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Assignment: Social Determinants of Health Reflective Paper (Coursework Sample)


Inconsistencies in health outcomes are readily identifiable across populations. Once data is used to confirm disparities, what actions can a public health nurse, partnering with a given community, take? If information were enough, many long-standing health issues would be resolved. Consider what you have learned so far about public health and specifically the role of the public health nurse as you deepen your knowledge on the breadth of issues with which public health professionals engage.
For this Assignment, you will analyze two media pieces providing additional perspectives on the social determinants of health.
To Prepare:
Review the media for this week.
Reflect on the role of the public health nurse in the situations presented.
The Assignment:
After viewing the “Place Matters” and “Not Just a Paycheck” videos, complete a 2- to 3-page reflective essay in which you address the questions below, while integrating your personal reactions/responses to the media content:
In “Not Just a Paycheck,” two communities experiencing job loss after the closing of local manufacturing plants are discussed: Greenville, Michigan; and Vastervik, Sweden. Explain why you think the health outcomes of the citizens in Greenville and Vastervik are so different.
Based on the video, “Place Matters,” explain why zip code and street address are good predictors of population health?
What is the overarching theme illustrated by these two videos?
Place Matters Program Transcript
NARRATOR: If you lived here, you'd be 30% more likely to live into old age than if you lived here. If you lived in this neighborhood, your child would be six times more likely to be hospitalized for asthma than if you lived in this neighborhood. Why is your street address and the place you live such a good predictor of your health?
JAMES KRIEGER, MD: Place matters -that's where someone works, where they go to school, or where they live because place determines what someone's exposed to in terms of a whole host of factors that affect their health. So place matters because it determines what kind of physical or chemical agents you might be exposed to. It matters what kind of social environment you're exposed to. It matters if there's a lot of violence or crime in your neighborhood. It matters if it's easy to go for a walk in your neighborhood or find healthy foods. Who your neighbors are, and the way you interact with your neighbors, can also affect your health. So, place ultimately is a critical determinant of health.
DAVID WILLIAMS: When we think about health, we usually think about health care, and access to care, and the quality of care. But what research clearly shows is that health is embedded in the larger conditions in which we live and work. So, the quality of housing and the quality of neighborhood have dramatic effects on health.
NARRATOR: How do we make an unhealthy neighborhood healthy? Here are two neighborhoods working to find answers, one in Richmond, in northern California, and another in Seattle, Washington -two neighborhoods with similar problems. Today in High Point in west Seattle, there's quality, low-cost housing, clean parks, safe streets, access to good food choices, and sidewalks that allow lots of social interaction. These features promote health in High Point, but they're not found in many low-income neighborhoods.
NARRATOR: Meet Gwai Boonkeut, age 49. A refugee from Laos, he moved to Richmond, California in 1980. He works as a school janitor.
DAVID S. WEILAND: The heart is still weak. And I would find it hard to believe that you would be able to go back to work and work a full day right now. So each time the heart beats, 15% or 20% of the blood is leaving the heart. Normal is 60%.
DAVID S. WEILAND: Yeah, so it's working about a third of a normal heart.
Place Matters
NARRATOR: Two weeks ago, Gwai suffered a major heart attack. This is his first check up since emergency surgery.
GWAI BOONKEUT: How long will I live?
NARRATOR: His cardiologist doesn't pull punches.
DAVID S. WEILAND: That's a really good question. I don't know. You had essentially almost died once. And a lot of it depends on how much stronger the heart gets over the next three to six months. If it doesn't get stronger, unfortunately, you are at risk of suddenly dropping dead.
GWAI BOONKEUT: You talk about heart stress. You mean like things including like worry and anxiety and all that stuff.
DAVID S. WEILAND: All those things could play a role.
DAVID S. WEILAND: The question is why would a young man like this present with such severe heart disease -Weakened heart and a heart attack at such a young age. Basic causes of this sort of disease that we ask questions about are smoking history -he's not a tobacco user. History of diabetes -he doesn't, no history of diabetes. Family history of heart problems at a young age, no family history. And one has to wonder whether environmental factors play a role.
NARRATOR: In Gwai's environment, petrochemical companies release tons of pollutants each year, but these toxins may not be the worst environmental health threat here. Tobacco, liquor, and fast food are easy to find. Fresh produce isn't, nor is quality housing. Many public places are unsafe.
WENDEL BRUNNER, MD: It's a community that has enormous number of problems, so we see much higher rates of asthma, hospitalization. We see much higher rates of diabetes, lower life expectancy.
ANA DIEZ-ROUX, MD: When most people think of the causes of chronic disease -for example, cardiovascular disease -they think of individual level risk factors, which we know about -diet, physical activity, smoking. However, it's also true that they are socially patterned. And one of the dimensions across which it's patterned is by neighborhoods. If we look at a map of almost any geographic area -but I'll just use the example of Richmond, California -and you map up rates of obesity, for example, or of hypertension, or of low birth weight, we'll see that these things overlap almost exactly. And if we overlay a map of environmental hazards, it fits in as well. And it's very common to see all these dimensions cluster.
