Macro-Social Influences - Health Psychology in the Context of Biology, Society and Methodology

Health Psychology: Theory, Research and Practice - David F. Marks 2010

Macro-Social Influences
Health Psychology in the Context of Biology, Society and Methodology

’As in earlier times, advances in the 21st century will be won by human struggle against divisive values — and against the opposition of entrenched economic and political interests.’

Human Development Report (2000: 6)


We employ a wide-angle lens to explore the macro-social context for human health. We discuss the fact that what individuals can do to change their lives is not simply a matter of personal choice; choices are constrained biologically, culturally, economically and environmentally. In spite of medical and technological advances, population growth, the globalized promotion of unhealthy commodities, increasing poverty and the shrinking availability of natural resources, especially safe drinking water, are acting to worsen health globally. Universal gradients both within and between nations are persistent over time and space. The ’doom and gloom’ prospects for human beings described in this chapter are not an inevitability, however. The prospects can be improved if elected governments take appropriate action to intervene independently from corporate interests.

Facts of Life and Death

Where a baby is born and the mother’s access to water, food and education determine whether the baby lives or dies. A baby in Sierra Leone has a 72% chance, while a Japanese baby has a 96% chance of reaching the age of 5. Health inequalities have always existed; in this chapter, we examine why.

Each individual human is a creation of genetics, environmental experience and the interaction between the two (see Chapter 3). The environment can be broken down into macro and micro levels. The macro-social environment affects health and well-being in a huge variety of ways. The term macro-social refers to large-scale social, economic, political and cultural forces that influence the life course of masses of people simultaneously. Macro-social influences include actions and policies of governmental organizations, non-governmental organizations (NGOs), cultures, historical legacies, organized religions, multinational corporations and banks, and unpredictable, large-scale environmental events, all of which have the potential to influence huge sectors of the entire human race.

First, devastating ’acts of God’ can have severe consequences for individuals and communities. The short- and long-term health impacts of these events are moderated by international readiness to respond. Interdisciplinary Emergency Response Teams can ameliorate the impact of natural disaster and extreme weather events, including earthquakes (Ding and Xia, 2013; Gan et al., 2013), tsunamis (Cassim et al., 2015), volcanic activity (Lowe and de Lange, 2000), droughts and famines (Wisner et al., 2004), floods (Alderman et al., 2012), hurricanes (Brodie et al., 2006; Scheib and Lykes, 2013) and typhoons (Cranmer and Biddinger, 2014). Microblogging on Twitter and other social media is helpful in expediting rapid disaster response (Tapia et al., 2013).

Second, a variety of pandemics that spread across continents include typhoid, cholera, avian flu (Shinya et al., 2006), influenza (Karademas et al., 2013; Mo and Lau, 2014; Flowers et al., 2016) and HIV-infection (Pellowski et al., 2013; Rohleder, 2016).

Third, the scourges of war, genocide, sectarian violence and terrorism take a significant toll with multiple deaths, injuries and trauma (De Jong and Kleber, 2007; Medeiros, 2007; Ciccone et al., 2008; Maguen et al., 2010; Zerach et al., 2013).

Fourth, the legacies of colonial genocide take centuries to heal. Indigenous ’First Nation’ communities have consistently disproportionate rates of psychiatric distress that are associated with historical experiences of European colonization (Gone, 2013). Aboriginal children experience a greater burden of ill health compared with other children, and these health inequities have persisted for hundreds of years (Greenwood and de Leeuw, 2012). Effective partnerships between Aboriginal and ’mainstream’ health services can be ’tenuous and unproductive’ owing to tensions from historical race relations (Taylor and Thompson, 2011).

Fifth, human recklessness with fossil fuels is causing global warming, climate change, rising sea temperatures, acid rain, coral bleaching, global dimming, ozone depletion, biodiversity loss and rising water levels, all transforming life on this planet as we know it (Pearce, 2009).

Sixth, the use of fossil fuels is peaking and, as oil and gas reserves run out, have become more costly; the world economy could go into decline, with significantly decreased agriculture and food production (Murphy and Hall, 2011; Pfeiffer, 2013).

Seventh, increasing poverty makes life a struggle for survival for a billion people. In spite of progress, almost 870 million people were chronically undernourished in 2010—12, the majority living in developing countries, where 850 million people, or 15% of the population, were estimated to be undernourished (Food and Agriculture Organization, 2012).

Eighth, lack of clean drinking water is a major cause of suffering, disease and early deaths: 3.4 million people die each year from a water-related disease, with 780 million people lacking access to clean drinking water; 2.5 billion people have no access to a toilet (, 2014;

The message of this chapter is summarized thus: what individuals can do to change their lives is not simply a matter of personal choice — such changes are constrained politically, economically and culturally. In the globalized economy, everything is interconnected. Macro-social economic, political and cultural factors create the context for everything else, including health, illness and health care.

Policy, Ideology and Discourse

The dominant discourse within neoliberal health policy has been that of the autonomous individual, in which each individual is an agent, responsible for his/her own health. The ideology of individualism dictates that each person is motivated by self-interest to elevate his/her well-being with the least effort and resources possible. Deep within the ideological substratum of modern culture lurks the credo of individualism — ’each man for himself’ — making his/her choices, and taking the consequences, as in: ’You made your bed, now lie in it.’ Theories in health psychology are imbued with this cultural presumption. The existential truth of ’do or die’ is embellished in polite language as ’making informed choices’.

