Sigrun Olafsdottir

Fundamental causes of health disparities: stratification, the welfare state, and health in the United States and Iceland.

Research has established that those with higher social status have better health. Less is known about whether this relationship differs cross-nationally and whether it operates similarly across different institutional arrangements. To examine the relationship between stratification and health, two Western, industrialized societies at opposite ends of an equal/unequal continuum are compared: the United States and Iceland. Using data from the 1998 General Social Survey and the 1998 Health and Living Standards of Adult Icelanders survey, I draw from two theoretical perspectives. First, I explore the notion of fundamental causes of disease by examining whether stratification has similar effects on health. Second, I examine whether the organization of welfare states affects this relationship. The results show that education, employment, and relative poverty have similar effects on health in both nations, thus supporting the notion of a fundamental cause. However, in Iceland relative affluence has a weaker relationship with health. Further, being a parent, regardless of marital status, has a stronger positive relationship with good health in Iceland. Welfare state intervention may be most successful in equalizing health outcomes by supporting families and by removing advantages traditionally accumulated by the wealthy in capitalist societies.

Similar Pressures, Different Contexts: Public Attitudes toward Government Intervention for Health Care in 21 Nations

Health care systems worldwide are experiencing similar pressures such as rising cost, aging populations, and increased burden of disease. While policy makers in all countries face these challenges, their responses must consider local pressures, particularly the implicit social contract between the state, medicine, and insurers. We argue that public attitudes provide a window into the social context in which policy decisions are embedded. Using data from the International Social Survey Programme (ISSP), we compare public attitudes toward government involvement in health care in 21 countries, testing the associations between various nationallevel variables (e.g., health care expenditures, aging of population, health care traditions) and public opinions. Specifically, we posit four national-level hypotheses (“health care traditions,” “expenditure crisis,” “demographic crisis,” “changing disease profile crisis”), one individual-level hypothesis (“individual vulnerability”), and two cross-level hypotheses (“cultural socialization” and “health care need”). Our findings indicate that public attitudes cluster around the historical organization of health care, but also relate to current economic and demographic realities. Individuals in countries adopting the “National Health Service Model” (the state directly provides health care but complete state control is absent) or the “Centralized Model” (the state directly provides health care and has much control) are more supportive of government involvement in health care than those in the “Insurance Model” (the state is limited to maintenance of the system) countries. However, citizens in countries currently spending more on health care and having a greater burden of chronic illness are less supportive. Our results cast doubt on arguments that increased cost will result in a questioning of the contract between the state and citizens in the social provision of health care. We end by discussing implications for recent work in political sociology that highlights the importance of public attitudes.

Health Inequalities in Global Context

The existence of social inequalities in health is well established. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between inequality and average population health across countries. Despite the theorization of (presumably variable) social conditions as “fundamental causes” of disease and health, the cross-national literature has focused on average, aggregate population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health, such as income inequality. We advance and redirect these debates by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from 48 World Values Survey countries, representing 74% of the world’s population, we examine cross-national variation in inequalities in health. The results reveal substantial variation in health inequalities according to income, education, sex, and migrant status. While higher socioeconomic position is associated with better self-rated health around the globe, the size of the association varies across institutional context and across dimensions of stratification. There is some evidence that education and income are more strongly associated with self-rated health than sex or migrant status.

The Global Financial Crisis and Individual Distress: The Role of Subjective Comparisons after the Collapse of the Icelandic Economy

Sociologists have emphasized that abrupt social changes can evoke subjective deprivation that can create subjective injustice and emotional distress. The global economic crisis offers an opportunity to examine this issue. This article builds on relative deprivation theory and proposes that economic crises evoke three subjective comparisons that influence distress: comparisons to 1) past outcomes; 2) the situation of others; and 3) expected future outcomes. Using a national survey obtained during the economic crisis in Iceland, we examine how these comparisons influence subjective injustice and emotional distress (anger and depression). Results indicate that perceived reduction in the standard of living has a more pronounced effect on subjective injustice and anger, 1) when individuals think that the crisis has harmed them more than others; and 2) when they have negative expectations about their future. The study implies that subjective comparisons can moderate the effect of sudden social change on distress.

Health and the Social Rights of Citizenship: Integrating Welfare-State Theory and Medical Sociology

Social scientists have long been interested in the link between societal processes and individual outcomes. The founders of sociology were interested in how social integration affected suicide rates (Durkheim 1951 [1897]), how the social organization of labor relations impacted worker experience (Marx and Engels 1964 [1848]), how religious principles translated into individuals’ work ethics (Weber 1930), how modern society impacted mental health (Simmel 1950), how mental health institutions shaped individual inmates (Goffman 1961) or how the social system impacted health care utilization (Parsons 1951). All addressed issues of health, illness, and healing in one way or another, yet medical sociologists have tended to pay less attention to the distal forces of societal-level institutions, focusing instead on the more proximate micro- and meso-level determinants of individual health.

