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Embodying social class: The link between poverty, income inequality and health
Stephen M. Rose and Stephanie Hatzenbuehler International Social Work 2009 52: 459 DOI: 10.1177/0020872809104250 The online version of this article can be found at: http://isw.sagepub.com/content/52/4/459

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International Social Work 52(4): 459471

i s w
Sage Publications: Los Angeles, London, New Delhi, Singapore and Washington DC DOI: 10.1177/0020872809104250

Embodying social class

The link between poverty, income inequality and health

Stephen M. Rose and Stephanie Hatzenbuehler

Poverty and illness are nearly inseparable. As Krieger et al. (1997: 343) so aptly summarize it: Poor living and working conditions impair health and shorten lives. Kristenson et al. (2004: 1511) echo this sentiment: The association between low socio-economic status (SES) and poor health is well established; the poorer the SES, the worse prospects for health development. Evidence confirms that this correlation persists even when universal health care is accessible (Isaacs and Schroeder, 2004; Pincus et al., 1998; WHO Commission on the Social Determinants of Health [CSDH], 2008). As the International Federation of Social Workers (IFSW) Policy Statement on Health (2008: 1) stated, Health is an issue of human rights and social justice; population health reflects distributive justice. Shaw et al. (2003: 332) remind us of observations made by Engels in The Condition of the Working Class in England in 1844, in which he vividly describes the physical appearance and behavioral characteristics of impoverished people forced to endure horrible living and working conditions: The physical effects of the living conditions of the poor had their effects from early life . . . The appearance of (these) children showed their circumstances and neglect, which left ineradicable traces which brings the enfeeblement of the whole (class) of workers with it.

Key words class embodiment empowerment income inequality social determinants of health

health inequality

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Engels powerful narrative creates a basis for social workers to perceive class as an indivisible coercive relationship penetrating far deeper into everyday experience than discrete indicators of social position imply, e.g. income, educational or occupational level (Graham, 2007). This relationship exists between those who benefit from producing the damaging living and working conditions of the poor and those who suffer a health impact from early life. Class, in other words, consists of a structurally created, relentless conflict of interest. Engels observation of ineradicable traces constitutes a subjectively measured health impact assessment based upon a pattern of inequality in the material and psychosocial conditions required for physical and psychosocial health. Krieger et al. (1997: 343) summarize this point:
Poor living and working conditions impair health and shorten lives. These associations persist well into the late twentieth century, despite marked improvements in living standards and medical care, and are not substantially explained by known biomedical and behavioral risk factors. In both industrialized and less industrialized countries, socioeconomic gradients are apparent for infant mortality, adult mortality, acute and chronic infectious and non-infectious diseases, and psychiatric morbidity.