Place Matters
NARRATOR: And they cluster in Richmond. The city has higher rates of death from heart disease and cancer than most surrounding communities. Children are hospitalized for asthma at twice the rate of other county neighborhoods. And the risk of dying of diabetes is almost twice as high.
DAVID WILLIAMS: Sometimes we naively think of improving health by simply changing behaviors, but the choices of individuals often are limited by the environments in which they live.
RICHARD J. JACKSON, MD: A friend of mine who worked in Richmond said that she's seen 10 or 12 teenage girls now who have had global their gallbladders removed. If you eat a lot of fat in your diet, you can get gallbladder disease. And it turned out they were eating virtually breakfast, lunch, and dinner in fast food outlets. And there were no farmers markets. There were no green grocers. There was no Safeway or supermarket that was reachable by these kids. And fast food is a bargain. You can get 1,500 calories for a couple of bucks. It's not a long-term bargain, but it's a short-term bargain and people make that trade.
NARRATOR: Even short term bargains can be few and far between.
TORM NOMPRASEURT: So there are a lot of Laos who live around here, those apartment around here. Over 50% people pay more than 30% of their income toward the housing costs. So if you pay more than 30% of your income, you are not in a good situation.
NARRATOR: And it's not just housing. According to a Brookings Institution report, buying a car in a low income neighborhood costs as much as $500 more than in an affluent community. Cashing a check, add up to 10% more. Furniture, appliances, and even groceries are more expensive. Researchers call this the poverty tax.
GWAI BOONKEUT: Until last year, I work two job.
KANORN BOONKEUT: I work two job, too, before.
GWAI BOONKEUT: My daughter used to say, like, mom stop. She says she doesn't want to see her mom or dad work like that. Now I take this.
DAVID S. WEILAND: We have patients like Gwai who come in very sick. We patch them up. We save their lives and send them out back in the same environment.
GWAI BOONKEUT: Calcium, potassium, I take at 4 o'clock.
ANA DIEZ-ROUX, MD: I think we sometimes forget that people who live in more well-off communities have a lot of advantages because they do have a lot of the
Place Matters
environmental support. Well, why are these neighborhoods so different? And, of course, these differences are not a natural thing. They arise as a result of policies, or the absence of policies, that create these enormous spacial inequalities and resources in the environments that people live.
NARRATOR: 60 years ago, Richmond was a boom town. During World War 2, the Kaiser Shipyards in Richmond ran 24 hours a day. The war effort drew workers of all ethnicities to Richmond. When the war ended, new governmental policies broad sweeping changes to communities like Richmond. As the shipyards closed, thousands of jobs left. So did anyone who could, but only white families could get the new government-backed mortgages to buy homes in the new suburbs. Richmond's population fell by a third.
ANGELA GLOVER BLACKWELL: We had vast, public investments in building the suburbs of America. Federally supported loans, FHA loans, went to people who were moving to the suburbs. And for many years, up until the '60s, those loans where available on a racially-restricted basis. African Americans and other people of color didn't have access to them.
NARRATOR: Until 1962, out of $120 billion in government-backed home loans, less than 2% went to non-white households. In northern California between the war in 1960, of 350,000 federally-guaranteed new home loans, less than 100 went to black families. In cities like Richmond, African Americans were left behind in increasingly neglected neighborhoods. In the 1980s, poor Latino and Southeast Asian immigrants, began joining them in these same neighborhoods.
LAURA KUBZANSKY: Once the community starts to go downhill, nobody wants to actually invest in the community. So the banks don't want to come in and the shops don't want to come in. Then you don't have a commercial base. You don't have the community taxes that can then feed back into the schools. Now you don't have good schools. So, families don't want to move into the community if they don't have to because you don't have good schools. And you get a sort of vicious cycle of everybody who can will leave the community.
ANGELA GLOVER BLACKWELL: This isn't something that happens overnight. And it isn't the fault of the people who live there. The people who live in low income dis-invested communities did not do this to themselves.
NARRATOR: 20 years before his heart attack, Gwai tried to move his family out of Richmond, but 11 months later, they had to move back.
GWAI BOONKEUT: I can't find my job up there, and she can't find her job up there. And [INAUDIBLE], my oldest son, you know, hang around with the wrong group and then used some kind of drug. I just don't know what to do. I tried to help him. I tried to straighten him out. Spend a lot of money. Owe people a lot of
Place Matters
money. That's what in my mind all the time, such worry, just worry, worry. When I'm going to pay up all of this? And how I'm going to do it?
LAURA KUBZANSKY: If you think about when you're worried, you know, you're always a little bit more activated. There's a little bit more vigilance. You're sort of checking things out a little bit more carefully. And if you can imagine that happening day after day, all day, every day -it's exhausting. And it wears on the body system.
NARRATOR: When stress is chronic, when we're endlessly worried about our bills, our job, our children's safety, the body pumps out cortisol and adrenaline. But too much of these stress hormones over time can increase arterial plaque, raise blood pressure, and weaken our immune system -increasing our risk for almost every chronic diseases, including heart disease, the leading killer in America.
