Being at the Bottom of the Social Ladder can be Hazardous to Your Health

Most societies around the world stratify their inhabitants according to one of two systems: by class or by caste. From a global perspective, there is a tendency for people in the lower socioeconomic strata to have many more health problems than people in higher strata, and the United States is no exception. This article examines some of the possible explanations for why Americans at or below the poverty level have poorer health than their counterparts in higher social classes. The poverty level in the United States was established in the 1960s by former President Lyndon Johnson, and is approximately $25,000 for a family of four. The rate is adjusted up or down according to family size, but is not adjusted for where in the country a family lives. It has not been appreciably changed since it was first adopted fifty years ago. The number of people in poverty can change in response to fluctuations in the economy or the job market, or as a result of natural disasters such as hurricanes. The United States has a population of 322 million, and a poverty rate of 12-14%, which means that roughly forty-three million people in this country live in poverty.

One of the most glaring explanations for the poor health status of people in poverty is the lack of access to medical care. While some poor people work, they are usually not highly skilled; the kinds of jobs for which they are qualified tend to be those that pay the minimum wage, which is approximately $7.25 an hour. Jobs that pay only the minimum wage, or those that are classified as part-time, temporary, or seasonal rarely provide health insurance, without which poor people cannot afford to seek medical care. It should not be surprising to anyone that the cost of medical care in the United States is among the highest in the world. Poor people in America tend to live either in dilapidated neighbor hoods in cities or in rural areas. In the former, medical facilities are usually overcrowded with long wait times. In rural areas, there might not be a doctor or a hospital for hundreds of miles. Poor people also have chronic stress, with few discernible ways of mitigating its effects. It’s stressful to not know if there will be enough food to feed the family for a whole week, or if the electricity or the telephone will be turned off because of lack of payment.

Many poor people live in crime-ridden areas, which adds to an already stressful life, as do the many unresolved health problems. We know only too well that prolonged stress can be hazardous to one’s health; poor people have disproportionately higher rates of stress-related illnesses such as heart disease, diabetes, and hypertension. Obesity is also higher among poor people than among people of higher social strata. In general, people live where they can afford to live, in a phenomenon called ‘residential segregation.’ Poor people live around other poor people; wealthy people tend to live around their financial counterparts. One of the ways that individuals often have of mitigating the stress of living in poverty is to turn to others for social support, whether that support comes in the form of a friend to talk to, a ride to the grocery store, an offer to take care of the children for the afternoon. While many have friends who are certainly well-intentioned, the social support they may be able to provide can be limited by the fact that the friends to whom one turns in times of stress are in the same disadvantaged position.

Food is another major issue. Poor people tend to be less educated than others, so the amount of knowledge they have about what constitutes a healthy diet may be limited. There is disagreement about what constitutes ‘healthy eating,’ and one of the most widespread myths is that it is expensive to eat a healthy, balanced diet. On the other hand, if food is scarce or its appearance on the table is uncertain, the nutritional content of the meal is not as important as is the fact that there is actually enough for a meal. Because eating out in a restaurant is an infrequent occurrence, there is a reliance on fast food as a special treat, and we are well aware that despite advertisers’ claims to the contrary, fast food is generally does not constitute healthy eating, as it is high in fat, sodium cholesterol, and calories. When a person from the middle or upper classes perceives that he/she has a health problem, the most common response is to call the doctor. Poor people usually don’t have an individual to whom they refer as ‘my’ doctor, as they have few options for medical care should the need arise. They can go to an emergency room or a public health clinic, both of which may involve long wait times to see a different medical professional each time. The medical professional, because he/she is highly educated, may be totally unfamiliar with the life style and chronic issues that plague poor people; this discrepancy is referred to as social distance’, which means that in this case, patient and provider come from vastly different backgrounds and may have troublecommunicating effectively. Poor people don’t usually have a lot of health information and are more likely than middle class people to feel uncomfortable or intimidated in a medical encounter, which may prevent them from asking questions or from participating fully in the process whereby their health concerns are addressed. Not every country is as highly stratified as the United States, with such a wide gap between the highest strata and the lowest strata; some are more high stratified. In those countries with stark differences in the highest and the lowest strata, those at or near the bottom invariably have poorer health.