The cult of the individual has spawned the notion of the responsible consumer (RC). The RC is an active processor of information and knowledge concerning health and illness. He/she makes rational decisions and responsible choices to optimize well-being. The epitome of the RC is the hypothecated ’anything in moderation’ person who eats five-a-day, never smokes, drinks alcohol in moderation, exercises vigorously for at least 30 minutes three times a week, always uses a condom when having sex, and sleeps eight hours a day. The stereotype of the more common ’irresponsible consumer’ (IC) is the so-called ’couch potato’ who enjoys beer and cola, smokes, eats junk food, watches TV for many hours each day, and rarely takes exercise. Accordingly, responsibility for illness relating to personal lifestyle is seen as the fault of the individual, not an inevitable facet of a social, corporate, economic environment designed to maximize shareholder profits.

Using a mixture of well-intentioned pleading, information and advice, the traditional approach to health education aimed to persuade people to change their habits and lifestyles. Information campaigns designed to sway consumers into healthier living were the order of the day. Combined with policy and taxation, health education justifiably can claim some limited success over the last 50 years, e.g., the fall in lung cancer rates. Tobacco control has become a benchmark for what may be achieved through consistent public policy, educational campaigns and behaviour change. A major public health call today is for a vigorous campaign to halt the obesity epidemic. If similar methods are deployed to those used for tobacco (i.e., voluntary controls, advertising restrictions, product labelling, health education), then the evidence suggests that it could take at least 50—70 years before obesity rates can be expected to go into any noticeable decline (Marks, 2016b).

In recent decades, appealing to the right-minded ’anything in moderation’ consumer has been prevalent throughout health care. The prescription to live well has always had a distinctively moral tone. Health promotion policy has been portrayed as a quasi-religious quest, a war against the deadly old sins of gluttony, laziness and lust. Discourse analysis of public health policy statements makes this fact all too clear (Sykes et al., 2004).

The demise of the construct of the RC is imminent within health policy. Common observation and decades of research show that people are really pushed and pulled in different directions while exercising their ’freedom of choice’. Emotions and feelings are as important in making choices as cognition. The beneficial satisfaction of needs and wants must be balanced against perceived risks and costs. Health policy is beginning to acknowledge both the complexity of health and the power of the market. Human activity is a reflection of the physical, psychosocial and economic environment. The built environment, the sum total of objects placed in the natural world, dramatically influences health. The ’toxic environment’ propels people towards unhealthy behaviours, directly causing mortality and illness (Brownell and Fairburn, 1995).

Recent government policy documents in the UK indicate that the reliance on consumers as responsible decision-makers has been waning, but it remains a primary strategy. The environment and corporations are being given a larger role. In Healthy Lives, Healthy People: Our Strategy for Public Health in England (Department of Health, 2010: 29), the government stated:

2.29 Few of us consciously choose ’good’ or ’bad’ health. We all make personal choices about how we live and behave: what to eat, what to drink and how active to be. We all make trade-offs between feeling good now and the potential impact of this on our longer-term health. In many cases, moderation is often the key.

2.30 All capable adults are responsible for these very personal choices. At the same time, we do not have total control over our lives or the circumstances in which we live. A wide range of factors constrain and influence what we do, both positively and negatively.

2.31 The government’s approach to improving health and wellbeing — relevant to both national and potential local actions — is therefore based on the following actions, which reflect the Coalition’s core values of freedom, fairness and responsibility. These are:

· strengthening self-esteem, confidence and personal responsibility;

· positively promoting ’healthier’ behaviours and lifestyles; and

· adapting the environment to make healthy choices easier.

In the above policy document, personal responsibility remains at the top of the agenda. The statement that ’we do not have total control over our lives or the circumstances in which we live’ is a small step forward but, unfortunately, taking two steps back negates this. Only holistic public policies can lower the toxicity of the environment and to declare otherwise is a cop-out. Yet large corporations are engaged as the new allies of health promotion in the twenty-first century. The UK government enlisted the food industry, including McDonald’s and Kentucky Fried Chicken, among other corporations, to help to write policy on obesity, alcohol and diet-related disease (MailOnline, 2010). Processed food and drinks manufacturers, including PepsiCo, Kellogg’s, Unilever, Mars and Diageo, were contributors to five ’responsibility deal’ networks set up by then Health Secretary Andrew Lansley. In a similar sponsorship arrangement to previous Olympic Games, McDonald’s and Coca-Cola sponsored the 2012 London Olympics. This is putting foxes in charge of the hen house!

In the USA there has been a similar shift in thinking: the ’anything in moderation’ philosophy of responsible consumption is no longer the principal foundation for public health interventions. The Surgeon General’s Vision for a Healthy and Fit Nation states:

Interventions to prevent obesity should focus not only on personal behaviors and biological traits, but also on characteristics of the social and physical environments that offer or limit opportunities for positive health outcomes. Critical opportunities for interventions can occur in multiple settings: home, child care, school, work place, health care, and community. (US Surgeon General, 2010: 5)

In twenty-first-century health care, the opportunities for health psychological interventions to assist within the major settings has never been greater. But one must ask whether the discipline is fit to meet these challenges. Alternative methods must be tried and tested if we are to make in-roads into the massive scale of issues on the public health agenda.

Economic analyses use gross domestic product (GDP) as a measure of output and, to a degree, an indicator of welfare also (Oulton, 2012). GDP measures the value of goods and services produced for final consumption, private and public, present and future. Across countries, GDP per capita is highly correlated with important social indicators. GDP is positively correlated with life expectancy and negatively correlated with infant mortality and inequality. One of the most traumatic events in anybody’s life is the loss of a child, and infant mortality rates might be thought of as a proxy indicator of happiness. Figure 4.1 plots infant mortality against per capita GDP for a large sample of countries. The graph shows that richer countries tend to have greater life expectancy, lower infant mortality and lower inequality. As always, it is important to state that correlation is not necessarily causation, although there is strong evidence that higher GDP per capita leads to improved health (Fogel, 2004).