ANA DIEZ-ROUX, MD: We've done studies that have shown that living in disadvantaged neighborhoods is related to an increased risk. It is about 50% to 80% increase in risk of developing heart disease. And this has been replicated in other studies.
DAVID WILLIAMS: In our society today, everybody experiences stress. However, in many disadvantaged communities, what we have is the accumulation of multiple, negative, stress source. And it's so many of them, it's as if someone is being hit from every single side. And it's not only that they're dealing with a lot of stress, they have few resources to cope.
NARRATOR: The health challenges of low income Laotians, Vietnamese, and Cambodians, are often masked when they're lumped together as Asian Americans. Gwai's cousin, Torm Nompraseurt, organizes his community to address local health and environmental problems, joining forces with other activists in Richmond.
WENDEL BRUNNER, MD: Richmond is a very diverse community, and there is a very rich and historical network of community agencies and community organizations. That's been enhanced by the new waves of immigrants who've brought and developed their own community agencies to address health problems.
NARRATOR: One of the greatest health challenges to the community and its children is exposure to violence. In 2005, Richmond had one of the highest murder rates in the United States.
Place Matters
GWAI BOONKEUT: Somebody just came and knocked at the door. She came out. She said, who's that's, dad? I say, I don't know. Just don't open the door. And then I heard a sound like they knock again. And I ran back. It wasn't a, it wasn't a knock. They already shoot her.
NARRATOR: Gwai and Kanorn's daughter, Chan, was a successful student who became the mistaken target of a Southeast Asian drug gang. The specter of community violence has completely transformed the way that people live in certain neighborhoods. So it's a public health issue, not only for the prevention of premature death through homicide, but for the ripple effects it has on the other things that contribute to people's poor health. The ability people to go out, to go shopping, to live a normal life.
NARRATOR: In fact, research now suggests that some adult health problems may be traced to living with violence as a child. The impact of that stress, the impact of that exposure to violence, triggers physiological responses in a child and can actually be disruptive to the developing brain and the developing immune system, such that you are primed, then, to be more vulnerable to physical and mental health problems all through your life.
MALE SPEAKING: When I'm outside, I hear gunshots in there by the school.
MALE SPEAKING: And I also hear some gunshot, too. I did.
S. LEONARD SYME: We work with the kids in Richmond and many of those kids didn't think they would live beyond the age of 20. So we propose to do a study on hope, trying to show kids that they can work their life around so that they do have a future.
NARRATOR: The program that resulted, Youth Empowerment Strategies, or YES, helps youth develop a sense of hope by showing them at an early age how, by their actions, they can work together to create positive change in their community.
NANCE WILSON: Hope impacts health because then you don't internalize a lot of the behaviors about feeling hopeless and feeling alienated from society. What it is that you do is you feel proactive, and you realize that you have a say in how things can be. And so you engage in making things be that way.
NARRATOR: Control over our environment gives us reason to be hopeful, and hope is an often overlooked factor for good health. But how might a neighborhood's residents gain that control? 800 miles north, in Seattle, Washington, at High Point, public health and housing agencies and developers took a radical approach to give one neighborhood some of the health advantages
Place Matters
found in wealthier communities. 60 years ago, High Point was a lot like Richmond. It began in the '40s as housing for temporary defense workers. By the 1990s, High Point Housing had deteriorated.
TOM PHILLIPS: These were built for temporary housing. We told the neighborhood they'll only be here a few years. And they're still here 60 years later.
FEMALE SPEAKING: I lived in the apartment here on the end on Graham here. It's right there behind that little tree.
BONITA BLAKE: I felt anxious because bullets were flying, and you did not know when that was going to happen or what the consequences would be.
NARRATOR: If it was unsafe outside, it was unhealthy inside. Asthma was endemic.
TIM TAKARO, MD: This is one of the old units. It's a pretty nasty looking one. The family has just moved out of here, though, into on of the new units. There's the leaking of the windows, that over the years, lets the plaster board soak and mold will form all along there, as you can see here. They didn't just have a mold problem, but with the moisture, you get more dust mites, that are a common asthma trigger. A lot of mold growth under there and nice places for the roaches to live and thrive. Not healthy home.
JAMES KRIEGER, MD: In the old High Point, one out of nine, one out 10 households were affected by asthma. Pretty much everybody knew somebody who had asthma in the community. It's almost like it was normal. Asthma was so commonplace it was normal.
NARRATOR: By 1997, it was clear to the city and residents that it was time to make a change.
TOM PHILLIPS: There was a community here. Even though this was a rough, dangerous neighborhood, there were still a community here. And people living in communities actually know what they want.
NARRATOR: They wanted the kind of healthy, living conditions that wealthier neighborhoods usually take for granted. Working with Seattle housing authority and the public health department, the community won federal grants to rebuild High Point.
