Health & Society: Critical Perspectives - PDF

 Health & Society Critical Perspectives Edited by James Gillett, Gavin J. Andrews, and Mat Savelli OXFORD UNIVERSITY PRESS k. Contents Part III Health Care Paradigms, Systems,...

 Health & Society Critical Perspectives Edited by James Gillett, Gavin J. Andrews, and Mat Savelli OXFORD UNIVERSITY PRESS k. Contents Part III Health Care Paradigms, Systems, and Policies 135 Chapter 8 Modern Biomedical Culture 136 Elena Neiterman Chapter 9 Health Care Systems: Public and Private 153 Michel Grignon Chapter 10 Social Determinants of Health 171 Anthony Lombardo Chapter 11 The Re-emergence of Other Healing Paradigms 198 Yvonne LeBlanc Chapter 12 Consumerism, Health, and Health Care 223 Mat Sauelli Part IV Future Challenges and Directions 241 Chapter 13 Technology 242 Joshua Evans Chapter 14 Ethical Issues in Health and Health Care 256 Elizabeth Peter, James Gillett, and Mat Sauelli Glossary 273 Index 278 Contributors Gavin J. Andrews is a professor in the Department of Health, Aging, & Society at McMaster University. He was the inaugural chair of the department and currently serves as graduate chair. As a geographer, his research examines how place and space can influence a wide range of areas including health care, holistic medicine, aging, nursing, fitness, popular music, and phobias. Joshua Evans is the human geography coordinator and an assistant professor in the Department of Human Geography at Athabasca University. His areas of interest include public health, hospital design, housing and homelessness, and urban policy. Chelsea Gabel is an assistant professor in the Department of Health, Aging, & Society and the Indigenous Studies Program at McMaster University. Her research interests include Aboriginal health, health policy, and community-based participatory research. Leigh-Anne Gillespie is a doctoral candidate in the Health Policy Ph.D. Program at McMaster University. Her research addresses aid agency policies and the ethical challenges of responding to humanitarian emergencies. Beyond this, her work as a research assistant at the McMaster Health Forum focuses on harm reduction interventions for people who use drugs. James Gillett is an associate professor in the Department of Health, Aging, & Society and the Department of Sociology at McMaster University. His research focuses on individual approaches to health care and cultural understandings of health. He also studies health in relation to sport, animals, and media. Amanda Grenier is an associate professor in the Department of Health, Aging, & Society at McMaster University, Gilbrea Chair in Aging and Mental Health, and the Director of the Gilbrea Centre for Studies in Aging. She is a social gerontologist with interests in the social constructs of aging, the relationship between public policy and the lived experience of older individuals, and social inequality. Her research draws on qualitative methods such as narrative and discourse analysis. She has published on frailty and late life transitions, and is currently finalizing a project on homelessness among older people.  Contributors Michel Grignon is an associate professor in the Department of Health, Aging, & Society and the Department of Economics at McMaster University. He is the director for the Centre for Health Economics and Policy Analysis and an Associate Scientist at the Institut de Recherche et Documentation en Economic de la Sante. His research focuses on the governance, finance, accessibility, and efficiency of health care systems. Yvonne LeBlanc is an instructor in the Department of Health, Aging, & Society at McMaster University. She is a medical sociologist who has taught core sociology and sociology of health and illness courses at various universities in Ontario. Through qualitative inquiry, her research focuses on how people construct and negotiate health and illness, primarily through the intersections of health care, aging, and gender. She has used complementary and alternative medicine as a portal to understanding the mechanisms and processes that shape our understanding of how health and health care are experienced within contemporary society. Anthony Lombardo is the executive director of the Canadian Association on Gerontology. He is an instructor in the Chang School of Gerontology at Ryerson University and has worked as a consultant in health research, health promotion, and grant development. Raza Mirza holds a Ph.D. from the University of Toronto and has specialized in gerontology. He was previously a fellow of the Health Care, Technology and Place initiative of the Canadian Institutes of Health Research. Elena Neiterman received her Ph.D. in sociology from McMaster University. Her research focuses on women’s experiences of pregnancy and the postpartum period, midwifery and health professions, health care policy, and interdisciplinary study of the body. She is currently a lecturer at the School of Public Health and Health Systems at the University of Waterloo. Dorothy Pawluch is an associate professor and former chair of the Department of Sociology at McMaster University. She currently serves as director of the university's Honours Social Psychology Program. Her research interests include the social construction of health knowledge, medicalization, constructions of deviance and social problems, health care professions, and complementary/alternative health care approaches. She is author of The New Pediatrics: A Profession in Transition, an exploration of pediatrics’ move into the treatment of childhood deviance and behavioural problems. She has also written about the lived experiences of individuals diagnosed with HIV/AIDS. Elizabeth Peter, RN, Ph.D. is an associate professor at the Lawrence S. Bloomberg Faculty of Nursing and a member of the Joint Centre for Bioethics and the Centre for Critical Qualitative Health Research, University of Toronto. Her scholarship reflects her interdisciplinary background in nursing, philosophy, and bioethics. Theoretically, she locates her work in feminist health care ethics, exploring the ethical dimensions of nursing work along with the ethical concerns that arise in home care. She is currently the chair of the Health Sciences Research Ethics Board, University of Toronto. A  Contributors Mat Savelli is a postdoctoral fellow in the Department of Health, Aging, & Society at McMaster University. He obtained a D.Phil in the history of medicine from the University of Oxford and specializes in the historical and socio-cultural dimensions of mental health. He is currently researching the history of mental health care in Eastern Europe and the global advertising of psychopharmaceutical drugs. Geraldine Voros is an associate professor in the Department of Health, Aging, & Society at McMaster University. She has designed and taught numerous courses on the subjects of health and aging and has received a number of accolades for her undergraduate teaching.  Foreword Engaging with the Health Studies Scholarly Community ».. Or, Why You Should Get Excited about This Book Blake Poland and Pascale Lehoux TJ ooks are powerful technologies. They open up the reader’s mind. Their content can be -U shared endlessly with others. And the ideas they convey prompt new, more incisive inquiry. As such, books can be transformative. While this book possesses the kind of power described above, it also performs something more important: it conveys what Karin Knorr Cetina (1999) calls an "epistemic culture” or a “culture of knowledge.” An epistemic culture—in this case, critical health studies—brings for­ 1 I ward what can be found “out there” that it deems as worth knowing. It defines the ways and purposes of knowing and makes explicit why one should care about that knowledge. Thus, the notion of “epistemic communities” as communities concerned with producing and dis­ seminating knowledge is described by Haas (1992, p.3) as a “network of professionals with recognized expertise” who possess a “shared set of... principled beliefs,” “common practices," and a “conviction that human welfare will be enhanced as a consequence.” In this sense, critical health studies is also what Brown (2003) calls a "community of hope” or “community of promise," structured around the imagining and creation of a better future. It is productive insofar as it mobilizes opportunities for collaboration and change (Meyer & Molyneux-Hodgson, 2010). By carefully organizing the diverse yet interconnecting bodies of knowledge that contribute to the richness of health studies today, this book unlocks the door for readers to engage with a vibrant scholarly community. The shared goal of this community is to examine health as a meaningful state of life, as opposed to a set of biomedical functions. To illustrate the many dimensions underlying the field, the book collects the thinking of scholars who draw on the social sciences to unpack (1) what constitutes health, illness, and care; (2) what ideologies underpin health and social care  Foreword systems; (3) what health challenges individuals and communities face; and (4) the emerging dynamics that are shifting experiences of health. Being Critical, Being Responsible As readers will discover throughout the book, health studies scholars share a marked concern for criticality. This implies, among other things, being able to open up and engage in challen­ ging conversations about established models of thinking and traditional authorities. Such conversations help students of health studies relate to, build on, reframe, or reject various knowledge claims. When