Figure 4.1 Infant mortality versus household consumption per head across 146 countries


Source: Oulton (2012)

Economic downturns trigger social ills that spread globally. Witness the impact of the 2008 ’Credit Crunch’ in the USA, which triggered a global financial crisis with banks all over the world going into meltdown, leading to many job losses and low interest rates everywhere from the USA to China. When the Icelandic banking system collapsed in 2008, managers of a Wessex children’s hospice in England worried about the future of the hospice, a specialist cancer hospital in Manchester redesigned its research programme, and millions worried about their pensions.

A key component of subjective well-being and quality of life is employment. A strong relationship exists between these factors. Unemployment brings stigma, lowered self-esteem and mental health problems, especially depression and feelings of low self-worth (Warr et al., 1988). In some cultures, for example in Japan, a particularly strong correlation exists between the suicide rate and unemployment rate among men (Chen et al., 2012). Under a blanket of statistics lies a multitude of individual calamities.

Population growth and the scourges of unhealthy commodities, unemployment, poverty and inequality place their fingerprints over human existence. In charting the macro-social environment for health, we consider the transitions that have accompanied the globalization of unhealthy commodities, population growth and widespread poverty; we briefly discuss inequalities both within and between societies, and the inequities that exist between genders and ethnic groups. In the following chapters, we take up social justice issues in more detail (Chapter 5) and explore the significance of culture (Chapter 6).

Epidemiological Transition and Globalization

Epidemiology is concerned with the distribution of disease and death and their determinants and consequences. Diseases can be divided into two broad categories: communicable and non-communicable. Communicable diseases spread from one person to another or from an animal to a person. This spread may happen via airborne viruses or bacteria, but also through blood or other bodily fluid. The terms ’infectious’ and ’contagious’ are used to describe communicable disease. Major examples are influenza, HIV infection, hepatitis, polio, malaria and tuberculosis. Non-communicable, or chronic, diseases are generally diseases of long duration and have a slow progression. Major examples are cardiovascular diseases (e.g., heart attacks and stroke), cancer, chronic respiratory diseases (e.g., chronic obstructed pulmonary disease and asthma) and diabetes. Non-communicable diseases (NCDs) are currently the leading cause of death in the world, representing 63% of all annual deaths (World Health Organization, 2014b). NCDs kill at least 36 million people each year, some 80% of which occur in low- and middle-income countries.

Omran (1971) described what he termed the ’epidemiological transition’. This refers to a reduction in prevalence of communicable diseases and an increase in the prevalence of NCDs that occur as a country becomes economically stronger. NCDs are lifestyle-related chronic diseases that accompany increased usage of unhealthy commodities such as alcohol, tobacco and processed foods. During this transition, countries that have low or middle incomes face a heavy burden from both communicable and non-communicable diseases. In industrial countries such as the USA, Germany, the UK and Japan, the prevalence of communicable diseases is much lower compared to chronic NCDs. In India, and other low- and middle-income countries, while communicable diseases are still present, the rise of NCDs has been rapid (Anjana et al., 2011). Low- and middle-income countries like India, therefore, are currently facing an epidemiological transition with a ’double burden’ of disease.

The major driver of the transition towards widespread prevalence of NCDs is corporate globalization. From the point of view of human health, globalization flies a banner of progress and freedom yet brings illness and an early death to millions of people. Transnational corporations are indeed the major drivers of NCD ’pandemics’ as they scale up their promotion of, and huge profits from, tobacco, alcoholic and other beverages, ultra-processed food and other unhealthy commodities throughout low- and middle-income countries.

Stuckler et al. (2012) observed that the sales of unhealthy commodities across 80 low- and middle-income countries are strongly interrelated. They argue (see Figure 4.2) that:

in countries where there are high rates of tobacco and alcohol consumption, there is also a high intake of snacks, soft drinks, processed foods, and other unhealthy food commodities. The correlations of these products with unhealthy foods suggest they share underlying risks associated with the market and regulatory environment. (Stuckler et al., 2012: 3)

Referring to these data, Moodie et al. (2013: 1) argued in The Lancet that:

Alcohol and ultra-processed food and drink industries are using similar strategies to the tobacco industry to undermine effective public health policies and programmes.

Unhealthy commodity industries should have no role in the formation of national or international policy for non-communicable disease policy.

Despite the common reliance on industry self-regulation and public—private partnerships to improve public health, there is no evidence to support their effectiveness or safety.

In view of the present and predicted scale of NCD epidemics, the only evidence-based mechanisms that can prevent harm caused by unhealthy commodity industries are public regulation and market intervention.

Figure 4.2 Associations of sales of tobacco, alcohol, soft drink and processed food markets, 80 countries, 2010


Source: Stuckler et al. (2012)

Population Growth

The US Census Bureau (2017) publishes online a continuous, second-by-second update of the world’s population on its website ( According to the Bureau, the total world population, at 05:07 GMT on 28 October 2017, was 7,430, 555, 770. That figure was increasing at a rate of 2.4 extra people every second. By 2025 there will be 8 billion people on Earth.

Dividing the globe into regions, the most populous region is China. With 1.379 billion people in 2017, China contains 19% of all people on Earth. The second most populous country is India, with 1.282 billion in 2017. It is expected that India’s population will surpass China’s, with around 1.5 billion by 2040. Fertility is falling in most of the developing world but there is a huge variation between countries.