DENISE SHARIFY: Seattle Housing Authority worked really hard to invite communities to the table and share in the design and access to power. Low income people -they're used to not having power. So they don't know they even can have power.
Place Matters
NARRATOR: What emerged from the design process was a new mixed income community with health as its focus.
JAMES KRIEGER, MD: Our hope is that the High Point community now be integrated with the rest of the surrounding neighborhood to make it easy for people to walk to stores or parks in the neighborhood as a whole. There is a new clinic that's been built here, a new public library that's been built here. So those services will be available right on site to residents as well. And then they'll be a community center that will have all sorts of other services, such as employment services, child care, and the like.
NARRATOR: The new High Point has community gardens where gardeners can sell their organic produce to neighbors.
JAMES KRIEGER, MD: Another factor that we know promotes health is for people to be socially connected. And having a lot of spaces that promote social interaction was a conscious design element here.
NARRATOR: One health problem community developers were determined to take on was asthma. Nationwide, the cost of asthma in health care and lost school and workdays is staggering -$20 billion every year. Low income neighborhoods are the most effected. Four-year-old Steven strong has asthma.
LANH TRUONG: At nighttime, he sleep and then throwing up and then too hard for him to breathe, yeah. I just bring him, go to children's hospital in the middle of the night. That time, I cannot go work, too. Yeah, I need to stay home to take care of him.
TIM TAKARO, MD: Over a year's time, we found our children were spending up to $3,000 to $5,000 on repeated emergency room visits.
NARRATOR: That's emergency room treatment each year for just one child. Bonita Blake, a High Point activist, came up with the idea to build some of the new homes with a range of special features for people with asthma.
TIM TAKARO, MD: The ventilation system is meant to bring in fresh air from the outside. Even small particles that might be bad for your health, such as diesel particulate, pollens, in the case of an asthmatic, will be filtered out. So the air outside the home is actually healthier than the air outside.
NARRATOR: Steven's family moved into a breathe-easy unit five months ago.
NARRATOR: Breathe-easy homes cost about $6,000 extra to build. That's less than two years of emergency room services for a child like Steven. But these
Place Matters
kinds of health innovations rarely come from private developers working alone. And the federal Hope Six Program, that provided financing to build the new High Point, is being phased out.
TIM TAKARO, MD: Market-driven forces are not going to build healthy homes for low income communities. That's only going to come from policymakers who recognize the societal benefits to having healthy communities like this one.
NARRATOR: But not everyone benefited. Some residents, who were supposed to be temporarily displaced to build this mixed income community, never came back. And rebuilding a neighborhood from the bottom up isn't possible or desirable everywhere. The real issue is who gets to make these decisions.
WENDEL BRUNNER, MD: The major health problems in a community like Richmond are extremely complicated and they're extremely deep. And it requires a whole spectrum of strategies, everything from educating individuals, to mobilizing communities and neighborhoods, to building coalitions, or to changing public policy.
ANGELA GLOVER BLACKWELL: The first thing we need to do is acknowledge that where you live impacts your health. That the environment in the community the social environment, the physical environment, and the economic environment, together -determine whether or not we're going to have a healthy existence.
DAVID WILLIAMS: What that means is the housing policy is health policy, educational policy is health policy, anti-violence policy is health policy, neighborhood improvement policy is a health policies, everything that we can do to improve the quality of life of individuals in our society has an impact on their health and is a health policy.
Major funding for Unnatural Causes has been made possible by the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the California Endowment, W. K. Kellogg Foundation, the Nathan Cummings Foundation, Joint Center for Political and Economic Studies, and Kaiser Permanente. Additional funding provided by these funders.
This program was also made possible by the Corporation for Public Broadcasting.
Place Matters Content Attribution
(c) California Newsreel, 2008. www(dot)unnaturalcauses(dot)org
2)Not Just a Paycheck Program Transcript
MALE SPEAKER: All of them said that the bigwigs from the corporation were there and they were going to have a Powwow with us or something. Everybody wondered what they were talking about.
FEMALE SPEAKER: You could hear a pin drop in the crowd and people were gasping. It was a funny feeling, just kind of like you were up on a ride that drops down real fast and makes your stomach feel queasy. That's how I felt.
MALE SPEAKER: It was once the largest refrigerator manufacturer in the entire world. Now moved away. And what sits is this enormous building that covers the acreage of a small farm. And it's so empty that if a family of rats wanted to move from one end of the building to the other, they'd have to pack their own peanut butter and jelly sandwich.
DON PELLOW: They called the bargaining committee and then they told us that they were closing the plant. So when I walked out on the floor, everybody's looking at your face. You know?
MALE SPEAKER: In the winter of 2006, the Electrolux Corporation closed its refrigerator manufacturing plant in Greenville, Michigan and moved it to Juarez, Mexico. The Greenville workers earned $15 an hour with about $5 an hour in health and pension benefits. The Mexican workers made $1.57 an hour plus bus fare and lunch.
