The Reality Of Redistribution
THE HEALTH CONSTRAINTS OF POVERTY
Within any society, certain groups have greater access to “desirable resources and rewards” (Williams, 1990:81). Health is one such social “reward.” Disease and premature death are not equitably distributed across socioeconomic strata. Individuals with the least income and least education—individuals living in poverty—are more likely to suffer from illness those farther up the socioeconomic ladder. It is certainly possible for the poorest to achieve and maintain health. But the literature, time and time again, confirms that while poverty does not necessarily cause disease, it restricts a person’s ability to stay healthy.
John Bowker, a professor of religious studies, argues that pathology is effectively understood using a model of constraints versus causality (1997). To justify his approach, he recalls Hume’s caution (Ibid, 372).
We never observe ‘cause,’ but only a constancy of conjunction from which we infer “cause.”
Whether or not a person falls ill, in short, is more complicated than matters of cause and effect. Even the “simplest” of relationships, such as the expression of a mutated gene that results in cystic fibrosis, is mediated by a larger context. A person’s access to knowledge, to medication, and even the development of an embryo’s genome are influenced by matters beyond the gene-phenotype “causal” chain. Overall, Bowker urges his reader to consider the following (Ibid, 374)
When we are trying to explain any complex phenomenon, we will always be wise to think of sets of constraints, even if we wish to isolate some among them as being proximate causes of particular outcomes. An explanation will then be an adequate specification of those constraints that have brought about the eventuality (or outcome) in question.
The poverty-disease link is one such “complex phenomenon” that operates through a related set of constraints. There is not one, or even a set, of neatly defined causal mechanisms. There is, rather, a network of related and interacting restrictions that constrain physical and mental well-being. Though not a sociologist by trade, Bowker’s framework effectively organizes countless sociological studies that explore the stratification of health.
Applying Bowker’s approach, it is quickly clear that economic marginalization is about more than federal thresholds. Life at the bottom of the economic hierarchy subjects a person to health-hazardous constraints—constraints that are both internal and external to the individual. I first consider how poverty can degrade a person’s sense of self-efficacy. I then consider how even if a person is absolutely determined to achieve and maintain health, economic and social marginalization constrain their ability to avoid illness. Overall, I consider how poverty restricts health through perceived control, stress, purchasing power, education, employment, residence, diet and exercise, race, and generational experience.
These issues are central to the experience of my Family Help Desk (FHD) clients. FHD clients regularly expressed feelings of powerlessness and stress as they recalled the reality of redistributive institutions. My clients and I, moreover, worked together to obtain subsidized GED programs, housing, food and other goods and services. Overall, the experience of FHD clients and the reality of redistributive institutions do not occur in isolation. Such experiences enter into a broader picture of poverty and health.
As I will discuss, Bowker’s approach counters trends in both academic and popular literature. He ultimately shares the same end goal as many of his fellow theorists—that goal being to understand and alleviate socially-stratified suffering. But the path that Bowker advocates is a necessary intervention. He brings debate and discussion away from simple causal relationships and toward a broader picture of human experience (Ibid, 376):
The point of reformulating the boundaries should be to shake loose the narrow concentration on single causes (important and successful though it may often be) in order to realize how profoundly the wider circumstances of existence constrain human lives into distress, some of which presents itself in what we now define as medical symptoms.
Bowker’s approach, in short, treats poverty as a “wider circumstance of existence that constraints human lives into distress.” This approach yields insight into the myriad connections between economic marginalization and disease. And his approach is a necessary intervention in the current debate on poverty and health.
THE PSYCHOLOGICAL CONSTRAINTS OF POVERTY: PERCEIVED CONTROL
There is a permanent and persistent tension between individual agency and external conditions. Human experience is necessarily a synergy of the two. Social hierarchy impacts health not only through extra-individual constraints, such as institutional racism, but also through psychological, or intra-individual, restrictions. Through external restrictions on life outcomes, poverty can foster a sense of inefficacy and powerlessness that is ultimately health-hazardous.
Poverty implies relatively limited access to material goods, which can translate into relatively low control over life events. Martin Segilman (1975) offers several illustrative examples rooted in past research. Babies usually cry to elicit a desired response. But if a caregiver fails to render food, perhaps due to poverty, then an infant will experience a disconnect between effort and outcome (1975:160). Peasants in South Italy, to cite another example, are frequently subject to uncontrollable and devastating eventualities (1975:160):
What for others are misfortunes are for [the peasant] calamities. When their hog strangled on its tether, a laborer and his wife were desolate. The woman tore her hair and beat her head against a wall while the husband sat mute and stricken in a corner. The loss of the hog meant they would have no meat that winter, no grease to spread on bread, nothing to sell for cash to pay taxes, and no possibility of acquiring a pig the next spring. Such blows may fall at any time. Fields may be washed away in a flood. Hail may beat down the wheat. Illness may strike. To be a peasant is to stand helpless before these possibilities.
The experience of American poverty is different in many ways from the daily life of a mid twentieth century Italian peasant. But poverty, across national and chronological boundaries, exacerbates the eventualities of life. What are “misfortunes” for middle and high income individuals can become “calamities” in the context of poverty.