One intervention for population growth, birth control, is practised in many countries. However, religious edicts influence sexual and reproductive practices, leading to population growth. This issue is difficult to ignore. Consider the position of the Roman Catholic Church as one example. On 25 July 1968, Pope Paul VI’s encyclical Humanae Vitae (’Of Human Life’, subtitled ’On the Regulation of Birth’) reinforced the traditional values of the Church by forbidding abortion and artificial contraception. This position was reinforced in 2008 by Pope Benedict XVI. The human failure to practise abstinence as the only acceptable method for birth control in South America and Africa is adding to population growth, poverty and the spread of HIV infection. Fertility is highest in sub-Saharan Africa, the poorest region in the world where the prevalence of AIDS is maximal. Birth control is also cheaper than other methods of reducing carbon emissions (Wire, 2009). Failing to prevent unwanted births increases the population and causes poverty and malnutrition, and the physical climate becomes more unstable.

Increasing Life Expectancy

Life expectancy has been increasing almost everywhere due to dramatic decreases in infant and adult mortality from infectious diseases. In Britain, life expectancy is currently around 75 years for men and 80 years for women. In 2010 in England a working man could expect, on average, about 10 years of pensioned retirement while a working woman could anticipate around 20 years. Recent research suggests that life expectancy will continue to increase in the twenty-first century and that by 2060 it could reach 100 years (Oeppen and Vaupel, 2002). Life expectancy is increasing by three months every year in developed countries. If life expectancy increases to 85, 90 or even 100, social, health and pensions systems will be difficult to maintain in their present form.

The age profile of any population is displayed as a ’population pyramid’, in which numbers in each age group are plotted on a vertical axis. In the UK, the number of people older than 85 is increasing dramatically. Inflows and outflows suggest that by 2050 the UK will be the largest country in Europe. In 2050, like many other places, the country will be both crowded and warm.

China has the fastest-changing demographic profile in the world, with the largest population of senior citizens. Currently, China has more than 130 million senior citizens aged above 60, more than 10% of the total population. By the middle of this century senior citizens in China will exceed 400 million, one-quarter of the total population. There will be a significant shift in the demographic profile of the Chinese population between 2010 and a projection for 2050. The population pyramids show the ageing process is changing China’s pyramid, with much larger segments in the higher age brackets.

In 1979 China adopted a one-child policy aimed towards keeping the population at around 1.2 billion in 2000. Family sizes in China are typically smaller in cities than in rural areas, where the two-child family is the preferred norm. China’s total fertility rate currently is running at around 1.7, with women giving birth to an average of 1.7 offspring. China’s one-child policy succeeded in reducing family sizes but led to a rising proportion of males, traditionally favoured in Asian cultures, through sex-selection abortion. The reported female:male ratio went from 1:06 in 1979 to 1:17 in 2001 with ratios up to 1:3 in rural Anhui, Guangdong and Qinghai provinces (Hesketh and Xing, 2006). It is predicted that by 2020, China’s population will reach 1.4 billion.


Of 7.2 billion people alive in 2014, approximately 5 billion (70%) live in so-called ’developing’ countries, i.e., low- and middle-income countries, the word ’developing’ being a polite euphemism for ’poor’. Poverty, by whatever name, exists on a massive scale. One billion to 1.5 billion people live on less than US$1.25 per day — i.e., more than one person in every five. For them, clean drinking water, flushing toilets, health services and modern medicines are completely out of reach. Initiatives that have attempted to improve the health of people in extreme poverty mostly have failed.

The UN Development Programme defined poverty as ’a level of income below that people cannot afford a minimum, nutritionally adequate diet and essential non-food requirements’ (United Nations Development Programme, 1995). Half of the world’s population lacks regular access to medical care and most essential drugs. International organizations such as the UN state with some justification that poverty is the greatest cause of ill health and early mortality. The health effects of poverty are tangible and the biological and economic mechanisms are the same everywhere. The major impacts of poverty on health are caused by the absence of:

· safe water;

· environmental sanitation;

· adequate diet;

· secure housing;

· basic education;

· income generating opportunities;

· access to medication and health care.

These are familiar themes. The most common health outcomes of poverty are infectious diseases, malnutrition and reproductive hazards (Anand and Sen, 2000). Poverty implies a lack of access to necessary medicines. HIV infection and AIDS provide a good example. A major killer disease is AIDS (acquired immune deficiency syndrome). In 2004, 6 million people living with HIV infection and AIDS in developing countries urgently needed access to antiretroviral therapy (HAART). The World Health Organization (WHO) began the ’3 by 5 Initiative’ in 2004 when less than 10% of sufferers had access to HAART. The WHO set a target of providing HAART to 3 million people living with HIV infection or AIDS by the end of 2005. The data show that this figure was half met. However, the number of people accessing antiretroviral therapy in low- and middle-income countries has risen, and reached an estimated 6.6 million at the end of 2010. The major barrier to increasing access to HAART is cost. The pharmaceutical industry holds the patents and loses profits if patent rights are relinquished to enable the generic production of HAART medication. Further discussion of HAART can be found in Chapters 9 and 23.

Economic growth refers to the rate of increase in the total production of goods and services within an economy. Such growth increases the capacity of an economy to produce new goods and services, allowing more needs and wants to be satisfied. A growing economy increases employment, and stimulates business enterprise and innovation. Sustained growth is fundamental to the raising of living standards and to providing greater quality of life (QoL). A key concept is gross national income (GNI), which is the monetary value of all goods and services produced in a country over a year. GNI is therefore a useful indicator for measuring growth.