JOHN HERNANDER: Electrolux's decision to move the plant from Greenville to Mexico is basically just a result of them facing a very competitive environment. It is a disaster for many people when they're being laid off, but our view is more to look at the company. And unfortunately, sometimes the stock market creates the pressure and the company is trapped in that respect.
MALE SPEAKER: In a global economy, corporations move capital at breathtaking speed to maximize profit for shareholders. Electrolux is a multinational corporation based in Sweden. The company has also moved plants from Western to Eastern Europe in pursuit of the cheapest labor.
Moving the Greenville plant to Mexico will add $81 million a year to the corporate bottom line. Good news for shareholders, many of whom are already in the upper income brackets. But the 2,700 people who once worked here lost a union job, a decent wage, and ultimately much more.
Not Just a Paycheck
RICHARD PRICE: A lot of people are left behind, and when they're left behind they're left behind with really diminished lives. And with a whole array of health problems and stresses that they didn't have beforehand.
MALE SPEAKER: Rick Price is a psychologist who's researched the impact of plant closings in Michigan for decades. He's studied the consequences of job loss for workers' health.
RICHARD PRICE: Involuntary job loss isn't just something that affects a particular individual who suddenly has got to find a new job, because it ripples through whole families and communities and becomes a major challenge and a major life event, and one that lots of them simply don't recover from.
MALE SPEAKER: It's not just happening in Greenville. All across the US, the transfer of work to low-wage countries undermines the kind of job security and benefits that made the American Dream a reality for millions.
Electrolux workers led a middle class life, owning homes, buying new cars, and taking vacations. Now, most are scraping by on severance pay, unemployment benefits, and a health plan that will end in a year. As personal finances spiral downward, health follows. Two months after the plant closing, some of the laid-off workers meet at a local restaurant.
FEMALE SPEAKER: That is really cute.
BRENDA BISSEL: When you've got to go to unemployment, I don't know if that's anxiety--but I didn't really think about it until Marcella said today, how like my jaw has been hurting like I'm clenching my teeth or something when I'm sleeping.
MITCH EVANS: I get nauseated. I'll be laying there and I'll just get--my stomach will be nervous and I'll be just nauseated. Some nights I'll wake up and I'll be up at 1:00 in the morning. I got up, I'm sitting in the chair, and was watching TV until
4:00. Went and laid down, and tossed and turned until 6:00 and got up. And I don't think I got two hours sleep all night.
MARCELLA ORT: And I started thinking more about needing a drink, which I don't need. I've stayed away from that. So then I go and eat. But I have never weighed this much in my life.
MALE SPEAKER: There are a lot of adaptive things we do in response to stress that long-term produce liabilities for us. It's not just people self-medicating for alcohol. It's even chronic eating. They're really treating themselves for anxiety and distress.
MARCELLA ORT: I think it's adding to Richard--his depression--because he's having health problems and he's old enough to draw social security and his
Not Just a Paycheck
pension, so he's fortunate there, but I do think that he's feeling like he needs to do more. We don't have anything coming in, and he isn't able to do more, so I think he's getting more and more depressed.
DAN ELLISON: I've been doing some thinking about some of the things that you were saying with regard to--I guess the best way I can say it is depression. A little bit of ambivalence taking your medicines here, there.
RICHARD ORT: I don't miss it too often.
DAN ELLISON: Not too often.
RICHARD ORT: It's just some days I just forget them. It's not that I do it intentionally.
DAN ELLISON: OK. Your wife was laid off after almost 38 years. Your daughter was working there also, is that correct?
DAN ELLISON: And she moved to Minnesota?
RICHARD ORT: Her husband and two of the kids were already moved to Minnesota because he had a line-up for a job. Because there wasn't any around here.
DAN ELLISON: How big of a financial impact is that for you? Is it a stress?
RICHARD ORT: I've got a set amount of money that's coming in. She gets a pension, but the unemployment--in order to keep it, she's got to go to school. And she's been out of school since--well, we've been married 40 years, and she's been out of school for 40 years.
DAN ELLISON: We are seeing a lot of walk-ins to the ER just coming in and saying they just don't know how to cope with everything that's going on in their life anymore.
Pleased to meet you. Medical issues are also increasing. Cardiac or gastrointestinal issues that are related to stress and anxiety. We were talking about some of the finances--the impact that it's had on him, on you, and how those stressors impact him.
And my thought was I'm seeing a lot more ambivalence of just whatever happens happens.
Not Just a Paycheck
MARCELLA ORT: Right now we still have a little money there, but when it's gone there's no way to replace it.
DAN ELLISON: There's worry about losing their home, losing some of their belongings, having things repossessed, not being able to meet the bills, not being able to afford their medication--they stop their medicines, and I would think that usually the first one that I see that gets stopped is the anti-depressant. That just spins in cycles and becomes worse when they don't have any hope.
MALE SPEAKER: In 2004, this local hospital treated 80 cases of depression, attempted suicide, and domestic abuse. In the year following the Electrolux closing, that caseload nearly tripled.
RICHARD PRICE: These external life events do get under the skin. They do create changes in the way our psychophysiological system operates. They create elevated stress responses that ultimately lead to both acute and chronic health problems.
