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

Access to healthInequality, marginalizationand poor healthArticle by Lenore MandersonVariations 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 onvulnerability and risk of infection, disease and injury, onaccess to medical and other care, on treatment, managementand outcomes, and on information and interventionsdesigned to maximize well-being. Similarly, such inequalitieshave profound impact on social health, resulting in individualvulnerability to social exclusion, lack of participation in thesocial, cultural, religious, economic and other aspects ofcommunity life, and differential access to the benefits thatderive from these various activities.The factors that influence health status and healthoutcomes occur at social, structural, institutional and systemslevels in all societies. Gender, differences in ability, race,ethnicity, class and caste are all fields of marginalization,discrimination and personal and structural violence. Thesedifferences that result in inequality – gender, ability, age, classor caste, race, ethnicity, sexuality, geography, etc. – co-existand are inter-related, contributing to poverty in much of theworld. Poor people moreover are more likely than others toexperience inequality within these social hierarchies, and theco-presence or intersection of various factors that result ininequality compounds the experience and impact of poorhealth and resultant poverty. These fields of vulnerability arereinforced through structural violence, leading to differencesin rates and patterns of infection and illness. For example,people from poor and marginalized communities typicallywork in industries and occupations and reside in areas thathave high risk of illness and injury, they are more likely to bedirectly exposed to pathogens, to have substandard medicalservices and poor quality of care, and to lack access to socialsupport mechanisms.Social inclusion, participation in decision-making, socialsecurity, equality, human rights and social justice are key,underlying determinants of health that influence (and areinfluenced by) education, income and employmentThe individual personal, social and economic factors thatcontribute to inequality, and associated poor health andpoverty, result in social exclusion, discrimination andmarginalization. Social marginality, discrimination andexclusion affect health negatively in numerous ways, asillustrated by current research on social dimensions of healthand illness. Social inclusion, participation in decisionmaking,social security, equality, human rights and socialjustice are key, underlying determinants of health thatinfluence (and are influenced by) education, income andemployment. Unjust social conditions therefore deprivepeople of the opportunity to be healthy and often lead tonegative health outcomes. In turn, inequitable conditionsoften limit access to health and medical services,discouraging people who are marginalized or disempoweredfrom presenting to clinics and influencing the quality of carethey receive when they do attend. A woman from a minoritycaste, living in an isolated rural area with physicalimpairments from polio, is far more likely to be poor, to havepoor access to health services, and to receive poor quality ofcare, than an urban dweller without impairment and from ahigher status caste. People with highly stigmatized healthconditions (mental illness, leprosy and still, in many cases,HIV), are similarly often denied quality health care. The directand indirect costs of seeking medical attention, and thehumiliation, embarrassment and disappointment experiencedwhen health workers are rude and the necessary equipment,medication or advice are not forthcoming, discourage theircontinued presentation.Marginalization affects the health of populations in verydifferent environments. In urban and other densely settledareas, individuals living in poverty, in poor housing, in areasof high population density such as slums or informal(squatter) settlements, or in other unsafe or inadequate livingconditions, are disproportionately affected by communicablediseases. Similarly, migrants, nomadic and seminomadicpastoralists and others living in very isolated areas arevulnerable to parasitic and other infectious diseases and maybe excluded from health care services run by settledpopulations. In these circumstances, other environmentalconditions, such as poor wet and dry waste management andlack of potable water, also favour vector breeding to promotethe spread of infectious diseases. These diseases create socialGlobal Forum Update on Research for Health Volume 4 ✜ 059