interlaced within a single book, these conversations contribute to the shaping of a collective identity, which generates new forms of expertise and new ways of knowing. By tackling the various cultural, political, social, and economic objects that are embedded in illness, health, and medicine, this book offers a solid introduction to the work of the health studies community. At the same time, its authors carefully set out the areas where complexity and puzzlement abound. In principle, one may wish to see a point of articulation between what scholars define as “knowable” and what policy-makers or practitioners deem "useful to know.” Yet, this book suggests that the relationship between knowledge and practice in health studies is not so straightforward. The knowledge-practice nexus reveals and deepens the moral foundations of research that critically explores what health, as a meaningful state of life, entails, and for whom. As academics who nurture a shared culture of knowing, health studies scholars seek ways to act responsibly when they develop new knowledge and put it into the public domain. This implies adopting a critical and reflexive posture that calls into question the power dynamics that are inherent in the relationship between those who decide and those for whom decisions are made. Knowing Together Each chapter in this book initiates a conversation that resonates with the other chapters that the book’s editors have carefully assembled. Taken as a whole, these are epistemic conversa­ tions that have a far-reaching transformative potential because those who engage in them can be enriched, challenged, or even censured through the process. Epistemic conversations are, after all, conversations through which something is learned, even if the knowledge acquired may at times prove hard to stomach. Knowing the intricacies of health, illness, and medicine leaves no one undisturbed. This book thus explains why health studies research is aspirational and shows how its researchers may articulate solidarity, humbleness, and creativity in their quest for know­ ledge. Scholarly practices are made up of, and structured by, the evolving disciplinary cul­ tures prevailing in a given field. Mutual learning across disciplines is partly dependent on building shared knowledge and developing a common language, both of which enable the reinforcement of values and the modification or discarding of others. More broadly, the book highlights the valuable contribution that the social and behavioural sciences make to understanding health, health care, and public health. While perspectives vary, the contributions of an explicitly “critical social science” perspective to understanding Foreword and explaining the nature and mechanisms of the individual, institutional, and societal con­ ditions and forces that determine health include the following: “Social relations” are conceived as central to health. Health status, health-related behav­ iour, and professional and institutional practices are understood as being shaped by human social interaction and by cultural, organizational, political, and societal structures and processes. Problems are framed and addressed at multiple levels. Perspectives range from “micro” (individual/behavioural) to “meso” (groups, organizations) to “macro” (institutional/ societal), often with reference to relationships across scale. Context is considered analytically important. Determinants, processes, and outcomes are viewed as contingent upon the circumstances and conditions in which they are located. Theory is employed as a key research resource. Theory is used to explain social processes that can only be inferred from observable phenomena (e.g., social class, power, racism, social learning) and to inform and link core assumptions, research questions, methodo­ logical design, data interpretation, and findings. Research methodology is aligned with the distinctive character of social/behavioural phenomena. A variety of qualitative, quantitative, and blended approaches, from varied disciplinary traditions, are designed to study phenomena that are mediated by human interpretation and meaning, and rooted in individual and social systems. A "critical” approach is taken to research and professional practice. Attention is directed to identifying underlying assumptions, the role of power in health and public health practi­ ces, and the political nature of knowledge and public discourse, (dlsph, 2015) A Vital and Timely Contribution Critical Health Studies builds upon but also problematizes and distinguishes itself from mainstream dominant formulations. For the first time, this book (aimed at undergraduates beginning their involvement with health studies) brings together a range of disciplinary perspectives on what constitutes "critical health studies,” at a time when health studies pro­ grams are proliferating. This is thus a timely and much-needed intervention in a rapidly expanding field. The book attends to the social production of health and illness, as well as individual, institu­ tional, and societal responses (health care systems, alternative and complementary medicine, social movements, health activism). A broad range of topics is covered, including social move­ ments; social constructionism; ethics; healthism; social justice; globalization; transdisciplinar- ity; intersectionality; health inequity; One Health; neoliberalism; culture; political economy; iatrogenesis; the governance, funding, and regulation of health care systems; evidence-based medicine; epistemology and methods; social determinants of health; consumerism; and tech­ nology. It draws on a range of critical scholarship across the disciplines of health psychol­ ogy, sociology, geography, economics, history, political science, and various fields of study (women’s studies, Aboriginal studies, social movements, policy analysis, and so on). While there is some repetition of key concepts across chapters (e.g., culture, biomedicine, medical- ization, political economy, professionalization) this is as it should be, given the centrality of  Foreword these concepts and their interconnectedness. The use of a standard format of study questions, recommended readings, case studies of contemporary examples (with a decidedly Canadian and global health focus), chapter summaries, and chapter-specific reference lists conspire to make this a favourite for undergraduate learning. Overall, it is a superb introduction to critical health studies, and a valuable addition to any health studies program. Books are powerful technologies because they contain and prompt crucial epistemic conversations that reflect, prolong, and may eventually modify cultures of knowing. Hence, what is there left to do when one has such a potent technology in hand? Discover the (critical) health studies scholarly community, share your understandings with others, and identify the key ideas upon which your own inquiries will draw. References Brown, N. 2003. "Hope against hype: Accountability Haas, P.M. 1992. "Epistemic Communities and in biopasts, presents and futures," Science Studies, International Policy Coordination," International 16(2): 3-21. Organization, 46(1): 1-35. DLSPH (2015). The contribution of the social and Knorr-Cetina, K. 1999. Epistemic Cultures: How the behavioural sciences to public health. Toronto, Sciences Make Knowledge. Cambridge, MA: ON: Dalia Lana School of Public Health. Harvard University Press. www.dlsph.utoronto.ca/discipline/social-and- Meyer, M. and S. Molyneux-Hodgson. 2010. "The behavioural-health-sciences. dynamics of epistemic communities." Sociological Research Online, 15(2): 14. Acknowledgements r I ^he editors would like to thank everyone who assisted in the production of the manu J_ script, especially the contributors. Completing the book was also made much, much eas ier through the input of two remarkable research assistants, Cristi Flood and Melissa Ricci They were especially helpful in transforming disparate submissions into a coherent whole Finally, we would like to thank the four anonymous reviewers whose feedback both high lighted the book’s strengths and reshaped some important aspects of the text.  