This article identifies and integrates population-based research applicable to social work. We discuss the relationship between class and health, noting that social works role in health and mental health care could change significantly by developing conceptual clarity about the relationship in order to create both policy and program innovations (Gorin, 2000; Graham and Power, 2004). The life course epidemiological perspective: a useful lens for defining health Engels may have been among the first public health researchers to identify what later became known as the life-course perspective in epidemiology (Kuh and Ben-Shlomo, 1997). Research from this populationbased framework demonstrates the cumulative health and psychosocial impact of severe material disadvantage and resulting negative psychosocial environments during the neonatal period (Barker, 1991; Bartley et al., 1994) and early childhood on later health and well-being (Marmot et al., 1991; Marmot and Wadsworth, 1997; Power et al., 1996; Siegrist and Marmot, 2004). Kuh et al. (2002: 287) characterize cumulative impact as a chain of risk, a sequenced life trajectory in which exposure to one established risk factor increases the probability of heightened susceptibility for another, so that as the number and/or duration of exposures increase,
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there is increasing cumulative damage to biological systems (see also McEwen, 1998, 1999; Poulton et al., 2002; Power and Hertzman, 1997; Seeman et al., 1997, 2004). The onset, duration and extent of susceptibility to cumulative physiological and psychosocial damage are not equally distributed (Davey Smith et al., 1998; Graham and Power, 2004; Halfon and Hochstein, 2002; Kuh et al., 2002). Researchers have shown a gradient effect of the impact of inequality of wealth on health: cumulative biological damage to adult health is distributed approximately parallel to the distribution of wealth (Marmot et al., 1991; Wilkinson, 1999). Kristenson et al. (2004: 1512) note this impact: This gradient is shown for all causes of mortality, but also for a wide range of diseases, especially coronary heart disease [CHD], diabetes, gastrointestinal disease, respiratory diseases, arthritis, adverse birth outcomes as well as accidents and violent deaths. Health, from the life-course view, is far more important than the presence or absence of disease or access to medical care. Its focus is distinguished by its insistence on explicitly investigating social determinants of population distributions of health, disease, and well-being rather than treating such determinants as mere background to biomedical phenomena (italics added; Krieger, 2001: 693). Krieger moves individual demographic data age, gender, ethnicity, income, occupation, education to the foreground of health professionals attention because these data are population-based reflections of inequitable social structural relationships (Graham, 2007). Put differently, these apparently discrete categories for describing individual patients constitute ubiquitous population impacts deriving from inequitable structures of power and control. The lens provided by this framework permits social workers to understand the health impact on populations and, from that standpoint, derive action strategies. Social structural factors When unequal distributions of health, morbidity and mortality recur in defined patterns, the society is inequitable and unjust (Braveman and Gruskin, 2003). Structural inequity becomes biomedically embodied in the majority of people who comprise the body politic, proportionate to their place in the wealth distribution hierarchy (the gradient effect). Coburn (2004) adds that the mere background Krieger mentions includes evolving changes in class structure at the international (e.g. globalization) and national levels. Specifically, Coburn (2004: 48) discusses different forms of welfare state regimes and different levels of
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social welfare buffers which might meliorate the effect of income and other inequalities on health. Generally, as class solidarity decreases, the gap in income inequality increases; this results in severe reductions in societal investment in human development and protection by welfare state agencies, rationalized by an expansion of neo-liberal, market-driven ideology (Coburn, 2004). Conversely, as class solidarity increases, income inequality decreases, substantially reducing the burden of poverty, social exclusion (Kawachi and Kennedy, 1999; Wilkinson, 1999) and their gradient-based impact on health. This improves the evidence base for the potential health impact of redistributive, multi-sectoral social and health policies. Towards understanding class: the role of embodiment Engels perceived the ontological condition of an oppressed class or what Hasan, many years later (1989), described as an imposed wayof-life, a cohesive entity comprised of indivisible, interrelated parts that could not be understood as an aggregate of its constituent components. He saw the physical, mental and emotional misery and anguish of impoverished workers as an imposed reactive adaptation to extreme material disadvantage or location in an inequitable occupational, income and wealth hierarchy. What some observers now call the psychosocial component of daily life or a negative psychosocial environment (Siegrist and Marmot, 2004) was both an inevitable and inseparable dimension of the structure of inequity (Braveman and Gruskin, 2003). This aspect of class consists of hidden injuries (Sennett with Cobb, 1972) including self-contempt and a lowered sense of self-efficacy (Bandura, 1985). Efforts to survive and to understand the impoverished material and cultural conditions of everyday life and their meaning were seen as essentially resilient, reactive adaptations to imposed, intolerable conditions. Lynch et al. (1997) develop this view in their discussion of unequal distribution of health risk factors reflecting the social context within which health risks or behavioral choices occur. Psychosocial theories separating human behavior from an inequitable socio-economic context decontextualize everyday life, severing it and its health consequences from what Link and Phelan (1995) call the fundamental cause. Krieger et al. (1997: 345) contextualize the relationship between class and health: We use social class to refer to groups arising from interdependent economic relationships among people . . . Stated simply, classes like the working class, business owners, and their managerial class exist in relationship to and co-define each other. Inequalities in the distribution of material resources and the power to make decisions about them arise in the course of structural conflict
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between classes (sometimes called class war) over contradictory social and economic class interests. Krieger et al. (1997: 346) elaborate:
Class, as such, is not an a priori property of individual human beings, but is a social relationship created by societies. One additional and central component of class relations involves an asymmetry of economic exploitation, whereby owners of resources (e.g., capital) gain economically from the labor effort of non-owners who work for them.

