A professor who for decades has studied linkages between socioeconomic status, access to medical care and health outcomes says the widening gap between rich and poor may be increasing health inequities, despite efforts to reduce them.
Bruce Link, a professor of public policy and sociology at UC Riverside, explained the “fundamental cause theory” that he developed in 1995 with his wife, Jo Phelan, in a Sept. 1 presentation to graduate students and faculty in the Sociology department at UC Merced.
In an interview with the Central Valley Journalism Collaborative, Link said a linkage between socioeconomic status and health outcomes isn’t necessarily novel. But when he worked in the epidemiology department at Columbia University’s School of Public Health in the 1980s and 1990s, much of the research on those connections focused on behaviors of people in various socioeconomic and demographic categories.
Fundamental cause theory, however, suggests that rather than behaviors, greater income or wealth associated with socioeconomic status “can be used in different places and at different times to gain a health advantage” over others, he said.
His research indicated that, historically, people with higher socioeconomic status have had earlier access to new medical advances.
For example, Link said, when Jonas Salk’s vaccine against polio was declared safe and effective in 1955, some people with higher socioeconomic status had access to it before it became broadly available.
In the current medical landscape, he added, the proliferation of GLP-1 injections and pills, ostensibly for diabetes but widely used for weight loss, followed a similar pattern of availability, first to people who could afford them before insurance coverage allowed access for a wider range of patients.
“The idea is that this is a dynamic process that keeps occurring, and that if you want to address the health inequities by socioeconomic status, you have to address the social inequalities,” Link said.
In examining associations between life expectancy, race and ethnicity, educational attainment and family income, he said, “we see within various race and ethnic groups that there is a gap [and] if anything, it’s been growing greater in recent years.”
The COVID-19 pandemic is one example in which the pattern of inequality changed between the earliest stages and the middle of the crisis later the same year.
Link said some of the earliest exposures to COVID-19 in early 2020 were among people of higher socioeconomic status, who were unaware of the virus and its spread in Europe and Asia.
“International world travelers, people who take cruises, people who go to expensive ski resorts” he said.
But within months, as the pandemic continued and the virus spread among the broader population, the disadvantages of lower socioeconomic status became clearer.
“Who cannot social distance? People in ‘essential’ jobs,” Link said. “Who’s living in tighter quarters? Who can get groceries delivered to them? Who can retreat to weekend houses? Who can jockey to get to the hospital and get the ventilators that were in short supply? Who gets first access to the vaccine?”
Link also proposed that a linkage exists between socioeconomic status and levels of discrimination, disrespect, exclusion and shaming – behaviors and attitudes, whether conscious or not, by higher socioeconomic classes toward the less affluent, less educated, and minorities.
In research studies in which people were questioned about experiencing disrespect, discrimination, exclusion and shaming, Link added, “the lower down the [socioeconomic status] ladder, the more they experienced this, and it was robustly related to measures of health and mental health.”
Reducing socioeconomic inequalities, and by extension health inequities, is a stiff challenge, he said.
“If your policy orientation goes towards reducing social inequality, that would be a way to address it,” Link said in his interview with CVJC. “If you’re in the public health domain, we tend to be a relatively individualistic society, so when we think about what we can do to improve health, we often think about, ‘What can you do?’ ‘What can I do?’ And we develop individualistic solutions that focus on, ‘What I can do to help me?’”
That individualized focus, Link added, tends to “invigorate this inequality,” rather than reduce it.
A widening gap between rich and poor, along with political polarization and growing disparities in education, “would suggest we’re not doing better,” he said. “We might even be doing a little bit worse in addressing the inequalities over time.”
Tim Sheehan is a senior reporter and Health Reporting Fellow with the nonprofit Central Valley Journalism Collaborative. The CVJC fellowship is supported by a grant from the Fresno State Institute for Media and Public Trust. Contact Sheehan at tim@cvlocaljournalism.org.