Part I Introduction and Overview Introduction to Critical Health Studies Gavin J. Andrews, James Gillett, and Geraldine Voros LEARNING OBJECTIVES In this chapter, students will learn what constitutes the field of critical health studies the nature of criticality the content of each chapter to come  Andrews, Gillett, and Voros Introduction to Critical Health Studies Introduction Critical health studies is a field of academic inquiry and teaching within which all of the following chapters comfortably sit. For many readers of this book, it also reflects the nature of the academic course they are currently taking, the degree program they are currently enrolled in, or the nature of their academic department. This chapter is initially structured by two themes. The first, “health studies," describes the basic composition of the field. The second, "being critical,” describes this specific approach and its priorities. A final section then walks readers through the remainder of book, summar­ izing the purpose and content of each remaining chapter. Health Studies Illness and medicine are important to people. This is unsurprising because the first is a nega­ tive life event and the second potentially relieves people from that event. Although we may not always be aware of it, these two concepts constitute much more than a biological process and a rational curative science. Through our experience of our own bodies, the numerous interactions we have had with doctors and nurses, our experiences with hospitals and clinics, and the ways in which illness and medicine are represented in the media, we are engaged with the breadth of the topic of health. Health studies picks up on this complexity, start­ ing with the basic observation that the nature of illness, health, and medicine are all up for debate. Each has personal, collective, cultural, social, political, and economic dimensions that need to be accounted for. As the name suggests, health studies is concerned with health (what else!). In this regard, reflecting the early ideas of the World Health Organization (WHO), health is considered as something particular in its own right, more than just the absence of disease (WHO, 1946). Indeed, health studies pays particular attention to the concept of “wellbeing,” namely when individuals and groups are content, healthy, and in a good place in their lives. This entails having their basic needs fulfilled, with reasonable opportunities and capacities to meet these needs (Fleuret & Atkinson, 2007). Wellbeing is thus conceived by health studies research­ ers as a meaningful state of life. Most recently, researchers have been interested in it as an immediate experience and feeling that can arise in the moment (Andrews et al., 2014). By contrast, the health sciences—a collection of disciplines that support and constitute medicine—are well established and well known. These can include: disciplines based around occupational categories such as nursing, occupational therapy, and pharmacy; disciplines based around medical categories and "basic sciences” (often about aspects of the body) including anaesthesiology, toxicology, genetics, immunology, and micro­ biology; and disciplines based around clinical specialties (types of services) including geriatrics, paediatrics, family practice, critical care, and mental health care. "Health studies is composed predominantly of social science sub-disciplines, the most notable of these being health sociology (the study of the interactions and relationships  Part I Introduction and Overview between society and health—see ; Germov and Hornosty, 2011). Beyond this, health studies encompasses the following: Health geography (the study of how space and place affect and represent health and health care—see Gatrell & Elliott, 2009) Medical anthropology (the study of the bio-cultural and ecological aspects of health and health care—see Joralemon, 2009) Health psychology (the study of the cognitive and behavioural aspects of health and health care—see Ogden, 2012) Health economics (the study of different ways of allocating resources for health with dif­ ferent outcomes—see Palmer & Ho, 2007) Indeed, by their very nature, these sub-disciplines help researchers address the afore­ mentioned personal, collective, cultural, social, political, and economic dimensions of ill­ ness, health, and medicine. However, the above list is far from exhaustive. Health studies also draws from, and is composed of, research from mainstream social science disciplines (including, for example, political science and religious studies), research from various humanities (including classics, history, philosophy, English, music, and other arts), and a range of contemporary interdisci­ plinary academic fields (including, for instance, women’s studies, cultural studies, Aboriginal studies, social gerontology, and labour studies). And as if this picture were not complicated enough, the health sciences cannot be totally excluded from the field of health studies. There are scholars across a number of health science’s constituent disciplines who produce critical research focused on health and society, including people working in public health, health services research, nursing research, or population health (Eakin et al., 1996). Although the individual chapters to come outline their own focused areas of interest and inquiries, broadly speaking health studies asks the following questions: How are health and health care socially and culturally constructed (i.e., what constitutes health, illness, and health care to different people in different times and places)? What are the ideologies, principles, and powers underpinning health care and public health systems? What health challenges are facing individuals now? What will they face in the future? How do we experience these challenges? Beyond this, the critical perspectives (as outlined in the next section) pose their own set of unique questions for health studies. These will be explored further on in the chapter. Health studies research uses both quantitative research methods (including health rec­ ords and statistics, census data, and survey questionnaires) and qualitative research meth­ ods (such as interviews, focus groups, observation techniques, and document analysis). It is, however, the latter group that is most popular. Data derived from qualitative research is well suited to answer the central questions of health studies, providing in-depth and person-sensitive perspectives (Bourgeault et al., 2013). Indeed, human circumstances are inherently complex, and a range of qualitative research methodologies is required to con­ vey this complexity. 1 Andrews, Gillett, and Voros Introduction to Critical Health Studies Health studies is not only diverse, it also an expanding field. This is reflected and sup­ ported by the increasing number of college- and university-based health studies programs and departments. Of course, these programs and departments are not all similar. Some are more scientific or bio medical in their approach, some are more humanistic, and some are com­ bined with other subjects (such as gerontology, kinesiology, and cultural studies—see www.canadian-universities.net/Universities/Programs/Health_Studies.html). Graduates of health studies programs enter a wide range of jobs, some going on take to specialist health professional qualifications (such as in public health, nursing, or medicine), others entering a variety of employment sectors (including health policy, health administra­ tion, health advocacy, health charities and NGOs, health IT, and health PR and advertising), Meanwhile, others join diverse private companies that produce health-related products and provide health-related services. Being Critical The hallmark of much of health studies is its “criticality,” which distinguishes it from other forms of health research. Critical thinking has precedent, for example in the Marxist (radical) social science of the 1970s and 1980s, particularly in relation to its concern for social justice. However, critical research emerged strongly in the 1990s as something unique and broader (Blomley, 2006). Reflecting this development, in contemporary research we now see a critical approach adopted in most social sciences. These are known, for example, as “critical sociology,” “critical geography," “and critical psychology." Across these disciplines, it is generally accepted that a number of core facets constitute and characterize a critical approach: Challenging social and institutional norms, models of thinking, and power rela­ tionships. Critical researchers do not simply accept that ideas, policies, services, and initiatives are appropriate simply because they are provided by those with power and authority. Instead, researchers should question them and be prepared to expose short­ falls, inequalities, and their consequences. Researchers might also question the funda­ mental ideas and concepts that are part of how power is exerted. Each will have relative merits, success or failures, and specific consequences. Finding and questioning the ideas behind everyday social practices. As Sayer (2009) notes, a critical approach goes beyond the consideration of practices—the things people do—to address the ideas and norms that inform these actions. Notably, critical research also develops and utilizes extensive bodies of thought as to why those ideas and norms are correct or incorrect and why they are held. So for example, as Sayer suggests, critical thinkers recognize that sexist practices are underpinned by ideas about women and men that feminism shows to be incorrect and entrenched. Advocating alongside and on behalf of people and issues that are neglected or mar­ ginalized in mainstream policy, administration, and research. It is observed that cer­ tain people—often the most vulnerable—“fall off the map” of policy, practice, and research. Critical researchers challenge the neglect of specific groups—such as disabled, LGBTQ, and Aboriginal peoples—and make a concerted effort to highlight the vulnerability, inequality, and oppression that that these groups experience. I Part I Introduction and Overview Addressing pressing social and health issues that negatively affect individuals and populations. It is argued that critical research should aim to alleviate mental and physical suffering, which is broadly a result of economic inequality, sexism, racism, homophobia, and other discriminatory beliefs and systems. It also aims to understand what constitutes human suffering, the extent to which this suffering is unacceptable, and what constitutes human flourishing. This interest brings health studies into proximity with broader social and welfare research. Drawing on philosophy and social theory to inform research. It is argued that this strat­ egy can theoretically enhance research, make sense of empirical observations, and articu­ late some of the underlying meanings and processes involved. Typically, researchers engage with