Chapter 5 – Poverty, Class, and Privilege
5.1 Acknowledging Poverty, Privilege, and Class Bias in Medicine
Laurie Belknap DO and Camilla Curren MD
Origins of Poverty and Social Class Differences
Persons at lower income levels have consistently demonstrated less social mobility overtime than have more wealthy Americans. So generally speaking, if you started out life at the bottom of the economic ladder, you have a decreased likelihood of moving up compared with those starting at higher levels.1 What is the influence on health and well-being of starting out at a lower socioeconomic status? The role of poverty and its social impact on childhood development is well established, as is the fact that poverty has a significant role in creating lifelong limitations and in continued promotion of poverty for future generations.2 The stunting of physical growth and cognitive development can make it less likely that a child will attend school, and can cause problems with social and emotional development that contribute to poor performance in school.2 Childhood poverty and the resulting consequences cause high levels of social and emotional stress.3 Social conditions such as foster care and the involvement of child protection agencies can lead to emotional dysfunction and predispose affected children to the development of mental illness later in life.3 Children from underprivileged backgrounds or from backgrounds of social and economic deprivation are more likely to perform poorly in school, leading to a lack of education that causes profound and lifelong impact.3
Socioeconomic status has been identified as a prominent stratification factor for determinants of health
Economically advantaged people have better health outcomes than the less advantaged.4 One study demonstrated that sociodemographic factors created additional access barriers for Hispanic patients with diabetes resulting in lower utilization of healthcare and higher disease management expenditures. The same study found that Hispanic patients with diabetes were typically younger, but had higher poverty rates, less education, and lower physical activity levels when compared to non-Hispanics in the general U.S. population.5 Another study demonstrated that a person’s neighborhood of residence can predict cardiovascular mortality.6 Low socioeconomic status is known to be linked to increased cardiovascular risk factors.7 The results of another empirical analysis showed that those with higher perceived socioeconomic standing and greater resources have better health than those who have lower standing and fewer resources. In this study, self-reported health, dental health, and happiness were strongly associated with subjective assessments of social position.8
The prioritization of daily necessities for disadvantaged populations can become a way of life, which can sometimes mean that health needs are postponed or not addressed at all when resources are scarce. Healthcare and medical insurance can come long after meeting basic needs for many people who experience financial constraints or poverty.9 For example, Pamela Taylor, a resident clinic patient with several chronic medical problems, regularly uses a food pantry and must often decide between going to the grocery or to physician’s appointments as she can only afford 1/8 tank of gasoline per benefit check. Even given this frugality, she has difficulty making house payments and may soon end up homeless.