Ample evidence demonstrates how the inequalities and exploitation that permeate the working and living conditions of the poor are incorporated into the body (Krieger, 2004; McEwen, 1998, 1999; Power and Hertzman, 1997; Seeman et al., 1997, 2004). The political and economic context of life becomes physiologically embodied (Krieger, 2005) in peoples lives. Embodiment is a concept referring to how we literally incorporate, biologically, the material and social world in which we live, from in utero to death; a corollary is that no aspect of our biology can be understood absent knowledge of history and individual and societal ways of living (Krieger, 2001: 694). Lynch (2000) describes this relationship as one in which people embody their class position or express through their biological being the social equality or inequity in the distribution of necessary resources for living and participating in society. In this framework, peoples bodies (including their brains, minds and emotions) contain the cumulative impact of their material existence and its meaning, primarily as the outcome of unequal levels of stress and its biological impact (McEwen, 1998, 1999; Seeman et al., 2004). We add to this biopsychosocial analysis the confinement of consciousness about ones situation to the socially available or ideological explanations for ones social circumstances (Rubin, 1976). Miller (1986: 94) argues: All forms of oppression encourage people to enlist in their own enslavement. In this sense, psychological problems are not so much caused by the unconscious as by deprivations of full consciousness . . . Lacking full consciousness, we create out of what is available. What typically is available is blame for making poor behavioral choices; e.g. not exercising sufficiently, smoking or overeating. Identifying the research base for population health policy: a focus for social work Graham (2002: 2006) describes how the relationship of socially structured or purposeful inequity can become hidden or obscured by camouflaging population-based data: The processes through which the social structure shapes the social circumstances and health experiences
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of different socioeconomic groups are difficult to detect through the individual data on which health inequalities research continues to rely. Specifically, the absence of population-based health data and the reliance upon individual medical diagnoses make structural analyses problematic. This problem is made more complex by confounding health and health-care access data, assuming, incorrectly, that ensuring health-care access will ensure health (Isaacs and Schroeder, 2004). Graham (2002) argues for shifting the research base to social policy research, a body of evidence more closely aligned with sociology than with medicine and its individual-patient databases. It constitutes an alternative data or evidence base for designing primary prevention strategies at a population or societal level, the level required for analysis of the degree of social injustice extant in any society. Social policy research appropriate to social work asks questions such as these: What are the health impact assessments of poverty and income inequality? What are the health effects of racism? Why do health risk behaviors and chronic diseases differentially occur in gradients parallel to income? How does exposure to childhood and adult poverty, and to the negative psychosocial environments they engender, effect medical condition, service use patterns and medical care outcomes? Why does the incidence of chronic illnesses, such as type 2 diabetes, increase as quickly as communicable disease once did? Graham (2002: 2006) claims that social policy research has long been concerned with how socio-economic disadvantage is reproduced across and between generations and with the role that governments can play in moderating inequalities in life chances and living standards. This type of research may include class analysis in the policy-formulating and impact assessment process. It can shift the focus of policy from remedial services provided to individuals to populations, prevention and the redistribution of material resources necessary for human development. Evidence capable of altering negative psychosocial environments will reduce biomedical and mental-health vulnerability by breaking the anchor for the chain of risk and reducing the onslaught of unrelieved stress. Application to health and mental-health care: the practice dimension Gathering data on life-course exposure and vulnerability supports social workers in creating interventions designed to disrupt evolving trajectories or predictable behavioral patterns (e.g. early use of cigarettes, drugs and alcohol, teen pregnancy, young single parents, continued intimate
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partner violence). It also encourages the search for intervention points to break the chain of risk earlier in the life course. Bhatia and Katz (2001) exemplified a way in which policy level research is translated into macro-level practice by identifying a significant improvement in family health impact resulting from instituting a living wage when compared with the health impact of the minimum wage. Public health professionals refer to the policy and structural realm discussed above as upstream measures (Bhatia, 2003). Upstream measures focused on social justice attempt to eliminate or significantly reduce resource inequities in order to prevent avoidable morbidity, incidence of co-morbidities and mortality. Because of social works dual focus, we turn now to downstream measures, targeting services for existing, affected populations that can be conceptualized within the same life course and social justice framework presented above. Siegrist and Marmot (2004: 1465) enhance this discussion through their analysis of the impact of socially derived psychosocial environments on health. Psychosocial environment is defined as the sociostructural range of opportunities that is available to an individual person to meet his or her needs of well being, productivity, and positive selfexperience. Schrijvers et al. (1999: 535) constructed the interaction between material disadvantage and behavioral risk involvement within a sociostructural framework:
Part of the unhealthy behavior in the lower socioeconomic groups is likely to be induced by adverse material condition. This implies that the unequal distribution of behavioral factors across socioeconomic groups can be partly ascribed to the unequal distribution of material factors. The independent contribution of behavioral factors to the explanation of socioeconomic inequalities in mortality is therefore easily overestimated.