MALE SPEAKER: But how do these stressors get under the skin? That's one of the questions Sir Michael Marmot explored for over more than 30 years in the Whitehall studies of British civil servants.
SIR MICHAEL MARMOT: The two pathways that have most been studied, and we ourselves also studied them, is the pathway that goes from the brain to affecting cortisol and the pathway that goes from the brain to affecting adrenaline, epinephrine--the acute stress response.
MALE SPEAKER: When stresses just won't stop, as bills keep coming and there's no hope for work, the level of these stress hormones can remain high.
SIR MICHAEL MARMOT: When you stress people in a prolonged way, you get changes to that cortisol pathway. And that seems in turn to lead to a whole set of metabolic biochemical disturbances in the body.
MALE SPEAKER: High levels of cortisol can trigger increases in blood pressure, blood sugar, and even inflammation. All risk factors for disease.
The The types of illnesses that are associated with high rates of unemployment are, first of all, the cardiovascular group of illnesses. And these are heart disease, stroke, kidney disease, many other illnesses involving alcohol, suicide, homicide, accidents, and the like.
MALE SPEAKER: For 40 years, Harvey Brenner has studied the relationship between unemployment and death rates. In reports for the US Congress and the European Commission, he developed models to predict what epidemiologists call
Not Just a Paycheck
excess deaths. Deaths that are over and above what would be expected under ordinary conditions.
HARVEY BRENNER: Our research has shown over the years that there is a reasonably direct relationship between unemployment changes and mortality changes. These changes in mortality occur over about a 10-year period, but are heavily concentrated within the first five or six years.
MALE SPEAKER: At the time of the Electrolux closing, unemployment rates in Greenville's Montcalm County jumped to 14%, nearly double that of the previous year. Among the 22,000 households here, Brenner predicts that this surge in unemployment will result in 134 excess deaths over the next 10 years.
GARY WHITE: After my last day at work, I just thought, well, I haven't had a vacation in 32 years. I think I'll take a vacation. And the vacation get to the point where I started looking for jobs, started doing everything to find a job, and there aren't any jobs anyway. You can't even find a job at a third of what I was making before.
I used to run around feeling like a 25-year-old when I was working. I'm starting to feel my age now because I'm sitting around not doing anything.
MALE SPEAKER: The free-market environment that allows Electrolux to prosper comes at a price. Three million American manufacturing jobs have been lost in the last 10 years. Here in Montcalm County the decline started in the late 1980s, with the closing of the Oreida potato-processing plant, the rise of corporate agribusiness, and the demise of small family farms.
JERRY JONES: Many of those farmers already had been feeling some economic pinch, and their spouses often went to work for industry to have health insurance, or just to add to the family income. When they lost the manufacturing sector, then, it kind of put a double whammy on those families.
MEIZHU LUI: In 1965, 1/3 of workers in the US had manufacturing jobs. Now it's under 13%. We used to make airplanes, we used to make steel, we used to make cars--now we make beds, we make pizza, and we make hamburgers. It's quite a shift.
MALE SPEAKER: And a painful shift in wages. When Sandy Beck was a supervisor at Electrolux, she earned over $21 an hour. After Electrolux, she made $7 an hour with no benefits and no job security.
For the first nine months after her layoff, Sandy received compensation from a federal program tied to the North American Free Trade Agreement, and Electrolux provided a severance package for her. But now these supports have run out. Her future is anyone's guess.
Not Just a Paycheck
SANDY BECK: I'm a little concerned that we can meet our budget and have enough money for taxes and emergency funds. Right now we're busy paying bills off and cutting down our monthly budget. Back up. Back up.
MALE SPEAKER: Sandy is better off than most. Her husband Bruce was also laid off by Electrolux, but he has a pension of about 1/2 his former salary. And they live on a farm that's been in Sandy's family for three generations. It's their safety net.
SANDY BECK: My grandfather bought this beautiful farm on the lake back in 1917. Then my dad took over the farming. And that was when the small farmers couldn't make it, so he had to get a job at Electrolux to help make things meet.
I'll turn you around. Then you won't have to wander.
MALE SPEAKER: Sandy's farm sits on Clifford Lake, a tranquil spot that middle-class families long called home. But many are leaving, their houses leveled to make way for high-end second homes, creating higher assessments and higher property taxes.
SANDY BECK: We're part of the eroding middle class that has seen our income recede. It's not good every year to see your tax report and know that next year it's going to be more than it was this year. First I didn't like seeing big houses in our hay field, but it's part of my life and I've come to accept my neighbors now as OK people.
JERRY JONES: There's something unfolding here in Greenville and all of Montcalm County that might have been what Dickens was talking about when he said the best of times, the worst of times. Because we are having an economic boom in some sectors.
There are new houses being built here. That makes it into a bedroom community for some larger areas around. We have had some national franchises move in here and build significant buildings here.
At the same time, there's this loss of jobs in West Central Michigan that goes far beyond Electrolux. And it seems to me like there's a growing chasm between the haves and the have-nots.