the work of specific continental philosophers. Beyond this, critical research involves a diversity of more general and often overlapping theoretical traditions that ebb and flow in popularity over time. For example, researchers may study issues within the framework of political economy, feminism, social constructivism, post-structuralism, post-colonialism, and/or post-humanism.1 All of these theoretical perspectives can pro­ vide new ways of understanding the complex matters of health and illness. Involving communities as partners in research, developing a “public” approach. It is argued that much social science has to an extent "lost the plot,” failing to directly engage with important public issues, debates, and agendas. However, scholars need not neglect this important potential aspect of their work; engaging with various “publics” can directly encourage social reform and change. This might, at times, involve direct action and an activist approach. As Wakefield (2007) suggests, there can be a real joy in working with others to change the world and make it a better place. Indeed, critical researchers might occupy a "third space” between academia and activism, continually and fluidly moving between the two (Blomley, 2007). Thinking and acting “outside the box.” It has been said that criticality involves the pro­ duction of new ideas and approaches, even those that might seem radical and uncon­ ventional, as they might better explain processes, tackle problems, and lead to positive change in the world (Parr, 2004). Such a bold approach requires courage on the part of researchers, as they must take risks with their scholarship. Understanding how local situations and events are related to global scale processes. The world is interconnected and interdependent. What happens in one place is connected I to what happens in another. Hence, researchers need a global imagination. They also need I to take responsibility for studying health issues in other non-Western places, realizing how Western values and systems have led to problems elsewhere. Specifically, global health involves critical consideration of (i) health phenomena of global significance, (ii) the local impacts of global health phenomena, and (iii) local health phenomena for which—from a moral perspective—international responsibility should be taken. Expressing the aspirations of, and for, individuals and society. It is argued that researchers need to articulate how they envision their ideal world and what this world entails. They need to be optimistic and provide a sense of a possible future, regardless of how unattainable it may seem (Blomley, 2008). In a world full of con­ flict, social problems, and health problems, academics need to address issues while still being a positive voice for change. 1 1 Andrews, Gillett, and Voros Introduction to Critical Health Studies £ Dl e a. I o One of the several aims of the critical perspective is to understand the relationship between local events and global processes. Some health scenarios, such as epidemics, can be linked to global processes relatively straightforwardly. What are some of the ways in which the West African Ebola virus outbreak, which started in 2014, can be critically considered both on a local and a global level? Being humble and reflexive. Kitchen and Hubbard (1999) note that the current divide between academia and “outside life” maintains academia’s supposed “authority.” It is thus suggested that researchers must situate their research in the same social and cul­ tural world as the subjects and issues they study. Researchers must not think that they are higher or better than other people, that they are neutral, that their findings are objective, that they operate external to realities, or that they are impartial (Eakin et al., 1996). Rather, they must recognize the shortfalls of their own disciplines. Critical public health research­ ers, for example, recognize how public health involves the regulation and enforcement of behaviours (Eakin et al., 1996). Critical psychologists, meanwhile, acknowledge the short­ falls and damages of contemporary mental health care (Parker 1999), whereas critical geographers must come to grips with their own discipline’s service to colonial, imperial, and nationalist projects (Smith & Desbiens, 1999). Expressing solidarity. As Blomley (2006) suggests, critical research must involve solidar­ ity with people, particularly those who are oppressed and victimized. Researchers have an obligation to their fellow humans and to the world in general. As Castree (2000) argues, critical scholarship might be a liberal/left rallying point for anti-racist, anti-homophobic, feminist, and other politics, producing academic work (post-colonialist research, queer research, feminist research) that reflects broader public social movements. I Part I Introduction and Overview ^A 8 kA Questioning the nature of “evidence.” It is -S 2 noted how the idea of evidence-based health o -£ care (EBHC) has quickly become a global g ? O priority. However, the wide-ranging cri­ tique of EBHC highlights that, although it is JI appropriate that the best health care is pro­ vided in the best known ways, EBHC goes far e beyond this objective, becoming a powerful J movement in itself that espouses a domin­ t S ant scientific worldview. EBHC selectively «i 5 s legitimizes and includes certain knowledge but degrades and excludes other—often qualitative—knowledge (Eakin et al., 1996). Morken, T., Haukenes, I., & Magnussen, L. Therapies, 20(1), 1-8 (2012). Attending work or not when sick—what Spector, R. E. (1996). Cultural diversity in health and makes the decision? A qualitative study among illness (4th ed.). Stamford, CT: Appleton and car mechanics. BMC Public Health Open, 12(813). Lange. (  Mirza Cultures and Meanings of Health Statistics Canada. (2011). Immigration and ethno­ practice. European Journal of Public Health, 1X1), cultural diversity in Canada. (Catalogue number 63-8. 99-010-XWE2011001). 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Intercultural communication in general 677-89.  1 I I IL I i ( I --^31 Identity, Intersections and Health James Gillett and Mat Savelli LEARNING OBJECTIVES In this chapter, students will learn how social identity can affect one’s health the role of social structures in forming identity about the concept of intersectionality and its relationship to health and illness  Gillett and Savelli Identity, Intersectionality, and Health Social Identity and Health Disparities in health across a society can be illustrated by what is often referred to as the “river story.” This story serves as a parable to highlight the value of thinking about health in a broad social context. There are many versions of the story but it usually begins with a physician talking about what makes her profession challenging. She says being a physician is like standing on the bank of a river while a drowning person—a patient—floats by. The doctor jumps into the river, pulls the person out, and revives them. Just as she is done, two more people call for help in the river. Again, she goes into the river to save the drowning patients and as soon as they are safely on shore, more drowning patients appear, yelling for help. Reflecting on the story, the physician concludes that she spends so much of her day saving people from drowning in the river that she never has time to see who is pushing them from upstream. This parable is used to demonstrate that health is influenced by “upstream” factors like the environment, social inequalities, poverty, sexism, and racism. Alongside such structural forces, certain lifestyle and behavioural patterns (like smoking, driving when fatigued, and drug use) can also contribute to ill health. In terms of producing health, the upstream con­ tributors are just as significant as, if not more so than “downstream" factors. While down­ stream contributors, like health care services, are clearly important in promoting wellbeing, they generally come into play when people are already unwell. Upstream factors, on the other hand, play an even more important role in promoting wellbeing and preventing illness. The river story can also provide an interesting perspective on the role of social identity in determining one’s health. We see that people from different social backgrounds are more susceptible to the risks posed by upstream factors. Furthermore, when people from diverse backgrounds fall into the river, the way they respond and experience floating downstream varies according to their social identity. In the social sciences the term social identity is used extensively; its meaning can be dif­ ficult to pin down. We all have a general sense of what it means: where one is from, our education and occupation, whether we are a man or a woman, our sexual identity, the ethnic heritage of our family, and even our passions and interests. This chapter utilizes the work of the sociologist Zygmunt Bauman (2000), who has written extensively on social identities in a globalized world. Without going into great detail, Bauman suggests that it makes sense to define social identify not as something fixed but rather as the product of structures of iden­ tification. How we develop our identity through these structures is seemingly contradictory. Our sense of self is built around structures that we all collectively encounter like gender, sex­ uality, class, and ethnicity. Yet our experience with these structures feels unique, individual, and different from anyone else’s. This process of identification helps us understand how we