The sociostructural limitations of an environment permeated by material disadvantage, income inequality and exposure to family chaos and violence (Anda et al., 1999; Felitti et al., 1998) confine the potential development of self-efficacy and self-esteem, two attributes linked directly to health (Siegrist and Marmot, 2004) and essential to active patient participation as a partner in all chronic illness care (Holman and Lorig, 2000). Kristenson et al. (2004: 1518) associate exposure to a poor psychosocial environment and its resultant damage to a persons self-esteem and sense of self-efficacy with heightened feelings of hopelessness and helplessness. They also describe this as negative outcome expectancies and loss of coping. These psychosocial developmental injuries become vitally important to the design and delivery of chronic illness
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care, especially in recent interdisciplinary chronic illness care designs where self-management of care is a prerequisite to optimal intervention outcomes. We turn briefly to that aspect of adequate and appropriate treatment. Chronic illness care requires active self-management of life-style changes (Von Korff et al., 1997; Wagner and Austin, 1996) and medication compliance as well as monitoring health variables such as diet, exercise, glucose levels and infection control. Self-efficacy and internal locus of control become vital components for clinical understanding of patients coping with the progression of disease, the emergence of co-morbidities and medical care outcomes. Bandura (1985) defines self-efficacy as a persons belief that he or she has the capacity and competence to accomplish specified tasks. Self-efficacy is directly related to ones intrinsic sense of control. Siegrist and Marmot (2004: 1467) conclude that a damaging psychosocial environment, where people experience concurrent low self-efficacy and low self-esteem would critically increase risk of ill health. Kristenson et al. (2004: 1517) conclude: A major obstacle for the introduction, acceptance, and compliance with the new rules for a healthy lifestyle is the feeling of helplessness and hopelessness. These characteristics bring with them a very low sense of intrinsic control over ones life, leading to an extrinsic sense of control where one believes that his or her life is predetermined. There is a feeling of being hopeless and helpless about change. These feelings and the perceptions of reality that arise from them (e.g. low self-efficacy interacting with extrinsic belief about control) occur as adaptations to negative psychosocial environments that have been out of the persons control. This adaptation can be seen as an asset a capacity to perceive and respond appropriately to relational stimuli however damaging it might be. This constitutes a potential asset for interventions guided by more mutual, non-exploitive, authentic partnerships with shared responsibilities for defining health needs and support mechanisms or empowering practices (Rose, 1991; Rose and Black, 1985). Social workers skills in engagement and empowering practice fit this model by bringing people into authentic partnerships with health or mental health teams and elevating their role in problemdefining and action step development. Chronic illness in the USA is the major cause of disability, (and is) the main reason why people seek health care (Holman and Lorig, 2000: 526). According to Von Korff et al. (1997: 1097), Persons with chronic illnesses account for three quarters of health care costs in the United States. It is the primary arena for health and mental health care and as such it must become a focus for social work intervention. Proponents of
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community-based primary care of chronic illness, both at the federal level (the Centers for Disease Control) and in the voluntary sector (see the Robert Wood Johnson Foundation website, www.rwfj.org, and the website for the Group Health Cooperative of Puget Sound, www.ghc.org), concur that new delivery models are required for illnesses and conditions that are chronic and non-responsive to traditional medical curative efforts. These models have common characteristics. According to Wagner and Austin (1996: 512), effective programs extend beyond medical care delivery to focus on the patients struggles to live meaningful lives, a focal point for social work involvement as it extends beyond the medical arena. Optimal outcomes in managing chronic illness integrate self-management tasks into medical care delivery. These tasks include health-promoting activities such as exercise, proper nutrition, social activation, and sleep; interacting with health-care providers and systems to adhere to recommended protocols, to monitor their own physical and emotional status and make appropriate management decisions on the basis of symptoms and signs, and to manage the impact of the illness on their ability to function in important roles, on emotions and self-esteem, and on relations with others. Von Korff et al. (1997) emphasize the self-care dimension, identifying its role in promoting health, building physiologic reserve and preventing adverse sequelae. The following principles central to the production of the behaviors required to effectively practice selfmanagement of care include:
1) illness management skills are learned and behavior is self-directed; 2) motivation and self-confidence (or self-efficacy) in management of illness are important determinants of patients performance of self-care; 3) the social environment of the family, workplace, and health care system can support or impede self-care; and 4) monitoring and responding to changes in disease state, symptoms, emotions, and functioning improves adaptation to illness. (Von Korff et al., 1997: 10978)