GORDEN STAUFFER: Please join me. I'm very happy to finally have some of my cars in one location. So please join me. This is the addition of the house-MALE
SPEAKER: Gordon Stauffer lives down the road from Sandy's farm. His lakeside home is a showcase for the high-end appliances his company manufactures.
Not Just a Paycheck
GORDEN STAUFFER: Refrigerator/freezer. Stainless steel inside and out.
MALE SPEAKER: Stauffer is founding CEO of Northland, one of Greenville's last working factories. His company is riding a wave of new consumption by the wealthy.
GORDEN STAUFFER: We certainly anticipated that there would be growth in the super high-end portion of the home appliance industry. There were probably more million-dollar homes built last year than any time in our history, and there is a lot of disposable income going into second homes--high-end second homes-and when they build these high-end second homes, they expect an ice-maker.
Very, very good ice.
GORDEN STAUFFER: They expect a wine-cooler. They expect all of these high-end appliances.
Pet food. Ice for the pet's water. The hot tub is right through those doors.
MALE SPEAKER: Trends in the appliance industry reflect growing inequality in America. CEO salaries are now more than 250 times the average worker's pay.
MEIZHU LUI: The number of products produced per worker has actually gone up. However, workers have not shared in the benefits of that greater productivity. It has gone to those at the top of the pay scale within the companies.
MALE SPEAKER: And where you stand on the economic ladder is a good predictor of health.
SIR MICHAEL MARMOT: The higher the grade, the better the health. The lower the grade, the higher the mortality rate and the shorter the life expectancy in this remarkably graded phenomenon.
So if you were second from the top, you had worse health than you were if you were at the top. If you were third from the top, you had worse health than if you were second from the top. All the way from top to bottom.
GORDEN STAUFFER: I have been very blessed and I've had exceptional health. I do like to work out, and in fact I'm waiting for this construction to be completed so I can put my basketball court back in operation because I still play basketball.
MALE SPEAKER: Stauffer and other wealthy Americans have more options, resources, and power to control their lives, all contributing to better health.
GORDEN STAUFFER: I told George W. that I had a photograph of myself with his mother. He said that's the one to keep. Keep that photograph.
Not Just a Paycheck
There is a perception that the CEO gets all of the stress. Actually, if you're a good CEO, maybe you give the stress rather than get the stress.
SIR MICHAEL MARMOT: Autonomy, control, and empowerment turn out to be a crucial influence on health and disease. People who are disempowered, people who don't have autonomy, people who have little control over their lives are at increased risk of heart disease, increased risk of mental illness in the Whitehall studies. Increased risk of absence from work, and increased risk of decrements in functioning.
MALE SPEAKER: You can't effect change in your life right now because there's nothing you can change. It's all dependent on outside forces and all you can do is try to work with outside forces.
SANDY BECK: We have less control now than when we worked at Electrolux and made what I call very good money. It's kind of scary when we don't have the money that we did have when those taxes go up. Living on the lake with the higher income people isn't a plus in that situation.
If we get really desperate, we might have to take the bitter pill and put some land up for sale ourselves. But we only want to do that if it's the last resort.
BRUCE BECK: I guess I'm getting up there where I don't worry like everybody else does. Like I'm more privileged than some.
SANDY BECK: Some people would say people like him that's got one year to social security are the lucky ones.
BRUCE BECK: Yeah. Our government's not guaranteeing that either.
And And there are no guarantees for Sandy's marriage, which didn't weather the Electrolux closing well. Feeling pressured and depressed, Sandy's husband left her for almost a year to carry on alone.
RICHARD PRICE: We do live in individualistic society. We believe that people are individually and personally responsible for their own fate. We enact our laws that way. We create our social policy that way.
MALE SPEAKER: Wealth inequality is much more extreme here in America than in any other industrialized nation. The top 1% of our population holds 38% of all personal wealth and nearly 1/3 of all corporate stock, and their tax rates are getting lower and lower.
Not Just a Paycheck
Is this the only way for a modern industrialized economy to operate? There are alternatives.
In 2004, Peter Stenberg lost his job when Electrolux moved a vacuum cleaner plant from his home town of Vastervik, Sweden to Hungary. Peter had worked at the factory for 21 years. But unlike the workers in Greenville, Peter isn't stressed out, he hasn't turned to drinking, and he's not worried about losing his house.
MALE SPEAKER: Like most of his coworkers who lost their jobs in Vastervik, Peter has unemployment benefits at 80% of his former salary. This support will continue as long as he goes to school or looks for new work. In Sweden, the costs of unemployment have been carefully calculated.
THOMAS OSTROS: Unemployment is very bad for individuals. You lose your connection in society, you lose your democratic empowerment, but you also suffer when it comes to health.
And that creates, of course, another discussion because it is a waste of resources to let people be laid off for long periods of time, or unemployed for long periods of time. But it also costs even more if you don't do anything.