are, ironically, bound together as a society through our desire to develop unique, individual identities. In this chapter we discuss how structures of identification—or social identities—relate to health on two levels. On one level, as with the river story, societal structures regarding gender, class, race and sexuality pose health risks for individuals in unequal and complex ways. For instance, women are far more likely to experience domestic violence than men. This not only creates immediate physical harm but sets the basis for longer-term emotional and mental health problems. At another level, the way people experience and respond to health and illness also varies according to their social identity. For example, a gay man may  Part II Society, Health, and Illness respond to the mental trauma of domestic violence differently than a heterosexual woman. I Finally, the chapter concludes by looking at the ways in which social identities intersect to 1 create disparities in health as well as distinct conditions that shape the way people respond to illness. The chapter concentrates on three primary structures of identification: class, gender, and ethnicity. Before beginning, it is important to understand the ways in which health status and health disparities can be measured. In general, social scientists and epidemiologists particu­ larly rely on two concepts. The rate of mortality, or the number of deaths over a period of time across a specific population, is arguably the most commonly used measure of health or well being in a society. Childhood mortality is expressed as the number of deaths among children (under 12, for instance, or whatever definition of “child” is being used) over a period of time, usually a year. It is often expressed as a ratio of deaths per 1000 individuals. Pan et al. (2005), for instance, found that between 1979 and 2002, the annual childhood mortality rate declined significantly in Canada. However, the mortality rate among children due to suicide increased slightly. Through epidemiological studies like this one, we gain insight into the rate of change among a population; however, we are left to verify the reasons why fatal injuries have decreased but suicidality has increased. A second common measure of health is morbidity. Put simply, morbidity is the preva­ lence and/or incidence of disease in a specific population. Keeping with the example of chil­ dren, Emerson et al. (2006) studied the relationship between household income and health status in British children between the ages of 5 and 15. In this study, morbidity was defined as the prevalence of nine different types of diseases and illnesses (including injury) among 5- to 10-year-olds and 11- to 15-year-olds from households with a range of income levels. Co-morbidity describes cases in which people have more than one condition (asthma and an injury, for instance). Not surprisingly, the study found that the prevalence of morbidity and co-morbidity was higher among low-income households. Studies like this one make it pos­ sible to track the future incidence of a condition or disease in a population. Determining the prevalence of a specific type of morbidity makes it possible to evaluate whether an interven­ tion is effective in preventing new occurrences of health problems in a specific population. I Social Class Clearly, one’s social class—a structure of identification—has a significant impact on health. The definition of social class is a highly debated topic in the social sciences. Most scholars would agree that the concept of social class helps us to understand the economic stratifica­ tion of a society. In other words, social class—or socio-economic status (SES)—is a reflection or measure of each person’s position in a society’s economy. As the definition of social class can vary, so can the factors we consider when determining a person’s social class. In the earlier study on the health of children, household income was used as a general measure of social class. To provide a more nuanced and comprehensive measure of social class, it is com­ mon to consider a person’s education and occupation in addition to their income. Using such markers makes it possible to rank people in relation to their position in a market economy. This ranking according to social class is also referred to as the social gradient. Social science research has shown evidence of a direct and complex relationship between health status and social class. Beginning in the 1970s, research demonstrated that health..  Gillett and Savelli Identity, Intersectionality, and Health status and outcomes vary as a result of social inequalities associated with income, education, and occupation (Kitagawa & Hauser, 1973). In the United Kingdom, several large studies have raised greater awareness of the negative impact of social inequality on health and well being. The Black Report, published in 1980, was one of the first commissioned by a govern­ ment to examine health disparities. While the study found that overall health had improved since the 1950s, there were increasing inequities in individual health status. It was initially thought that this was a result of ineffective health services. However, this inequality was actually a result of differences in social class or socio-economic status (Gray, 1982). The most privileged members of society fared much better across a range of health measures—mor­ bidity and mortality—than those who were less privileged. Since the Black Report, similar reports (the Acheson Report in 1998; the Marmot Review in 2010) confirm the initial findings about the connection between social inequalities and health disparities. One significant investigation of this kind is the Whitehall study of British civil servants. It began in the late 1960s and continues today, following both the initial and subsequent cohorts (Marmot et al., 1991; Heraclides et al., 2012). Across the hierarchy of the occupations in the civil service, those in higher positions have fared better in terms of both mortality and mor­ bidity. The higher one's position in the civil service, in other words, the better one's health. The Whitehall studies demonstrate that differences in health are a product not only of income but also of social status and lifestyle behaviours. Subsequent studies began to look more closely at how factors like education and income affect health disparities. In Canada, for instance, Mustard and colleagues (1997) expanded on the Whitehall study by exploring the influence of education and income gradients on morbidity and mortality in Manitoba. The study found, < predictably, a direct relationship between the social gradient and health. However, differences were greater among adults than children: the burden of the gradient increases over time, and income was more influential than education. In comparison to other developed nations, Canada is higher in health inequality given the degree of income inequality in the country. As awareness of the social determinants of health has increased, scholars in developed countries have begun to explore more nuanced dimensions of these factors. The influence of socio-economic status on the health of children is a good example. In research on health inequalities, children occupy a unique position in that anything that affects them is cumu­ lative. In other words, the effects of lower income on health may compound over the course of a person's life. Determining the level of influence of the social gradient is an important step in exploring the overall influence of inequalities on health. Across developed nations, research supports the claim that income and education differences are related to disparities in health. This connection is evident in Canada (Mustard et al., 1997), Germany (Reinhold & Jurges, 2012), and Australia (Khanam et al., 2009). Gradients in socio-economic status appear to have differential effects across the life course. To illustrate this point, Chen and colleagues (2006) argue that the effect of growing up in lower socio-economic circumstances is greater for adolescents than for younger children: age and the life course are important additional factors that affect the relationship between the social gradient and health. Studies on health disparities across the life course have demonstrated the need for care­ fully timed interventions to decrease inequalities that lead to differences in mortality and morbidity. From the first studies in the 1970s, research on social class and health has identified policy and program interventions that could reduce the burden of the social gradient on the population. The mantra of reducing inequalities to improve overall health echoes across the Part II Society, Health, and Illness last thirty years of research in this area. Strategies for addressing poverty through affordable housing, designing opportunities for education among lower-income citizens, and ensuring a fair wage are examples of initiatives intended to foster a fairer and healthier society. Social class is one of the structures of identification that determines access to resources like income and education, thereby directly influencing a person’s health over the course of their life. As an identity, social class can be very important to a person. It may be explicit in their society, like in Britain or India, where social position is publically and historically woven into a person's sense of self and the way they are treated. In the contemporary era, however, scholars argue that the significance of class status is becoming less central (Currie, 1992; Marshall