Achieving these goals requires that the patient must become a partner in the process, contributing at almost every decision or action level (Holman and Lorig, 2000: 526). Citing the work of Hart, Holman and Lorig (2000: 527) state that in health care, the product is clearly health and the patient one of the producers, not just a customer. This construction of partnership fits social works dedication to selfdetermination and empowering practice at the clinical level. The physical and emotional outcomes of class-based, negative material and psychosocial environments embodied biological vulnerabilities, low self-efficacy, low self-esteem, low intrinsic locus of control, and helplessness or hopelessness completely contradict the exact capacities required
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for effective self-management of care. Population-specific adaptation of the chronic care model acknowledges embodied physical and psychosocial vulnerabilities, seeks to identify multi-generational exposure to material disadvantage and negative psychosocial environment, and uses this knowledge to develop counter-acting supports as part of interdisciplinary care. This form of practice also emerges as a form of cost control, focused on keeping services in the primary care context. Concurrently, social workers can use this evidence base to assess the potential health impact of public policy initiatives by examining the level of redistribution involved. This empirically-guided conclusion creates the opportunity for social work intervention. Social work has the potential to become a vital player in the interdisciplinary primary health and mental-health team. What makes social work so well positioned for this responsibility is our long-standing commitment to empowerment-based practice, the foundation for creating the partnerships that are prerequisites to meaningful and effective patient participation in chronic illness care. As Wagner et al. (2001) note, active and informed patients are keys to more effective interventions. Active and informed patients must have the opportunity to build or re-build self-efficacy, self-esteem, an intrinsic sense of control and a feeling of hope, in order to have the viable self that is required for the effective self-management of care. These necessary aspects of patients lives can be stimulated and enhanced by empowering social work intervention. Population-specific adaptations to the chronic illness model will recognize embodied oppression; will elicit multi-generational socioeconomic and family violence data at intake; will construct empowering partnerships designed to contradict and counteract the impact of damaged senses of self-efficacy, self-contempt, and the self-concepts of hopelessness and helplessness. This is the domain of social work. As Kristenson et al. (2004: 1518) say, Empowerment strategies . . . build on the ambition to enhance individual chances of developing positive expectancies, hopes, self-esteem and trust. Social work practice, embedded with the value of social justice, and armed with populationbased theory and research methods, will be better able to see the population-based dimension of social policy analysis and primary patient care and make them visible and amenable to preventive policy development and empowering clinical practice. This opportunity will be met with challenges arising from more narrow, medicalized approaches to health. These models, however, are themselves challenged by the failure to produce medical outcomes and cost controls for chronic illness care. Empowering social work practice,
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produced by social workers participation in primary care teams, must create a capacity for outcome-based evaluations of care at both the patient and population levels in order to build and sustain our role in emerging health-care delivery.
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Stephen M. Rose is Professor of Social Work in the School of Social Work at the University of New England, 716 Stevens Ave, Portland, ME 04103, USA. [email: srose@une.edu] Stephanie Hatzenbuehler is a social worker, also at the School of Social Work at the University of New England, at the same address.