MALE SPEAKER: During the last century, Sweden built a political system that distributes wealth to provide economic security to all its citizens. But it hasn't been at the expense of prosperity.
Sweden's economy has kept pace with the US for the last 10 years. And while its economic system rewards entrepreneurs, it also protects workers.
THOMAS OSTROS: Sweden is a country very much dependent on free trade. We can't hide our production from international competition.
But globalization also means greater demand on public policy and public efforts to see to it that it is an environment where it is possible for individuals to live and to have a good life. And thereby, globalization also means that you must have taxes high enough to have resources to help people to get the skills and the support they need to be able to come back.
MALE SPEAKER: Sweden continues to evaluate how much support to provide its citizens. For now, Swedes are guaranteed a college education, health care, five weeks paid vacation, 16 months paid leave for new parents, and much more.
And these policies seem to make a difference. The average Swede lives nearly three years longer than we do.
Not Just a Paycheck
For this security, Swede's willingly pay more taxes than Americans do. This helps to ensure that health is not dependent on personal income, wealth, or job security.
MALE SPEAKER: Nearly 80% of Swedish workers are protected by unions. When Electrolux decided to move the Vastervik factory, the union and the government pressured the company to make restitution to the workers and their community.
The company responded with $3 million to stimulate the creation of startup businesses in Vastervik. The city of Greenville, Michigan received nothing.
MALE SPEAKER: The Swedish union workers raised the real question. What will happen to the unemployed in Greenville? And why are the unemployed across America left to fend for themselves?
DON PELLOW: Every one of us here has at least 25 years in here, over there at the plant. Me and Gary, 30. Marcella, 40. And you're always working for the future.
That's why you worked every day. It was for the future. Now there is no future.
JERRY JONES: As a Christian, I really do understand that we have a responsibility to the whole community. To me the notion of individualism is right in the face of caring for your brothers and sisters.
RICHARD PRICE: Well, the Scandinavians know something that we don't know, and they've known it since the middle of the 19th century. And that is there's a sense of shared social responsibility about the fate of workers.
They're not just sort of cannon fodder. They're not just resources to be thrown away. That really makes an enormous difference.
MALE SPEAKER: Major funding for Unnatural Causes has been made possible by the Ford Foundation, the John D. And Catherine T. MacArthur Foundation, the California Endowment, W.K. Kellogg Foundation, the Nathan Cummings Foundation, Joint Center for Political and Economic Studies, and Kaiser Permanente.
Not Just a Paycheck
Additional funding provided by these funders. This program was also made possible by the Corporation for Public Broadcasting.
Not Just a Paycheck Content Attribution
(c) California Newsreel, 2008. www(dot)unnaturalcauses(dot)org


Social Determinants of health
Institution/ Affiliation
Social determinants of health
Globally, the health of an individual in a community is influenced by a pool of social, economic factors. Well-being starts from our workstations, localities, institutes and communities. The environment that a person lives determines to some extent whether a person is healthy or not. It is widely known that individual initiatives such as better eating habits, physical activity, less drug and substance intake, receiving suggested vaccinations and screening tests and regular checkup with physician helps improve health. However, health cannot be solely based on these factors. To a large extent, our health is influenced by the social, economic opportunities such as the quality of education, availability of cleanliness and water, the state of the environment, availability of food, nature of our social interactions and relationships, safety of workplaces, education level, genetics and infrastructure. For instance, this explains why some Americans living on a high-end level are healthier as compared to those on the other end (Murray, 2018).
The social elements of health are considered to be the settings in which people are born, grow, live, work and age. These factors range from accessibility to medical care, environmental living conditions, residential locations, social, economic position, health risks and health-seeking behaviours. Disparities in health status and outcomes can be associated to the ecological frameworks in which persons live which are further shaped by the structural realities such as the distribution of wealth, power, ethnic norms, and cultural norms, economic and political forces (Murray, 2018).
To achieve equity in health, the structure that perpetuates these factors must be identified and addressed especially in disadvantaged populations. For instance, individuals who have limited financial resources reside in neighbourhoods with high rates of poverty and crime levels, lack of variety of foodstuffs, limited sites for social interactions, and limited green space. The resources needed for health are not just limited to access to medical care but also the homes, neighbourhoods and workplaces. Therefore, the disparities in health outcomes can be closely connected to the degrees of social disadvantages. The mere fact pinpoints the localities that a person lives have a powerful influence on the health and wellbeing of an individual. Health complications are known to begin before the patient seek a health care provider. Hence it is crucial to determine the interventions outside the health care system that affect daily life especially the impacts on the health status (Lopez & Soley2014). For example, Research shows that living in a disadvantaged neighbourhood increases the risk of related heart disease with a proportion of 50-80%.
The social, economic status incorporates not only the income but also the financial security, subjective status perceptions of social status and class and the educational attainment. Moreover, it factors the aspects of quality life as well as opportunities and privileges afforded to people and the community. On the other hand, poverty is not an independent factor but is categorized by a multiple of other factors such as physical and psychosocial stressors. The social, economic status plays a vital role

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