By Stefania Bucur and Leonie Schorrlepp
Globally, wealth inequality heavily influences (ill-)health, both directly and indirectly. Directly, through an increased number of people living in poverty experiencing ill-health due to more stressful and unhealthy lifestyles due to lack of security. Indirectly, through a trend of worse overall health in more unequal societies (1). This essay will discuss how the dimensions of poverty – scarcity and precarity – create stress and are connected to ill-health, specifically using the example of obesity. Poverty is not fair; it does not affect people in an equitable manner. Poor levels of education, an ethnic minority background, a family history of deprivation are all factors that predict poverty. Thus, we suggest a policy change in favour of universal basic income to address the unfair health inequity caused by poverty.[
After inequality was decreasing in Western countries from the 1930s up until the 1970s, it has been continuously increasing since the 1980s, potentially owing to the establishment of a neoliberal capitalist system in the Western world (2). Consequently, income insecurity has been rising again in recent years, meaning it has become a more prevalent societal challenge. In 2017, 689 million people worldwide lived underneath the poverty line. The following year the income of the poorest half of the world decreased further whilst the world’s billionaires only grew wealthier (3). Fastforward another two years and 2020 sees poverty reduction efforts suffering the biggest setback in decades. The world bank estimated that 100 million new people would be pushed into extreme poverty due to the Covid-19 crisis in 2020 alone (4).
This comes at a high individual cost for people’s wellbeing and happiness, but also economic costs (decreased tax incomes, increased welfare costs and a less productive workforce due to health-related absences). Accordingly, a 2019 report by the World Health Organisation found that reducing the health inequities that follow the wealth inequalities would have economic benefits for states in the Europe region and increase their Gross Domestic Product (GDP) by 0.3 – 4.3%. This beckons the question, why are nation states not doing more to reduce income inequality, and what can be done to decrease it? We will come to this later, but first, let us investigate how health, poverty and stress are all connected.
Less wealth, less health?
It is a relatively robust finding that greater inequality is associated with worse health in a society (1). Especially, the association of physical health and poverty is useful for exemplifying how intertwined societal health and income inequality are, as socio-economic circumstances can prime unnecessary stress (5).
In Europe, overall, 19% more women and 17% more men report ill health in lower income groups than in high income groups (3). In the UK, for example, patients from low-income areas present more than one illness at a higher rate than those from higher income areas. As people age, the likelihood of multimorbidity increases, however, low-income patients in the UK experience this 10 to 15 years earlier than people who live in wealthier areas. Meaning that poorer people experience 10 to 15 years more illness, possibly influencing their ability to work and care for themselves, their families and their communities (6).
The COVID-19 crisis has served to exemplify these differences in health in the cruellest way. Patients who came from the most socioeconomically deprived areas of Scotland and were admitted to the hospital with COVID-19 were disproportionately admitted to critical care and had a higher 30-day mortality rate than patients coming from the least socioeconomically deprived areas (7). To summarise this, people with lower socio-economic status (SES) are ill more, earlier, and are more likely to suffer worse courses of COVID-19 and are more likely to die. Why is that?
More stress, less security, none of the health.
As can be seen in figure 1, poverty affects health directly in two ways: (A) disadvantaged environment and (B) increased stress (which is further divided into (a) scarcity, i.e., reduced individual resources and (b) precarity, i.e., reduced security) . Living in a disadvantaged environment (A) includes living in unhealthy living conditions, having fewer green spaces available, worse healthcare and worse educational opportunities. Whilst this is an important dimension of how poverty influences health and is related to the other pathways, this essay will focus on the stress dimension (B).
Moving forward, we will cover the two ways in which poverty induced stress has an influence on health. First, through existential threat to the stability and security of the individual (precarious living conditions, dealing with insecure employment that, in turn, affects the security of food and shelter etc.). Second, through reduced individual resources (time, energy, finances etc.). Scarcity can lead to both a decrease in healthy behaviour (for example, not having enough time to cook a healthy meal or enough money to buy healthy ingredients) and increase unhealthy behaviour (for example, picking up smoking as a coping mechanism).
Ultimately, health problems caused by these factors can lead to a decreased ability to work, which, in turn, worsens the financial situation, keeping people in poverty and creating an inescapable cycle.
The stress of having less.
As mentioned before, one of the ways in which poverty affects health is through increased levels of stress over a longer period of time, making it a chronic stressor (8, 9). Persistent precarity, changes the way the body reacts to stressful events. Individuals in low-SES parts of the population are impacted more strongly by decisions outside their control than those with higher SES, leaving them “long-term stressed by virtue of unpredictability” as Johnson and colleagues put it (5, p.4). This exemplifies how the poorest part of the population is disproportionately out of control regarding their income and, thus, security of their livelihood.
However, which aspects are most threatening and thus stressful for individuals may depend on cultural context. In Zambia, for example, a study found that food insecurity was the one poverty indicator significantly related to increased levels of subjective stress. Thus, only the consequence of insecure income, that is, not being able to afford food, led to a stressful state. Nonetheless, the consequences of prolonged precarity and scarcity are long-term.