Constraints, again, are not just about extra-individual control. As explored by Martin Seligman (1975), individuals can internalize a feeling of helplessness. Repeated experiences where effort fails to yield positive results can lead to a persistent perception of powerlessness, or learned helplessness. Seligman explains how humans, like animals, can be conditioned to feel powerless even when their actions can yield desirable results (1975:164):
People, dogs, and rats first learn that relief is uncontrollable. Then, because the experimenter has changed the conditions, relief actually becomes attainable; but because of their expectancies of independence between relief and responding, the subjects have difficulty forming a new, hopeful expectancy.
A learned sense of inefficacy can pervade all aspects of an individual’s life. And even when a person has the opportunity to perform productive action, she may choose to refrain based on the expectation that “it doesn’t matter anyway.”
Perceived control and learned helplessness are central to poverty and disease. Albert Bandura formalizes the concept of perceived self-efficacy as follows (1995:3):
Perceived self-efficacy is a person’s belief in [his or her] capabilities to organize and execute the courses of action required to manage prospective situations.
In extensive studies, Bandura and his colleagues have confirmed that perceived self-efficacy is a powerful predictor of actual life outcomes. The old adage of “if at first you don’t succeed, try, try, try again,” in light of Bandura’s work, is more than popular knowledge. It is scientifically verifiable. Locke and Lantham (1990), among others, have confirmed that “the stronger the perceived self-efficacy, the higher the goals people set for themselves and the firmer is their commitment to them” (cited in Bandura, 1995:6). When it comes to disease, a wealth of studies substantiate that individuals with a higher perceived self-efficacy are more likely to not be depressed, to be academically successful, and to engage in health promotive behaviors (Bandura, 1995:26). People with a higher perception of their self-efficacy, moreover, are less likely to become stressed in difficult situations—allowing them to think more clearly and to avoid the physiological effects of stress hormones (Ibid, 8).
The psychological constraints of poverty have been attacked and maligned by many leading sociologists and anthropologists. Judith Goode and Edwin Earnes (1996), for one, offer a counterargument in “An Anthropological Critique of the Culture of Poverty.” The popular presentation of a “culture of poverty,” however, strays from Seligman and Bowker’s approach. Neither Seligman nor Bowker proposes that poverty inevitably engenders feelings of powerlessness and lowers motivation. Seligman himself prefaces his discussion of poverty as follows (1975:159):
It would be glib to equate poverty with helplessness. Having an annual income of $6,000 per year, instead of $12,000, does not automatically produce helplessness. The lives of poor people are replete with instances of courage, of belief in the effectiveness of action, and of personal dignity.
Poverty, nonetheless, is characterized by lived exclusion from the economic, political, and social domains of society. And real and repeated experience of having little control over life can degrade a person’s determination to keep a “can-do” attitude. There are, as Seligman points out, many “instances of courage” and “belief in the effectiveness of action.” But the issue is not about causality. It is about constraints. Poverty as an experience of economic marginalization constrains a person’s perceived self-efficacy, and can condition a person into persistent feelings of helplessness. And perceived self-efficacy, as explored by Bandura, is about more than mental motivation. It manifests in very real ways, including physical and mental illness.
THE PSYCHOLOGICAL CONSTRAINTS OF POVERTY: STRESS
What one person finds stressful might not phase another individual. But the daily experience of poverty can constrain an individual’s resolve to “not get stressed.” People living in high poverty neighborhoods are disproportionately affected by violent crime (Sampson, 2003). And many low-wage jobs provide workers with little control over potential stressful and even health hazardous conditions (Marmot, 2004). Unemployment, furthermore, can be a demoralizing and stressful experience (Wilkinson, 2001). And as highlighted by the example of Italian peasants, purchasing power buffers an individual from the anxiety of expensive emergencies and routine expenditures. In the context of twenty first century America, unexpected medical expenses and car repairs—as well as monthly rent and phone bills—are more stressful when disposable income is severely limited (Adler, 2001).
Increased exposure to stressful events restricts mental and physical health. When a person experiences stress, he or she reacts with a “fight or flight” mechanism. “Fight or flight” involves release of stress hormones and a cascade of bodily response, including breakdown of glucose stores, inhibition of the gastrointestinal and immune system, dilation of blood vessels, and increased respiration. While helpful in moments of intense performance, such as fleeing a bear, prolonged activation of the stress response is harmful. The American Institute of Stress (AIS) outlines many stress-linked conditions (Effects of Stress, n.d.):
…depression, anxiety, heart attacks, stroke, hypertension, immune system disturbances that increase susceptibility to infections, a host of viral linked disorders ranging from the common cold and herpes to AIDS and certain cancers, as well as autoimmune diseases like rheumatoid arthritis and multiple sclerosis.
People in poverty are more likely to have higher levels of “physiological stress indicators,” such as cortisol (Krantz et al., 1999). Very-low income individuals are at higher risk for mental illness due to stress mediated pathways (Takeuchi et al, 1991:1031).