Box 4.1 International Example: Reducing poverty in Brazil

The Brazilian economy came under the media spotlight in June 2014 when it hosted the FIFA World Cup. In spite of its anti-hunger programme, protests and strikes in Brazil’s cities were a prominent feature of the 2014 World Cup. Life in the favelas was shown in TV documentaries as exotic, entrepreneurial and exciting, in spite of the child prostitution, drug trafficking and extremely impoverished communities. Graffiti art was used to draw attention to the contradiction between the lavish expenditure on 12 new stadia and the chronic levels of extreme poverty among a large proportion of the Brazilian population.

The Millennium Development Goals previously had set the target to halve poverty and hunger from 2000 to 2015. In the early 2000s Brazil was working towards, and expected to reach, these targets using the Bolsa Família (family stipend) and Fome Zero (zero hunger) programmes (Galindo, 2004). Doctors at a local health clinic in Brazil observed that their patients, who regularly came in with health problems related to poverty, were visiting less often. This can be reasonably attributed to the national, anti-hunger Fome Zero (zero-hunger) programme that aimed to give every Brazilian at least three meals a day. With one-quarter of Brazil’s 170 million people below the poverty line, this goal was a challenge. To date, the government has provided emergency help to 13 million families.

The scheme involved giving ’something for something’ by making cash transfers conditional upon regular school attendance, health checks, and participation in vaccination and nutrition programmes. Almost three-quarters of benefits reached the poorest 20% of the population and absolute poverty halved from 21% in 2001 to 11% in 2008 (Hall, 2012). Opinions vary about the success of the programme. Commentators suggested that the Workers’ Party gained many extra votes as one consequence of Bolsa Família, and also that there was shift in policy towards short-term solutions to poverty rather than long-term investments in health and education (Hall, 2008, 2012).

Poverty reduction has been a priority for many international organizations. At the United Nations in 2000, 189 countries adopted the ’Millennium Development Goals’, including halving poverty rates by 2015, reducing child mortality, decelerating the growth of AIDS and educating all children. The greatest progress is being made in China, India and Brazil. It is expected that the world poverty rate of 28%, as it was in 1990, will have been reduced by half by 2017, a tremendous achievement. However, poverty in sub-Saharan Africa is still getting worse. In September 2008, world leaders pledged to reinvigorate the ’global partnership of equals’ to end poverty, hunger and underdevelopment in Africa. However, the United Nations Secretary-General Ban Ki-moon was pessimistic in indicating that no African country would achieve all of the Goals (United Nations, 2008). Depressing reading!

The production of good population health requires much more than simply providing doctors, nurses and hospital services. Basic economic, educational and environmental foundations need to be put into place. This means that some fairly dramatic economic changes are needed if we are to see health improvements during the twenty-first century. Among these changes, the cancellation of unpaid debts of the poorest countries and trade justice have the potential to bring health improvements to match those of the last 50 years.

A case can be made that health improvements are a necessary precondition of economic growth. This was suggested by the WHO Commission on Macroeconomics and Health. The Commission Report stated: ’in countries where people have poor health and the level of education is low it is more difficult to achieve sustainable economic growth’ (World Health Organization, 2002). If current trends continue, health in sub-Saharan Africa will worsen over the next decades. If the Millennium Development Goals are going to have any chance of success in Africa, health must be given a higher priority in development policies. Sub-Saharan Africa contains 34 of the 41 most indebted countries, and the proportion of people living in absolute poverty (on under US$1 per day) is growing. The health of sub-Saharan Africans is among the worst in the world. Consider the following indicators:

· Two-thirds of Africans live in absolute poverty.

· More than half lack safe water.

· A total of 70% are without proper sanitation.

· Forty million children are not in primary school.

· Infant mortality is 55% higher than in other low-income countries.

· Average life expectancy is 51 years.

· The incidence of malaria and tuberculosis is increasing.

These figures indicate the very large gaps that exist between the ’haves’ and ’have-nots’ on the international stage. International debt is a significant factor in poverty. Rich nations will need to honour pledges they have given to cancel debts and establish fair trade to produce reductions in poverty and hunger in Africa.

Inequalities within a Country

The existence of health gradients within health care is a universal constant. Many of the determinants of ill health were identified by Edwin Chadwick in his studies of public health in Victorian England: poverty, housing, water, sewerage, the environment, safety and food. In addition, we recognize today that illiteracy, tobacco, AIDS/HIV, immunization, medication and health services are also important (Ferriman, 2007).

Recent studies of the social determinants of health have pinpointed various kinds of inequity. The first of these is based on socio-economic status (SES): people who are higher up the ’pecking order’ of wealth, education and status have better health and live longer than those at the lower end of the scale. To illustrate this, Figure 4.3 shows a map of the Jubilee Line, which travels along an east—west axis across London. If you travel eastwards along this tube line from Westminster to Canning Town, the life expectancy of the local population is reduced by one year for every stop.

Health gradients are found in all societies. Wealthier groups always have the best health; poorer groups have the worst health. These differentials occur in both illness and death rates, and health gradients are equally dramatic in both rich and poor countries. The majority of studies have been carried out in rich countries.

Figure 4.3 Differences in life expectancy within a small area of London


Source: Department of Health (2008)

Box 4.2 Key Study: The Whitehall Studies

The Whitehall studies investigated social class, psychosocial factors and lifestyle as determinants of disease. The first Whitehall study of 18,000 men in the Civil Service was set up in the 1960s. The Whitehall I study showed a clear gradient in which men employed in the lowest grades were much more likely to die prematurely than men in the highest grades.

The Whitehall II study started in 1985 with the aim of determining the causes of the social gradient and also included women, including potential psychological mediators. A total of 10,308 employees participated, two-thirds men and one-third women. The cohort was followed up over time with medical examinations and surveys. Most participants are now retired or approaching retirement.