et al., 2005). In countries like Canada or those in Northern Europe, social class tends to be more muted and in the background of self-identity. Despite this point, class is still significant when it comes to social inequalities and health disparities. CASE STUDY Class and Schizophrenia For many years, researchers and health care workers have noted that rates of schizophrenia are far higher among individuals from lower-class backgrounds (Golderg & Morrison, 1963; Argyle, 1994). The exact reasons for this disparity, however, are the source of substantial debate, largely because the causes of schizophrenia are still unclear. On one hand, some theor­ ists explain this phenomenon through what is called the social causation theory. Put simply, this model holds that individuals from lower-class backgrounds are more likely to receive a diagno­ sis of schizophrenia for a host of potential reasons. For example, these individuals tend to have limited access to health care resources, potentially resulting in complications during pregnancy and childbirth, many of which have been linked to the development of schizophrenia (Geddes & Lawrie, 1995; Hultman et al., 1999)- Similarly, we know that working-class individuals generally have poorer health; mothers from lower-class backgrounds may thus be more likely to develop infections during pregnancy—another potential cause of schizophrenia (Sham et al., 1992). Another theory holds that individuals from lower socio-economic statuses experience greater levels of stress (leading lives that are generally more insecure) and that this fact may be responsible for higher rates of schizophrenia (Gallagher, Jones, & Pardes, 2013). Other researchers (Kohn, 1972) have focused on variations in how individuals from different classes are socialized. They argue that individuals from neighbourhoods with lower SES are taught to be conformist and obedient rather than flexible and independent, leading to a general feeling that life is beyond their control. Evidence that could support this notion is that deficit schizo­ phrenia (a variant of the disorder characterized by social withdrawal, blunted emotions, and difficulties in communication) is far more common among working-class individuals than those from the middle and upper classes (Gallagher et al., 2006). Still another set of researchers reject the social causation theory, instead arguing that the correlation between lower SES and schizophrenia can best be understood as one of cause and effect: people with schizophrenia (regardless of their class background) find it difficult to obtain education and hold down steady jobs; as a result, they drift down the social gradient (Jones et al. 1993; Aro et al., 1995). In reality, all of these factors probably play some role in explaining why individuals from lower-class backgrounds tend to have higher rates of schizophrenia.  Gillett and Savelli Identity, Intersectionality, and Health Race and Ethnicity Like social class, race and ethnicity is a structure of identification that influences how we understand both ourselves and our health. The term race refers to the socially constructed cat­ egories that differentiate people based on cultural heritage (Smedley & Smedley, 2005). Racial categories, or ethnicities, can be a source of pride and collective identity among a community, as in the case of the Black Power movement in the late 1960s and the struggle for civil rights. Yet at the same time, racial categories can be used to discriminate when they are assigned specific meanings that disenfranchise ethnic communities on the basis of their cultural herit­ age. African Americans in the United States and the First Nations peoples of Canada provide examples of groups that have long suffered from systemic racism in North America (Regan, 2010; Aiderman, 2010). The policies and practices that have historically supported racism against these groups (such the legacy of slavery and the residential school system) continue to differentiate people on the basis of racial categories. Through this process, these structures create inequalities and injustices that reverberate for all members of a society. Research on the relationship between social identity and health extends beyond social class to examine race and ethnicity. In the United States, Nickens (1986) found differences in morbidity and mortality across different ethnicities. African Americans in particular fared worse compared to other ethnicities, especially in relation to Caucasian Americans. Seeking to understand health disparities and race, Dressier and colleagues (2005) examined four possible models that could account for the connection between health status and racial cat­ egorization: (1) genetic variation; (2) differences in lifestyle and behaviour; (3) level of psy­ cho-social stress from life circumstances; and (4) social inequalities. Based on their extensive review, the authors argue that the social inequality model is the most plausible. The genetic variation model has no bearing on health disparities related to race. In Canada, First Nations peoples experience a similar reality. In a study from 2005, Adelson examined the health of members of Aboriginal communities across Canada. On all measures of mortality, life expectancy, morbidity, and self-reported health status, Aboriginal individuals fared worse than other Canadians. The researchers also asked Aboriginal people what they perceived to be the most significant problems related to health and well-being. Participants mentioned broader social and political factors such as unemployment, sub­ stance abuse, suicide, and family violence. This study also highlights social inequities (related to race and ethnicity) as the primary factor that accounts for the drastic health dis­ parities that First Nations peoples encounter. The kinds of inequities that exist in Canada have affected Aboriginal communities over a long period of time. Unless changes are made to address the underlying inequities, there will continue to be health disparities related to race and ethnicity. The social inequities encountered by African Americans and First Nations peoples are compounded by their historical mistreatment within the medical system. For example, in the infamous Tuskegee experiment, researchers allowed rural African American men infected with syphilis to remain untreated in order to study the natural progression of the disease. Crucially, the researchers did not obtain the participants’ consent for the experiment, nor were the men informed about the true nature of the study. Despite the existence of effect­ ive treatments for syphilis, these individuals were denied care. Such examples reflect what some believe to be a blatant disregard for and discrimination against racial minorities within medicine (Gamble, 1997). In Canada, the systemic barriers that Aboriginal people face in  Part II Society, Health, and Illness > I I -X > g < o © The remoteness of many rural communities in Canada limits adequate health provision and can be a systematic barrier for certain populations (such as Inuit, First Nations, and Metis populations, who are disproportionately represented in remote communities). What are some potential ways to increase health care access for residents of remote communities? accessing health care services, due to the structures in place within the reserve system or the remoteness of many communities, also limit health care provision (Brown & Fiske, 2001). On i the whole, there are considerable ethnic and racial disparities in health care provision, and therefore health (Smedley et al., 2009). As awareness of the social inequities facing racial minorities increases, a range of interest­ ing initiatives hold promise for potentially decreasing health disparities. Kirmayer, Simpson, and Cargo (2003), for instance, argue that First Nations peoples’ mental health can be improved by offering programs driven from within these communities, rather than imposed from outside. Concentrating on youth and community empowerment, these programs would address deeply entrenched inequities in health and health care services. Instead of simply concentrating on healing the individual—the approach favoured by dominant types of men­ tal health care—these programs would aim at more collective forms of healing, targeting the broader community. Many First Nations communities are initiating their own programs and - projects designed to combat the negative effects of racism and to alleviate its negative influ­ ence on health. As mentioned earlier, First Nations communities in Canada still experience - health challenges at an alarming rate compared to the overall population. Health disparities across racial categories will continue, unfortunately, unless racially based systemic inequi­ ties are effectively addressed.  