Apart from the malignant effects of stress hormones, individuals sometimes turn to unhealthy coping behaviors, such as alcohol or substance abuse, to deal with intense anxiety. Severe economic marginalization, then, can work through psychological coping mechanisms to constrain health. Overall, poverty can restrict health through increased exposure to social stressors, and perhaps through coping mechanisms.
THE ECONOMIC CONSTRAINTS OF POVERTY
Poverty implies limited ability to access material resources. Poverty, therefore, constrains health by restricting access to health-enhancing commodities, such as food, healthcare, and safe shelter. The Capitol Area Foodbank (CAFB)—D.C.’s largest NGO focused on food provision—notes that “when there is not enough money to cover all household expenses, food is often eliminated. The working poor, children, families and senior citizens are those who suffer the most” (Hunger in the DC Metro Area, n.d.). Lack of healthy food, for all ages, leads to malnutrition; for children it leads to failure to thrive. Healthcare also costs money. Poor individuals are more likely to be uninsured, and uninsured individuals visit the doctor less and receive lower quality healthcare (King, 2005:v). Healthcare largely focuses on treatment, not prevention. But diagnostic tests allow a person to detect illness before it gets worse. And health insurance often lowers the cost of medications that directly treat or suppress disease. Avoiding toxic housing conditions can also be expensive. If lead paint, harmful fumes, or any environmental pathogen is discovered, middle or high income individuals can more readily address the problem by moving or hiring professional help. Food, insurance, and housing, overall, shape illness through economic constraints.
THE ACADEMIC CONSTRAINTS OF POVERTY
A recent New York Times Article, titled A Surprising Secret to a Long Life: Stay in School, highlights the link between education and health (Kolata, 2007). Dr. Lleras-Muney found that when states increased the term of compulsory education, people who attended school for more time—due to the new state laws—were more likely to live longer. Dr. Muney and other experts propose a “plausible” mechanism: “as a group, less educated people are less able to plan for the future and to delay gratification.” And health risks—such as unprotected sex, overeating, and drinking copious amounts of beer—usually yield short term gratification.
Educational attainment is not just about personal drive. Students are educated in a certain social context. And poverty, as explained by David Williams, often constrains academic achievement (2001:76):
Children from poor families are more likely to come to school sick and with an elevated risk of experiencing violence, abuse, alcoholism, divorce and desertion, and frequent residential moves (Orfield and Eaton, 1996). All of these problems can create challenges for the school. Schools with high concentrations of poverty tend to have a less demanding curriculum, lower teacher expectations and limited connections to employment opportunities and to higher education. Moreover, the teachers tend to be less qualified, the neighborhoods less safe, and the buildings more deteriorated. All of the factors combine to produce lower test scores, higher dropout rates, higher teen pregnancy, and peer pressure against academic achievement and in support of crime and substance abuse.
The link between poverty and education, overall, derives its strength from psychological and material pathways. Children who receive positive academic reinforcement from parents, peers, and teachers are encouraged to desire scholastic achievement. But children who consistently deal with a disconnect between academic effort and reward, both inside and outside the classroom, can eventually lose motivation. And students that stay determined to achieve academic success are constrained by poorer quality teaching and “more deteriorated buildings,” among other external constraints.
THE OCCUPATIONAL CONSTRAINTS OF POVERTY
Poverty constrains a person’s ability both to find employment and to work at job that enables healthy behavior. Unemployment operates both through economic and psychological constraints. Life without a job, for most, means life with little money, and therefore limited ability to access health-enhancing commodities. And unemployment can foster illness through psychological demoralization and depression (Wilkinson, 2001).
Individuals in the workforce face a somewhat different set of constraints. As conceptualized by Michael Marmot, low wage jobs are often “high demand/ low control” (2004:122). Both factors—high demand and low control—make it hard for employees to stay healthy. A low wage job is often physically demanding. And employers usually provide less material and psychological rewards for low versus high wage employees (Marmot, 2004). A low level of control, moreover, makes it hard to “incorporate health-promoting behaviors into [the] workday” (Adler, 2001:61). Company exercise facilities are usually reserved for middle and high salary employees (Ibid, 61). And as illustrated in the following example, “high demand/low control” can complicate a doctor’s recommendations (Ibid, 61):
Researchers found a high rate of uncontrolled hypertension among [a group of bus] drivers (Ragland et. al, 1998). Rigid driving schedules inhibited many of the drivers who had hypertension from taking their prescribed medications because the diuretics increased the frequency of their need to use bathroom facilities. Frequent bathroom stops were difficult to make given their bus schedules. The drivers resolved the dilemma by stopping their medication.
The “high demand/ low control” model partially explains why low-wage workers are more likely to be in poor health. Low-wage employees, for one, are more likely to have musculoskeletal disorders (Lundberg cited in Auerbach and Krimgold, 2001:7). And after controlling for the effects of income, Marmot found that British Civil servants in the lowest paying job categories were at twice the risk of mortality compared to the average civil servant (1978). Overall, middle and high income employees have an occupational health advantage over their less generously remunerated counterparts.
The Reality Of Redistribution
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