Combining health and social protection measures to reach the ultra ...

Access to health
Inequality, marginalization
and poor health
Article by Lenore Manderson
Variations in health status and outcomes occur in high-,
middle- and low-income countries. Economic, political,
social and other inequalities between individuals,
communities and nations all have profound effects on
vulnerability and risk of infection, disease and injury, on
access to medical and other care, on treatment, management
and outcomes, and on information and interventions
designed to maximize well-being. Similarly, such inequalities
have profound impact on social health, resulting in individual
vulnerability to social exclusion, lack of participation in the
social, cultural, religious, economic and other aspects of
community life, and differential access to the benefits that
derive from these various activities.
The factors that influence health status and health
outcomes occur at social, structural, institutional and systems
levels in all societies. Gender, differences in ability, race,
ethnicity, class and caste are all fields of marginalization,
discrimination and personal and structural violence. These
differences that result in inequality – gender, ability, age, class
or caste, race, ethnicity, sexuality, geography, etc. – co-exist
and are inter-related, contributing to poverty in much of the
world. Poor people moreover are more likely than others to
experience inequality within these social hierarchies, and the
co-presence or intersection of various factors that result in
inequality compounds the experience and impact of poor
health and resultant poverty. These fields of vulnerability are
reinforced through structural violence, leading to differences
in rates and patterns of infection and illness. For example,
people from poor and marginalized communities typically
work in industries and occupations and reside in areas that
have high risk of illness and injury, they are more likely to be
directly exposed to pathogens, to have substandard medical
services and poor quality of care, and to lack access to social
support mechanisms.
Social inclusion, participation in decision-making, social
security, equality, human rights and social justice are key,
underlying determinants of health that influence (and are
influenced by) education, income and employment
The individual personal, social and economic factors that
contribute to inequality, and associated poor health and
poverty, result in social exclusion, discrimination and
marginalization. Social marginality, discrimination and
exclusion affect health negatively in numerous ways, as
illustrated by current research on social dimensions of health
and illness. Social inclusion, participation in decisionmaking,
social security, equality, human rights and social
justice are key, underlying determinants of health that
influence (and are influenced by) education, income and
employment. Unjust social conditions therefore deprive
people of the opportunity to be healthy and often lead to
negative health outcomes. In turn, inequitable conditions
often limit access to health and medical services,
discouraging people who are marginalized or disempowered
from presenting to clinics and influencing the quality of care
they receive when they do attend. A woman from a minority
caste, living in an isolated rural area with physical
impairments from polio, is far more likely to be poor, to have
poor access to health services, and to receive poor quality of
care, than an urban dweller without impairment and from a
higher status caste. People with highly stigmatized health
conditions (mental illness, leprosy and still, in many cases,
HIV), are similarly often denied quality health care. The direct
and indirect costs of seeking medical attention, and the
humiliation, embarrassment and disappointment experienced
when health workers are rude and the necessary equipment,
medication or advice are not forthcoming, discourage their
continued presentation.
Marginalization affects the health of populations in very
different environments. In urban and other densely settled
areas, individuals living in poverty, in poor housing, in areas
of high population density such as slums or informal
(squatter) settlements, or in other unsafe or inadequate living
conditions, are disproportionately affected by communicable
diseases. Similarly, migrants, nomadic and seminomadic
pastoralists and others living in very isolated areas are
vulnerable to parasitic and other infectious diseases and may
be excluded from health care services run by settled
populations. In these circumstances, other environmental
conditions, such as poor wet and dry waste management and
lack of potable water, also favour vector breeding to promote
the spread of infectious diseases. These diseases create social
Global Forum Update on Research for Health Volume 4 ✜ 059