of what lies ahead. This
book is about letting go of that fish so it can drift away.
We are not even recommending seeking another fish from the same
body of water. Fundamentally, this book is a suggestion that we visit an
alternative body of water where there are different fish, even fish that
swim against the current. There might even be creatures we haven’t yet
anticipated.
If you are satisfied with the current state of play in the health inequity
field, this book will not be for you. You might think that there is more
1 Stearns, J. K. (2011). Dancing in the glory of monsters: The collapse of the Congo and
the Great War of Africa. New York: PublicAffairs.
ix
x PREFACE
Index 169
xiii
About the Authors
xv
List of Figures
xvii
List of Tables
xix
xx LIST OF TABLES
Sometimes, some things just don’t add up. For us, health inequity is one
of those things.
We have a lot of expertise in the field of mental health. Collectively,
we have accumulated decades of experience working in different settings
with different people. We’ve worked in numerous inner-city services, as
well as rural and underserved communities, in places such as England,
Scotland, Ireland, Australia, the United States (US), and Europe. We’ve
also worked in remote and very remote communities of the central
Australian desert. Since the beginning of 2020, Tim (first author) has
been working at the University of Global Health Equity in Rwanda. We’ve
worked in primary care, secondary care, schools, inpatient wards, and
prisons. We’ve worked with people from a range of different cultural and
ethnic backgrounds, and with a wide range of psychological and social
difficulties. We’ve developed and conducted many hours of training for
other health professionals and have provided countless hours of supervi-
sion for different researchers and clinicians. We’ve created and evaluated
innovations such as patient-led appointment scheduling, an effective and
efficient first-person perspective a-diagnostic cognitive therapy, an online
mental health university course, self-care training for health professionals,
and smart phone apps. Almost our entire professional lives, and a good
deal of our personal ones, have been geared towards helping ourselves
and other people live contented lives.
One thing was clear to us by now. The problem was definitely not due to
a lack of resources. The problem, primarily, seemed to be one of distri-
bution. Hickel (2017, p. 47), for example, points out that “Hunger is
not a problem of lack. It is a problem of distribution. A disproportionate
amount of the world’s food ends up flowing to rich countries, where
much of it ends up as waste.” According to Hickel (2017), enough food
is produced each year so that every global citizen could consume 3000
calories daily.
4 T. A. CAREY ET AL.
So, why should it matter if the person in the apartment across the hall
earns more than you, or if other parents from your child’s class go abroad
for their holidays? Are we really that fickle as a species that we can become
psychologically and socially debilitated, as well as seriously compromised
by life-threatening physical health conditions, at the idea of people doing
better than us? And if that’s the case, why is it apparently so much worse
in societies where those with the least money, and those with the most
money, are a long way apart? Do people in a given society have any idea
of the incomes of their poorest and richest residents?
To help us resolve our growing sense of bewilderment, we constructed
a table to think through some of the information we encountered (see
Table 1.1). In simplistic terms, our understanding of the general idea
being communicated is that, in countries where there is a large differ-
ence between the richest and the poorest, and particularly in developed
countries, there is a raft of serious physical, psychological, and social prob-
lems that affect everyone on the income continuum, from the ones at the
very bottom to those at the pinnacle. In countries where the difference
between the richest and the poorest is not so great, there are fewer prob-
lems. Since a lot of the research seems to draw a distinction between
the developed and developing nations, for the purpose of this thought
exercise, we focus on developed countries.
The conclusions we reached as we mulled over these ideas were that
health and social living in Country A (see Table 1.1) would be much
worse than in Countries B and C, because Country A has startling income
inequity compared with the other two countries (14 compared with 3 on
the fictitious scale we are using for the point of this exercise). Health and
Table 1.1 An illustration of the way in which income inequities could manifest
in different developed countries
*Income Units Income
Income
Country Inequity
Inequity Poorest Richest Measure
High A 1 15 14
B 2 5 3
Low
C 9 12 3
*These are hypothe cal income units for the purpose of
illustra on with lower numbers indica ng less income, and higher
numbers indica ng greater income.
1 BEGINNING THE SEARCH FOR ANSWERS 5
The key distinction between the terms inequality and inequity is that the
former is simply a dimensional description employed whenever quantities
are unequal, while the latter requires passing a moral judgment that the
inequality is wrong.
Explaining Why Income Inequity Might Have the Effect That It Does
While we were intrigued about the extent of the reported association
between income inequity and physical, psychological, and social func-
tioning, we were especially surprised at the explanations given for this
relationship. Wilkinson and Pickett (2018, p. xxi), for example, argue
that “if well-educated people with good jobs and incomes lived with the
same jobs and incomes in a more equal society, they would be likely to
live a little longer and less likely to become victims of violence; their
children might do a little better at school and would be less likely to
become teenage parents or to develop serious drug problems”. This is
an example of the reasoning we were depicting in Table 1.1. Wilkinson
and Pickett (2018, p. xxi) go on to suggest that the issue is “the way
larger income differences across a society immerse everyone more deeply
in issues of status competition and hierarchy”. They explain that “these
problems are driven by the stress of social status differences themselves,
stresses which get worse the lower you are on the social ladder and the
bigger the status differences. In effect, bigger income differences make
status differences more potent” (Wilkinson & Pickett, 2018, p. xxii). In
the same source, Wilkinson and Pickett (2018, p. 25) clarify their posi-
tion by suggesting that although “low incomes limit what poorer people
can buy, they leave status aspirations undiminished – or even heightened
– by the desire to escape the stigma of low social status”. They also
link extreme shyness, which they acknowledge can be diagnosed as social
phobia or social anxiety disorder, to income inequity, and they report that
the prevalence of people diagnosed with social anxiety disorder in the
US has increased over three decades from 2% to 12% of the population
(Wilkinson & Pickett, 2018).