There have been many phases of data collection, alternating postal self-completion questionnaires with medical screenings and questionnaires. In addition to cardiovascular measures, blood pressure, blood cholesterol, height, weight and ECGs were taken, along with tests of walking, lung function and mental functioning, questions about diet, and diabetes screening.

Figure 4.4 Death rates (%) vs. employment grades over a 25-year period in the Whitehall studies


Source: Ferrie (2004). Reproduced with permission

The Whitehall studies found that an imbalance between demands and control lead to illness. Control is less when a worker is lower in the hierarchy and so a worker in a lower position is unable to respond effectively if demands are increased, supporting Karasek and Theorell’s (1990) demand—control model. Other mechanisms can buffer the effect of work stress on mental and physical health: social support (Stansfeld et al., 2000), effort—reward balance (Kuper and Marmot, 2003), job security and organizational stability (Ferrie et al., 2002). Figure 4.4 shows the gradient of death rates versus employment grades over a 25-year period in men from the Whitehall studies. The death rate is shown relative to the whole Civil Service population (reproduced from Ferrie, 2004).

Virtanen et al. (2015) examined whether midlife adversity predicts post-retirement depressive symptoms in 3,939 Whitehall II participants (mean age 67.6 years at follow-up). Strong associations occurred between midlife adversities and post-retirement depressive symptoms, including low occupational position, poor standard of living, high job strain and few close relationships. Associations between socio-economic, psychosocial, work-related or non-work-related exposures and depressive symptoms were of similar strength. The data suggest that socio-economic and psychosocial risk factors for symptoms of depression post-retirement can be detected in midlife.

Source: Ferrie (2004)

There are relatively few studies of health gradients in poor countries. The data are cross-sectional rather than longitudinal, but show a similar pattern to those observed with Whitehall civil servants. One of the authors analysed data from the Demographic and Health Surveys (DHS) programme of the World Bank (2002) (Marks, 2004). These are large-scale household sample surveys carried out periodically in 44 countries across Asia, Africa, the Middle East, Latin America and the former Soviet Union. Socio-economic status was evaluated using answers about assets given by the head of each household. The asset score reflected the household’s ownership of consumer items ranging from a fan to a television and car, dwelling characteristics such as flooring material, type of drinking water source and toilet facilities used, and other characteristics related to wealth. Each household was assigned a score for each asset and scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was divided into population wealth quintiles — five groups with the same number of individuals in each.

The gradient of under-5 mortality rates (U5MRs) for 22 countries in sub-Saharan Africa are shown collectively in Figure 4.5. The U5MR indicator is the number of deaths of children under 5 years of age per 1,000 live births. This figure shows gradients in all countries. A wide gap in health outcomes exists between the rich and the poor even within these very poor countries. Similar gradients exist for countries in Latin America and the Caribbean and throughout the 44 countries included in the DHS. Infant mortality is halved between quintiles 1 and 5, representing the poorest of the poor and the wealthiest of the poor.

Figure 4.5 Under-5 mortality gradients for sub-Saharan Africa plotted against asset quintile. The area under each line represents the individual country rates. Quintile 1 has least assets, quintile 5 the most


Source: Marks (2004)

An interesting set of relationships was observed between the U5MRs, literacy and resources (Marks, 2004). The U5MRs in 44 countries were positively correlated with female illiteracy rates and the proportion of households using bush, field or traditional pit latrines, and negatively correlated with the proportion of households having piped domestic water, national health service expenditure, the number of doctors per 100,000 people, the number of nurses per 100,000 people and immunization rates.

The most important predictors of infant survival are educational and environmental. The most effective long-term structural interventions to combat inequality are to improve the educational opportunities for women and to improve the supply of drinking water. High literacy among mothers and access to water supplies and toilets are highly associated with low infant mortality. High numbers of doctors and nurses, immunization rates and health service expenditure are associated with lower mortality rates, but these health service variables are less influential, statistically speaking, than literacy, domestic water and sanitation. The latter provide the foundations of good health, while health services are the bricks and mortar.


Significant differences exist in health outcomes between men and women. Attitudes have changed a little over the last 100 years. A medical textbook from the nineteenth century stated: ’child-bearing is essentially necessary to the physical health and long life, the mental happiness, the development of the affections and whole character of women. Woman exists for the sake of the womb’ (Holbrook, 1871: 13—14; cited in Gallant et al., 1997).

In industrialized societies men die earlier than women, but women generally have poorer health (Macintyre and Hunt, 1997). Men in the USA suffer more severe chronic conditions, have higher death rates for all 15 leading causes of death, and die nearly seven years younger than women (Courtenay, 2000). Similar figures exist in the UK. In 1996, UK males had a life expectancy of 74.4 years compared with 79.7 years for females. This excess mortality of 5.3 years in males in 1996 increased over the course of the twentieth century from only 3.9 years in 1900—1910.

Evidence suggests that from the Paleolithic period to the industrial revolution men lived longer than women, 40 years as compared to 35. Also, in less developed countries (e.g., India, Bangladesh, Nepal and Afghanistan) men still live longer than women (World Health Organization, 1989). To complicate the picture further, the health gradient is steeper for men than for women, while illness rates, treatment rates, absenteeism and prescription drug use are generally higher for women (Macintyre and Hunt, 1997). Women suffer more non-fatal chronic illnesses and more acute illnesses. They also make more visits to their family physicians and spend more time in hospital. Women suffer more from hypertension, kidney disease and autoimmune diseases such as rheumatoid arthritis and lupus (Litt, 1993). They also suffer twice the rate of depression. Men, on the other hand, have a shorter life expectancy, and suffer more injuries, suicides, homicides and heart disease.