Studies show that children who grow up under a lot of stress become more reactive to it and can become prone to depression or anxiety in their adult lives (10). This development may be differentiated by individual trajectories of poverty during formative years. Researchers in California investigated whether changes in income of adolescents’ families of Mexican origin, would lead to different stress responses of these adolescents. Indeed, they found that experiences of poverty development predicted activity in the hypothalamic-pitiuary-adrenal (HPA) axis at age 17, which is strongly implicated in the physiological reaction to stress. Those youths who entered adolescence in deep poverty and remained there (even with small increases in family income) were desensitised to the experience of stress. Compared to those adolescents, young people who started adolescence in an economically well-off household and then lost income between the ages of 10 and 16 experienced stress as more threatening. This study showed two things. First, continued economic stability is extremely important for developing a healthy stress response. Second, adolescents from the most deprived circumstances might benefit from an increased family income, rather than staying in stable poverty, in order to develop a healthy stress response.
The impact of poverty on the stress response, however, does not stop at neural pathways. Even more shockingly, external conditions have the potential of altering the expression of genes (11). The adversity that children growing up in poverty face can alter the epigenetic state of genes. This happens mainly through interaction with their parents. These epigenetic changes lead to further changes in the regulation of the HPA axis. Moreover, these differences can be observed between people living in wealthy compared to impoverished areas. For example, researchers found a substantial number of epigenetic differences between people living in poverty-stricken areas of Glasgow compared to more affluent areas (12). So, the stress of poverty has incredibly deep-reaching consequences.
Can poverty nurture obesity?
Let’s use obesity to look at how reduced financial resources can lead to ill-health through decreased healthy and increased unhealthy behaviour. Researchers find that one’s neighbourhood can play a big role for one’s diet, health outcome, and health-related behaviour (13) and can have a direct impact on BMI for both adults (13) and children (14). For example, studies have shown that children who grow up in low-income neighbourhoods are less healthy throughout their entire childhood than children coming from more affluent neighbourhoods (16, 17).
The other challenge that individuals with a lower income face is that they might not be able to afford healthy foods, even in the cases where it is technically available to them. Healthy food, being more expensive, is simply out of reach for people living in poverty. Studies have shown that high prices of foods lead to a significant decrease in fruit, vegetables and dairy consumption in the case of low-income families. Even more, both adults and adolescents have indicated that the second most influential deciding factor when buying food is the price, while taste being the most important (13). Therefore, low-income is not only associated with consumption of unhealthy food, but also with a decrease in consumption of healthier alternatives such as fruits and vegetables (13).
Both lack of access and affordability of healthy food as well as increased intake of unhealthy “comfort food” are potential reasons for the link between poverty and ill-health in the case of obesity. The case of obesity makes it clear how living in poverty and income insecurity can have a damning influence on one’s health. Now, what to do?
Policies for everyone.
There are different ways to tackle the influence of poverty on stress but what unifies different ideas is that it is not on the individual to change their behaviour but rather government policies are the most effective way to address this issue. As can be seen in the case of obesity, it is external circumstances that have a deciding influence on the choices one makes when living in precarity and scarcity. The WHO European Health Equity Status Report (3) suggest that employment and working conditions must be improved so that poorer parts of the population do not experience income insecurity and precarious employment disproportionately. One way of reducing income insecurity that has received increasing attention in recent years is the introduction of a universal basic income (UBI) that presents an upstream solution as can be seen in Figure 2.
UBI “fixes” the insecurity that stems from the power imbalances experienced in unequal societies, especially by the poorest parts of the population. Whilst many states already have a welfare system in place, this is usually needs- and means-based, leaving individuals in a position where they are still subject to arbitrary decisions about their need. In such a system, someone who is unemployed or not earning enough to keep their family fed, has to continually prove their need and might have benefits taken away at the change of a governments’ priorities. Thus, they stay in a stressful state of precarity (5). So how is a UBI different? Whilst there are different ideas of how UBI can be implemented, the core idea is that a state transfers cash to its citizens, it is paid to all, is not needs-based and, thus, does not get reduced when the receivers are starting to earn above a certain threshold (5). Consequently, a UBI reduces the insecurity that many people are experiencing due to precarious employment, thus reducing chronic stress, which has a positive impact for their health.
Receiving a UBI has various health benefits, some of which are suggested to be moderated by the decrease of experienced stress (5), both via decreased existential threat and increased resources. It is intuitive how receiving “free” money each month would reduce the impact of insecure employment (if the employment is suddenly terminated, at least there is some secure income still) and consequently that of precarious living (the rent can still be paid, no matter what happens to other income). Additionally, a UBI means that one can reduce working hours a little, thus freeing up time to exercise, cook healthy and help the children with their homework. There is some evidence that in negative tax income interventions, which are similar to UBI but address only those with a low-income, people receiving additional financial support would spend more time in the home and work slightly reduced hours to before (18). However, whilst there might be some reduced work hours, UBI interventions have not caused participants to drop out of work. Indeed, usually unemployment rates are largely unchanged. The reduced insecurity and increased resources have repeatedly proven health benefits. A Finnish trial of a system similar to UBI with only small increases to the benefits that people were receiving before (about 50€ more) significantly improved people’s well-being (5). More specifically, it has been found that there are moderate to large positive effects on low birthweight, mental health and diet with health outcomes being most improved in the most disadvantaged groups (18).
A UBI seems like such a simple solution. With just a little bit of extra financial support, low-SES individuals would not have to endure the ill-health that they are at risk for now. Our obesity example shows that just availability and affordability of something as simple as our everyday food can keep you in a cycle of poverty and insecure income that leads to ill-health, that leads to less resources, that leads to more stress, that leads to worse health, that leads to less resources, and so on. Living in poverty is not a choice, living in insecurity is toxic. If governments are concerned about the cost of a UBI, they might want to take out their calculators again and look at the cost of healthcare for those ill before their time, those out of work due to ill-health, and quite frankly, the cost for their morality.
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