It was perhaps our familiarity with the mental health field that indi-
cated to us that there might be something amiss with the explanatory
conclusions being drawn in the inequity arena. There is, in fact, a volumi-
nous literature outlining the many different problems with the Western
biomedical approach to understanding psychological and social func-
tioning as it is described in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM 5; American Psychiatric
Association, APA, 2013). Timimi (2014) provides an excellent overview
of some of the major problems. Social phobia was created and first
introduced into the DSM system in its third edition in 1980 (Whitaker
& Cosgrove, 2015). There is compelling evidence that the explosion
1 BEGINNING THE SEARCH FOR ANSWERS 13
colleagues, not with people who were far away on the social ladder. To
the extent that people engage in social comparisons at all, if they only
compare themselves to those with whom they are similar, we could not
understand the significance of a wide income gap. Perhaps part of the
problem here is the application of findings obtained from population level
data to individual lives.
although they could not see the gentle face of their beloved daughter, they might be
sure that she had found a second father, who would ever watch over her happiness,
and never permit her to want anything he could procure her.
A few short months and Arthur’s death had left the little Spanish
Princess, then not seventeen years old, a widow in a strange land;
while fatherly kindness wrangled furiously over the cost of her
maintenance and the disposition of her dowry. It was well for the
immediate fortunes of Catherine of Aragon that she soon found a
husband in Arthur’s younger brother Prince Henry, though perhaps,
could she have read the future, she would have preferred to decline
the honour.
De Puebla, the Spanish Ambassador entrusted by Ferdinand with
the greater part of the marriage negotiations, had also tried his hand
during the years that he resided in England, at enticing the King of
Scotland into the anti-French web. The friendship between France
and Scotland was of ancient date; but De Puebla felt that the offer of
a royal bride from the Spanish Court would make a deep impression
on King James’s susceptible vanity, and since, at the date when this
idea occurred to him, all the Spanish Infantas were either married or
betrothed, he suggested instead Doña Juana, one of Ferdinand’s
illegitimate daughters, concealing as he believed with considerable
statesmanship the fact of the bar sinister. Ferdinand, when he heard
of it, was most contemptuous. Such a deception, he wrote, could not
possibly be maintained and therefore was not worth the lie. Let De
Puebla, on the other hand, hold out false hopes if he could of one of
the real Princesses, and by this bait induce the Scottish monarch to
quarrel with France. Even moderate success in this strategy would
prove of considerable value.
James IV. did not marry a Spanish Princess but Catherine of
Aragon’s sister-in-law Margaret Tudor; and what harm he might
inflict on Spain and her Allies in French interests was a mere pin-
prick to the stab administered by Ferdinand’s immediate family. On
the death of Prince Miguel in July, 1500, Joanna, Archduchess of
Austria, became heiress to the throne of Castile and Aragon; and,
though there was cause for rejoicing that a son had been born to her
early in the same year and thus the succession was assured, yet the
situation arising from the new importance of her position tended
every day to grow more critical. Joanna and her husband had been
from the first an ill-matched pair, his light careless nature acting like
a spark to fire the mine of her sullen temper and quick jealousy; and
his faithlessness and her lack of self-control combined to keep the
Flemish Court in a perpetual flame of scandal.
Had they been merely private individuals, the evil effects of their
passions might have spread no further than the street or town in
which they lived; but unfortunately Joanna had gone to Flanders not
merely as a bride but as an agent to influence her husband’s policy in
her father’s favour, and the odium and exasperation her behaviour
aroused reacted to the detriment of Spain. Philip had nothing in
common with the Castilian race. Their pride irritated him, their deep
religious feeling awoke his incredulity, their sense of reverence and
gravity a flippant scorn and boredom, that his selfishness found it
difficult to disguise. Personal tastes inclined him rather to the
volatile, easy-mannered Frenchman; and, as domestic differences
increased, so also did his dislike for the Aragonese and sympathy
with their enemies.
“The French rule everything,” wrote Fuensalida, the Spanish
Ambassador at the Archduke’s Court despairingly. “They alone
surround him and entice him from feast to feast, from mistress to
mistress.”
TILTING ARMOUR OF PHILIP THE
FAIR
My hand [says Peter Martyr] falls powerless by my side for very sorrow. The
world has lost its noblest ornament ... for she was the mirror of every virtue, the
shield of the innocent, and an avenging sword to the wicked.
It has pleased Our Lord [wrote Ferdinand to the chief citizens of Madrid] to take
to Himself the Most Serene Queen Doña Isabel, my very dear and well-beloved
wife; and although her loss is for me the greatest heaviness that this world held in
store ... yet, seeing that her death was as holy and catholic as her life, we may
believe that Our Lord has received her into His glory, that is a greater and more
lasting kingdom than any here on earth.
The day after her death, the coffin with its funeral cortège left
Medina del Campo for Granada, amid a hurricane of wind and rain
such as the land had rarely witnessed. Peter Martyr, who was one of
the escort, declared that the Heavens opened, pouring down torrents
that drove the horsemen to shelter in the ditches by the wayside,
while the mules sank exhausted and terrified in the road. Never for a
moment was there a gleam of either sun or star, until on December
25th, as the funeral procession entered Granada, the clouds lifted for
the first time.
There in the city of her triumph, in the Franciscan monastery of
the Alhambra, the very heart of the kingdom she had won for
Christianity, Isabel of Castile was laid to rest.
CHAPTER XIII
CASTILIAN LITERATURE