Psychosocial and lifestyle differences play a role in gender-linked health differences. In industrialized societies women suffer more from poverty, stress from relationships, childbirth, rape, domestic violence, sexual discrimination, lower status work, concern about weight and the strain of dividing attention between competing roles of parent and worker. Financial barriers may prevent women from engaging in healthier lifestyles and desirable behaviour change (O’Leary and Helgeson, 1997).

Social support derived from friendships, intimate relationships and marriage, although significant, appears to be of less positive value to women than to men. Although physical and mental well-being generally benefit from social support, women often provide more emotional support to their families than they receive. Thus, the loss of a spouse has a longer and more devastating effect on the health of men than on that of women (Stroebe and Stroebe, 1995). The burden of caring for an elderly, infirm or dementing family member also tends to be greater for females in the family than for males, especially daughters (Grafstrom, 1994). Gallant et al. (1997) reviewed psychological, social and behavioural influences on health and health care in women.

Gender is a social construction, and social constructions of masculinity and femininity have relevance in particular to young men’s and young women’s health-seeking behaviour. The concept of ’hegemonic masculinity’ as a locally dominant ideology of masculinity has been a focus of research (Connell, 2005). Hegemonic masculinity includes the demonstration of ’machismo’ through the possession of physical and emotional strength, predatory heterosexuality, being a breadwinner and being unafraid of risk. Recent studies have focused on the health of men, why they suffer more from alcoholism and drug dependency, and why they are so reluctant to seek health from professionals. Gender-specific beliefs and behaviours are likely contributors to these differences (Courtenay, 2000). Men are more likely than women to adopt risky beliefs and behaviours, and less likely to engage in health-protective behaviours that are linked with longevity. Practices that undermine men’s health are used to signify masculinity and to negotiate power and status. Social and institutional structures often reinforce the social construction of men as the ’stronger sex’.

One of the cornerstones of masculinity is violence, especially violence against women. This violence cuts across culture and, with only a few exceptions, is a near-universal constant. Kaufman (1987) argues that violence by men against women is one corner of a triad of men’s violence. The other two corners are violence against other men and violence against self. Kaufman asserted that the social context of this triad of violence is the institutionalization of violence in most aspects of social, economic and political life:

The first corner — violence against women — cannot be confronted successfully without simultaneously challenging the other two corners of the triad. And all this requires a dismantling of the social feeding ground of violence: patriarchal, heterosexist, authoritarian, class societies. These three corners and the societies in which they blossom feed on each other. And together, we surmise, they will fall. (Kaufman, 1987: 485)

Highly publicized cases, such as the 2002 rape of Mukhtar Mai in Pakistan, the 2012 Delhi gang rape, and rape used as a weapon of war in the Democratic Republic of Congo in 2014 (and throughout history everywhere) have led to an international campaign against rape. Violence against girls and women is the most extreme example of a spectrum of ills with hegemonic masculinity. Risk taking with alcohol (Lemle and Mishkind, 1989), tobacco (Pachankis et al., 2011), drugs (Liu and Iwamoto, 2007) and sexual predation (Prohaska and Gailey, 2010), and presentations about homophobia (Kimmel, 2004) are examples.

Alternative constructions that subvert normative ideas of masculinity include non-drinking. A study of non-drinkers’ discourse examined the manner in which not drinking alcohol is construed in relation to the masculine identity. Three prominent discourses about non-drinking were revealed: (1) as something strange requiring explanation; (2) as simultaneously unsociable yet reflective of greater sociability; and (3) as something with greater negative social consequences for men than for women (Conroy and de Visser, 2013).

Constructions of masculinity extend to young men’s help-seeking and health service use online. In one study, 28 young men took part in two online focus groups investigating understandings of health, help-seeking and health service use. Discourse analysis was used to explore the young men’s framing of health-related practices. Young men are interested in their health and construct their health practices as justified, while simultaneously maintaining masculine identities surrounding independence, autonomy and control over their bodies (Tyler and Williams, 2014).


The health of minority ethnic groups is generally poorer than that of the majority of the population. This pattern has been consistently observed in the USA between African-Americans (’blacks’) and Caucasian-Americans (’whites’) for at least 150 years (Krieger, 1987). There has been an increase in income inequality in the USA that has been associated with a levelling-off or even a decline in the economic status of African-Americans. The gap in life expectancy between blacks and whites widened between 1980 and 1991 from 6.9 years to 8.3 years for males and from 5.6 years to 5.8 years for females (National Center for Health Statistics, 1994). Under the age of 70, cardiovascular disease, cancer and problems resulting in infant mortality account for 50% of the excess deaths for black males and 63% of the excess deaths for black females (Williams and Collins, 1995). Similar findings exist in other countries. Analyses of three censuses from 1971 to 1991 have shown that people born in South Asia are more likely to die from ischaemic heart disease than the majority of the UK population (Balarajan and Soni Raleigh, 1993).

There are many possible explanations for these persistent health differences between people of different races who live in the same country and are served by the same educational, social, welfare and health care systems (Williams and Collins, 1995; Williams et al., 1997). First, the practice of racism means that minority ethnic groups are the subject of discrimination at a number of different levels. Such discrimination could lead directly or indirectly to health problems additional to any effects related to SES, poverty, unemployment and education. Discrimination in the health care system exacerbates the impacts of social discrimination through reduced access to the system and poorer levels of communication resulting from language differences.

Second, ethnocentrism in health services and health promotion unofficially favours the needs of majority over minority groups. The health needs of members of minority ethnic groups are less likely to be appropriately addressed in health promotion, which in turn leads to lower adherence and response rates in comparison to the majority population. These problems are compounded by cultural, lifestyle and language differences. For example, if interpreters are unavailable, the treatment process is likely to be improperly understood or even impaired and patient anxiety levels will be raised. The lack of permanent addresses for minority ethnic group families, created by their high mobility, makes communication difficult so that screening invitations and appointment letters are unlikely to be received.