Beyond dichotomies: confronting the complexity of how and why individuals come or do not come to mental health care

With up to 50% of individuals in the “developed” world and up to 85% in the “developing” world assessed to have mental health problems but receiving no treatment (1), inevitable questions arise about the reasons for the gap. There are standard explanations – issues of access, cost and manpower; issues of mental health literacy or lack thereof; and of course, the large set of issues of prejudice and discrimination that we call stigma. But the now extensive list of research correlates that have been documented across hundreds of studies have yet to unravel the subtleties that underlie the dilemma of unmet need.

The Theory of Industrial Society and Cultural Schemata: Does the “Cultural Myth of Stigma” Underlie the WHO Schizophrenia Paradox?

The WHO’s International Studies of Schizophrenia conclude that schizophrenia may have a more benign course in “developing” societies than in the West. The authors focus on this finding’s most common corollary: cultural schemata are shaped by the transition from agrarian to industrial society. Developing societies are viewed as traditional, gemeinschaft cultures lacking the stigmatizing beliefs about persons with mental illness held in modern, gesellschaft cultures of developed societies. The Stigma in Global Context—Mental Health Study formalized the cultural myth of public stigma (CMPS) with propositions linking level of development to intolerant, exclusionary, and individualistic attitudes. In 17 countries, the authors find no support for the corollary; where support is found, the findings are opposite expectations, with developed societies reporting lower stigma levels. Reconceptualizing of the cultural landscape on more specific dimensions also produces null or contrary findings. This correction to nostalgic myths of cultural context in developing societies thwarts misguided treatment, policy, and stigma-reduction efforts.

Social Construction and Health

Social construction represents a major theme in sociology. Ever since Berger and Luckman (1967) suggested that some of our most taken-for-granted assumptions about society are embedded in specific “realities”, sociologists, across the board, have been interested in such processes and applied them to a wide array of topics. Social constructs are viewed as the by-products of countless human choices, rather than laws that result from divine will or nature. This approach stands in contrast to essentialism that considers specific phenomena as inherent and transhistorical essences independent of human actions and decisions (Burr 1995). The theoretical contributions of medical sociologists within this perspective are shaped by the development of medical sociology itself. Early on, Strauss (1957) pointed out the inherent tension between sociologists in medicine and sociologists of medicine. The former generally collaborate closely with medical doctors to solve practical problems in medicine, but the latter are committed to use issues of health, illness, and healing as a window to help us understand larger sociological questions. Increasingly, sociologists are interested in questions that simultaneously advance sociological theory and have implications for the well-being of populations and individuals. Not surprisingly, these questions often center on how social and cultural factors matter for the way in which we understand and respond to biological processes.

Public or private? The role of the state and civil society in health and health inequalities across nations

Social scientists have long recognized that macro-level factors have the potential to shape the health of populations and individuals. Along these lines, they have theorized about the role of the welfare state in creating more equal opportunities and outcomes and how this intervention may benefit health. More recently, scholars and policymakers alike have pointed out how the involvement of civil society actors may replace or complement any state effort. Using data from the World Values Surveys and the European Values Study, combined with national-level indicators for welfare state and civil society involvement, we test the impact of each sector on health and health inequalities in 25 countries around the world. We find that both have a statistically significant effect on overall health, but the civil society sector may have a greater independent influence in societies with weaker welfare states. The health inequalities results are less conclusive, but suggest a strong civil society may be particularly beneficial to vulnerable populations, such as the low income and unemployed. Our paper represents an early step in providing empirical evidence for the impact of the welfare state and civil society on health and health inequalities.

Citizenship and Healthcare Policy

Dating back to the writings of T. S. Marshall on social citizenship, social scientists and policy-makers alike have debated the rights and responsibilities associated with citizenship. Originally defined by Marshall in 1949, citizenship encompassed ‘the whole range from the right to a modicum of economic wel- fare and security to the right to share to the full in the social heritage and to live the life of a civilized being according to the standards prevailing in the society’ (Pierson and Castles, 2000:32). Notably, this conceptualization refers to politi- cal, civil, and social rights that individuals should ideally have as members of society, which would certainly include the right to healthcare, as the ability to participate fully in society is clearly linked to one’s health status.