Gillett and Savelli Identity, Intersectionality, and Health CASE STUDY Race and Schizophrenia.I The connections between health, race, and racism can be clearly seen when considering schizo- ’ phrenia. For many decades in much of the Western world, black people have been far more likely to receive a diagnosis of schizophrenia than white people, even when controlling for other factors such as class and income (Fearon et al., 2006; Mukherjee et al., 1983; Strakowski et al., 1995). Why is it that psychiatrists and other physicians tend to overdiagnose schizophrenia in black individuals? Researchers have advanced a wide range of theories to explain this phenomenon. As Krieger (1987) points out, psychiatrists, like many scientists, originally tried to explain health discrepan­ cies between African Americans and Caucasians in terms of racial biology. They assumed that physiological differences in black individuals made them more prone to certain types of ill­ nesses. This type of work relied upon racial stereotypes rather than any actual biological data. It is clear that clinician bias continues to play a role in the overdiagnosis of schizophrenia in black individuals. As Trierweiler and colleagues (2000) note, psychiatrists are more likely to attribute paranoia and hallucinations (two common symptoms of schizophrenia) to African Americans than to other racial groups. Even when black individuals exhibit symptoms asso­ ciated with other disorders (such as depression), they are still more likely to receive a schizo­ phrenia diagnosis. Such notions have a long history in psychiatry; during the era of colonial expansion, many European psychiatrists argued that black populations in their African colonies were too "happy-go-lucky" to truly suffer from feelings of sadness and despair (Vaughn, 2013). Historian and psychiatrist Jonathan Metzl’s (2009) research on race and schizophrenia in the United States may provide another part of the answer. To begin, Metzl points to a long history of institutionalized racism in psychiatry, remarking upon diagnostic categories such as drapetomania, a diagnosis assigned to black slaves in the South who tried to escape their white masters. Metzl also notes that Caucasian anxieties about "black belligerence" during the civil rights movement helped spark a dramatic spike in the diagnosis of schizophrenia in African Americans. Coupled with pharmaceutical advertisements that reframed the illness as a "black disease," Metzl's work points to the fact that there are large, overarching structural issues that shape the way health care workers and society thinks about health, illness, and race. Gender Of the different structures of identification, gender is arguably the most evident and visible in our everyday lives. The identification of male or female is built into our environments, institutional structures (like the family), and most definitively into our sense of self (Wood, 2012). Conventionally, the gender order works as a binary dividing the world into either male or female. Masculinity and femininity each have their own associated meanings, and we understand gender in relation to these terms. These notions produce reproduce power differ­ ences and are often referred to as hegemonic (Connell & Messerschmidt, 2005). Patriarchal institutional structures emphasize male privilege and male domination, creating social rela­ tions that are oppressive to women and those men who do not embody or demonstrate trad­ itionally dominant forms of masculinity.  Part II Society, Health, and Illness This gender order creates the conditions for health disparities HALF OF ALL between men and women. One of the established trends in this CANADIAN WOMEN research states that women live longer than men (lower mortality) WILL EXPERIENCE but that they experience greater AN INCIDENT OF morbidity (Denton et al., 2004). PHYSICAL OR This dilemma has sparked a number of interesting studies exploring dif­ ferences between men and women, 1 SEXUAL VIOLENCE. especially with regard to reported 1 levels of illness. Denton and col­ 1 leagues (2004) explored the fac­ tors that might help explain these i differences, and put forward three possible sources: (1) psychological i factors like stress and challenging life events; (2) health-related behav­ iours like exercise or smoking; and Gender and health are intricately linked. This poster (3) social contextual factors like speaks to the fact that women are far more likely family structure, work, and age. than men to suffer injury and death because of In their findings they argue that abusive relationships. How else does gender affect "social structural and psychosocial health? determinants of health are gener­ ally more important for women and behavioural determinants are generally more important for men” (Denton et al., 2004, p. 2585). In other words, men may behave in ways that put their lives at risk either in the short term or the long term. Although these behaviours may be harmful, men will generally not develop illnesses as a result of these actions. Women, meanwhile, are better at taking care of them­ selves (and others) but, because of their life circumstances, are under pressures that can i cause physical, mental, or emotional illnesses. Annandale & Hunt (1990) argue that differences in morbidity are actually a result of our social understandings of masculinity and femininity. Rather than morbidity being a strictly sex-related biological phenomenon, it may have a social basis. In our society, higher rates of reported illness are generally associated with femininity. In such debates, it is instructive to take a multifactorial, non-reductionist approach, seeking value in the idea that phenomena like differences in morbidity among men and women are complex and the result of many intersecting forces combining together over time. |l Regardless of why gender differences in health exist, scholars agree that one key way to redress them is by increasing gender equity. Unless men and women have similar access to resources, disparities in health outcomes will continue and arguably worsen. Further to this, despite improvements in gender equity, women continue to be subject to the negative and  Gillett and Savelli Identity, Intersectionality, and Health CASE STUDY Gendered Division of Mental Disorder The gendered division of mental health diagnoses has intrigued commentators for quite some time. Why is it that women are more likely to receive some diagnoses including depression, anx­ iety disorders, eating disorders, and borderline personality disorder, whereas men experience higher rates of addiction, attention-deficit hyperactivity disorder (ADHD), antisocial person­ ality disorder, and suicide (Rosenfeld et al. 2000; Kessler et al., 1994)? As ever, there are many potential explanations beyond biological difference. Unsurprisingly, differences in socialization seem to contribute to the differential rates of mental disorder. Many theorists believe that typical female gender roles involve greater emo­ tional awareness and openness in discussing vulnerability; these factors might account for the higher rate of depression and anxiety among women (Rosenfeld et al., 2000; Addis & Mahalik, 2003). Society's tendency to overtly sexualize women may also be a factor. Women are far more likely to experience sexual violence—an important contributory factor for the development of a range of disorders. Further, the pressure to maintain a particular body shape has been linked to the development of eating disorders (Mullen et al., 1993; Garner & Garfinkel, 1980). There is also the issue of gender bias in diagnosis. Some researchers have found that physicians are more likely to diagnose depression in women than in men, even when the same constellation of symptoms is present (Callahan et al., 1997; Stoppe et al., 1999). Many of the risk-laden or harmful behaviours in which men are more likely to engage can also have a deleterious effect on their mental health. As teenagers and adults, males are more likely to abuse alcohol and illicit drugs—both of which can contribute to the development not only of addiction but of other mental disorders as well (Kessler et al., 1994). Men, perhaps because of gender role expectations, are also less likely to seek out assistance for emotional dis­ tress. Failing to engage in preventative or health-protective activities, such as psychotherapy, may explain why men have far higher rates of addiction and suicide (Komiya, Good & Sherrod, 2000; Delenardo & Terrion, 2014). In the same way that a clinician's gender bias might increase the diagnostic rate of depres­ sion in women, theorists have speculated that gender expectations might be a reason that men are disproportionately diagnosed with certain types of personality disorders, namely antisocial and paranoid personality disorders (Rienzi & Scrams, 1991). Similarly, gender bias among teachers and parents might help explain why boys have historically been far more likely than girls to receive diagnoses of ADHD (Sciutto, Nolfi, & Bluhm, 2004). On the whole, it is clear that social conceptions of gender, beyond biological sex, play a vital role in the causation, reporting, and perception of mental illness. harmful consequences of patriarchal forces that make them vulnerable to illness and harm. Raising awareness of issues like domestic violence and formulating programs and policies that seek to address the underlying causes of oppression are facets of a movement toward seeking gender equity to improve health for men and women (Bent-Goodley, 2007). Doyal (2000, p. 932) writes that “the only practicable strategy for reducing unfair and avoidable inequalities in health outcomes between men and women is to ensure that the two groups M Part II Society, Health, and Illness have equal access to those resources which they need to realize their potential for health.” With regard to health, the challenge now is to articulate and put into place strategies that can overcome the deeply entrenched inequalities in the gender order. One approach that we examine in the next section is looking at the intersection between different structures of identification in order to better understand and reduce health disparities (Weber & Parra- Medina, 2003). Intersectionality In this chapter, the overall objective is to discuss the relationship