Third, health status differences related to race and culture are to a large extent mediated by differences in SES. Studies of race and health generally control for SES, and race-related differences frequently disappear after adjustment for SES. Race is strongly correlated with SES and is even sometimes used as an indicator of SES (Williams and Collins, 1995; Modood et al., 1997).

Fourth, differences in health-protective behaviour may occur because of different cultural or social norms and expectations. Fifth, differences in readiness to recognize symptoms may also occur as a result of different cultural norms and expectations. Sixth, differences can occur in access to services. There is evidence that differential access to optimal treatment may cause poorer survival outcomes in African-Americans who have cancer, in comparison with other ethnic groups (Meyerowitz et al., 1998). Seventh, members of minority ethnic groups are more likely to inhabit and work in unhealthy environments because of their lower SES. Eighth, there are genetic differences between groups that lead to differing incidences of disease, and some diseases are inherited. There are several well-recognized examples, including sickle cell disorder affecting people of African-Caribbean descent; thalassaemia, another blood disorder that affects people of the Mediterranean, Middle Eastern and Asian descent; and Tay—Sachs disease, which affects Jewish people.

Other possible mechanisms underlying ethnicity differences in health are differences in personality, early life conditions, power and control, and stress (Williams and Collins, 1995; Taylor et al., 1997). Research is needed with large community samples so that the influence of the above variables and the possible interactions between them can be determined. Further research is needed to explore the barriers to access to health care that exist for people from different groups. We will return to this topic in other chapters.


Macro-social conditions determine how the single set of resources in this world are shared. Perfect equality will never happen, but currently the shares are extremely far from equal. Macro-social conditions require radically different policies if the health of more than 5 billion people living in poverty is ever to be improved. The next 50 years is a thin slice of time in which the world population is expected to expand by 25% to around 9 billion. The lion’s share of this expansion will be in the poorest countries. Eleven million homeless children today live in India alone. Poverty and AIDS/HIV are not abating in sub-Saharan Africa, and life expectancy will continue to be in decline there for some time to come. Policy changes are necessary if AIDS prevention and poverty reduction are going to be more successful than has been achieved to date.

The globalized expansion of transnational industries that promote the widespread use of unhealthy commodities has accelerated an epidemiological transition towards the high prevalence of non-communicable diseases. The only mechanisms that can be used to prevent harm caused by unhealthy commodity industries are public regulation and market intervention (Moodie et al., 2011). The prospects can be improved if governments have the will to intervene. It all depends on what actions are taken by our elected governments. The electorate puts them there and receives what it demands. If the population allows the world to be filled with Walmarts, fast food and Big Brand cigarettes, that is what it will get. Unless prevented from doing so, then inexorably the globalization steamroller will follow its own course.

Sadly, the research that fills the majority of psychology textbooks is almost all irrelevant to the social and economic issues of today. For the Brave New Worlds of 2050 and 2100, we wonder if priorities will have changed. Will global warming, population, poverty, ideologies of oppression, survival and suffering be on the agenda? Will concepts such as ’stress’, ’coping’, ’resilience’, ’hardiness’ and ’change’ be given wider interpretation and meaning? Will theories and research concerned with compassion, empathy, emancipation, altruism, sharing, cooperation, sustainability, and cultural, spiritual and religious understanding be more prominent? Will new concepts, theories and methods have been created to deal with the social and psychological problems of the day? The answer to all of these questions must be ’Yes!’ — but ultimately this all depends on the actions of you and your successors.

Future Research

1. The causes of poverty and interventions to ameliorate poverty should be the priority for economic and social policy and research.

2. Studies in psychology and sociology are necessary to understand humanitarian values, altruism, oppression, fear, aggression and cross-cultural issues.

3. Possible mechanisms underlying ethnicity differences in health, such as differences in early life conditions, racism, power, control and stress, must be explored.

4. Research is needed with large community samples so that the influence of the above variables and their possible interactions can be determined.


1. The world population is increasing dramatically. From 1 billion in 1800, it is expected to climb to 9 billion by 2050, while the amount of drinkable water available per person over the same period will fall by 33%. The increasing shortage will affect mainly the poor in countries where water shortage is already chronic. Conflict about water will become as prominent as the conflict about oil today.

2. The consumption of tobacco, alcohol, ultra-processed food, drink and other unhealthy commodities is increasing throughout the low- and middle-income countries and is driving a huge increase in the prevalence of non-communicable diseases.

3. The greatest influence on health for the majority of people is poverty. Half of the world’s population lacks regular access to treatment of common diseases and most essential drugs. Globally, the burden of death and disease is much heavier for the poor than for the wealthy.

4. In developed countries, life expectancy is increasing by three months every year. If this trend continues, life expectancy will approach 100 years by 2060, placing social, health and pensions systems in a perilous position.

5. Economic growth does not reduce disparities in wealth across a society. ’Trickle-down’ is a myth. Health gradients remain a universal feature of the health of populations in both rich and poor countries.

6. Gender differences in health, illness and mortality are significant and show striking interactions with culture, history and socio-economic status.

7. The health of minority ethnic groups is generally poorer than that of the majority of the population. Possible explanations include racial discrimination, ethnocentrism, SES differences, behavioural and personality differences, cultural differences and other factors.

8. ’Doom and gloom’ is not inevitable. Prospects can significantly improve if policy makers intervene. The future health of populations depends upon actions taken by governments, corporations and opinion leaders supported by improved education about the social, political and economic determinants of health and illness.