between social identity I and health outcomes along three structures of identification: gender, social class, and race. There are a number of other important structures related to identity that we are not able to address such as age, sexuality, illness, geography, and disability. Power relations that are embedded in the institutional structures of society create conditions whereby those with less access to resources are more vulnerable and at greater risk of illness, injury, and sick­ ness. In addressing the consequences of social inequalities on health, scholars have begun to look more at the intersection between different structures of identification. Rather than studying the relationship between health and gender, or class, or race, research now tends to focus on the combined effect of intersecting social and power relations on health and health disparities. This perspective, known as intersectionality, developed from the theor­ etical work of important feminist scholars such as Kimberle Crenshaw (1989) and Patricia Hill Collins (2000). It provides a useful and much needed way to think about how the many facets of a person’s social identity relate to overarching power structures. Taking an intersectional approach means attending carefully to unique health outcomes that result from the combination of different power relations and structures of identifica­ tion. When examining health disparities, for instance, Kawachi and colleagues (2005) stress that the result is something greater than just combining data on race and class and adding them together. One cannot merely “add” the identities of "working class” and "Aboriginal” and assume that this produces a simple "doubling" of oppression. Rather, the interaction between the two social relations produces unique effects on the health of individuals and groups. Taking an intersectional approach to research allows for a more nuanced and detailed understanding of how and why health disparities arise. We can determine which strategies may be useful for addressing these disparities, both in specific contexts and more broadly across populations. By examining multiple structures of identification together, one can witness the effects of this interaction. Rosenfield (2012) analyzes this issue directly in a study of gender, race, class, and mental health. In prior research, the assumption was that mul­ tiple forms of oppression—in this case, race, class, and gender—would usually compound one another and produce a “triple threat” with regards to mental health. While this is often the case, Rosenfield argues that there is a multiple, complex, and interactive effect across class, race, and gender that can create paradoxical or even contradictory results in terms of mental illness or one’s ability to avoid illness. Studies taking an intersectional approach also do not privilege one category over another and tend to emphasize the importance of context, meaning, history, and experience in understanding health dispar­ ities (Hankivsky et al., 2008).  Gillett and Savelli Identity, Intersectionality, and Health Chapter Summary This chapter has explored the ways in which different facets of individuals’ identities— notably social class, race, and gender—play an important role in shaping their health. It began by briefly exploring the concept of identity, noting that identity carries per­ sonal meaning but is also embedded in broader social structures. As a consequence, identity is important in shaping how we see ourselves and how others see and treat us. Depending on one’s location, certain characteristics of identity are privileged while others are marginalized. In order to understand inequalities in health, it is fundamen­ tal to consider how individuals’ identities structure their life experience; for example, they might face greater exposure to particular health risks or receive preferential care depending on their identity. Social class, also known as socio-economic status, represents one very meaningful com­ ponent of identity. Connected to a person’s education, occupation, income, and family back­ ground (among other characteristics), class consistently produces substantial variability in health. In short, the lower one is on the social gradient, the more likely one will experience poor health. Within the framework of capitalism, class is an especially important driver of health inequalities. It can limit or promote a person’s participation in a variety of activities such as job choices, educational opportunities, and overall lifestyles, all of which profoundly affects health. Race and ethnicity represents another central element of an individual’s identity. Race is a socially constructed category connected to a person’s cultural heritage and physical appearance. Independent of any biological differences, race can have a profound effect on a person’s health. It can structure their beliefs and behaviour around health while also influencing how they are treated by others. Within the context of North American society, where white identity is privileged, individuals from some racial communities (notably African Americans and First Nations peoples) experience much more illness and poor health. Gender is another component of identity that greatly influences our daily life. Traditionally, gender has been divided into two primary categories—male and female—each associated with a variety of societal assumptions about what constitutes “proper” or “nor­ mal” behaviour. Unquestionably, this masculine-feminine binary deeply affects people’s health far beyond the biological differences often associated with gender identity. In most places across the world, society is patriarchal: men with traditional masculine traits are at an advantage. Consequently, women, men whose behaviour deviates from this masculine norm, and individuals who identify outside the gender binary altogether all face greater barriers to good health. Intersectionality is an important tool for seeking to understand how these and other components of identity affect health. Recognizing that identity interacts with overarch­ ing power structures, intersectionality examines the connections or intersecting points between various facets of identity, paying special attention to the issues of marginaliza­ tion and privilege. Possessing certain combinations of identity traits (for example, being a working-class female or an Asian-American male) creates unique constellations that can significantly impact an individual’s health. Intersectionality addresses the insepar­ able facets of human identity. Thus, it encourages us to dig deeper to understand the ways in which health inequalities are connected to a person’s identity. If health equity ! Part II Society, Health, and Illness is to be achieved, it will be necessary to understand the intersections between identity, power, and health outcomes. STUDY QUESTIONS 1. How can we explain the relationship between the social gradient and health? 2. What are the main health differences between men and women? How can these be explained? 3- How might other facets of identity (such as sexuality or disability) affect health? 4- What are the connections between race, racism, and health status? 5- Why must we consider intersectionality when discussing identity and health? SUGGESTED READINGS Hankivsky, O. (Ed.). (2011). Health inequities in Canada: Intersectional frameworks and practices. Vancouver: UBC Press. Harris, J. (2003). "All doors are closed to us": A social model analysis of the experiences of disabled refugees and asylum seekers in Britain. Disability & Society, 18(4), 395-410. Haslam, S. A., Jetten, J., Postmes., Er Haslam, C. (2009). Special issue: Social identity, health and well-being. Applied Psychology, 58b). Weber, L. Er Peek, L. (Eds). (2012). Displaced: Life in the Katrina diaspora. Austin: University of Texas Press. SUGGESTED WEB RESOURCES Canadian Women's Health Network: Women and Mental Health: www.cwhn.ca/en/resources/ I mentalhealth Peggy McIntosh's TEDx talk: How Studying Privilege Systems Can Strengthen Compassion: http:// tedxtalks.ted.com/video/How-Studying-Privilege-Systems Metzl, J. (2012, April 23). "Schizophrenia's Identity Crisis" Retrieved from www.youtube.com/ watch?v=hzcldCdPuUs GLOSSARY Class A component of one's identity, also known as socio-economic status. It is related to one's education, income, family background, and occupation. Gender Unlike biological sex, gender has meaning beyond chromosomes; it involves complex social roles and expectations. Many societies divide gender along binary lines (men/women) but it should be noted that many individuals and societies recognize the existence of multiple gender identities.  Gillett and Savelli Identity, Intersectionality, and Health Intersectionality The relationship between any and all of one's social identities. Posits that one’s social identity is a result of the relationship between all of their various identities (gender, sex­ uality, race, class, etc.). None of these should be neglected. Morbidity The prevalence and incidence of a disease in a given population. Mortality The rate of deaths in a population over a period of time. Patriarchal Relating to a patriarch, the male head of a society. In the context of this textbook, "patriarchal" refers to a male dominated society. Social gradient Ranking in society based on socio-economic status and one's relative position in a market economy. Social identity Our sense of self in relation to society as a whole and its broader social structures. 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