Thinking about Social Positionality & Social Determinants of Health

Chicago 2

Per 2015 American Community Survey (Census Bureau) data, non-institutionalized U.S. civilians with disabilities ages >16 had a median income of $21,572, approximately 33 percent less than their non-disabled counterparts ($31,874) (source: University of New Hampshire, Institute on Disability). This is due, in part, to a disparity in the educational attainment by disability status. In 2014, only 16.4 percent of U.S. adults with disabilities had a bachelor’s degree or more, compared with 34.6 percent for their non-disabled counterparts. Worse still is the disparity in employment rates between disabled and non-disabled people with college degrees: 26.1 percent of PWDs with a college degree were employed, compared with 75.9 percent of non-disabled people with college degrees (Bureau of Labor Statistics). Broken down by race and gender, these numbers are even more damning.

My point in providing this information is this: one’s disability status is an important consideration. My foundational conception of disability is the social model of disability (Shakespeare, 2013). That is, we live in a world that is configured for non-disabled bodies and minds, and those disabling contexts and spaces must be made accessible with the participation (and leadership!) of disabled people. This gets at the core ethical mooring of disability advocacy- disabled people have a right to full participation in the activities of life- including education, employment, health care access, and housing- all key social determinants of health.

But that’s one ideal to which we strive.

The reality we grapple with is one where disability intersects with other social positionalities (not identities) – gender, age, race/ethnicity, socio-economic status, citizenship status- to shape health outcomes. That’s not to say that one’s social position(s) are the primary determinants, but that they are co-constitutive with broader processes- such as the construction of space and place itself.

This is readily apparent when one considers housing as a social determinant of health. A recent illuminating example of how the housing stock & built environment in an area shapes health outcomes: Low SES, mostly Black residents in Baltimore’s 21223 zip code are four times more likely to visit the ER for asthma than neighbors in wealthier zip codes. And in this context, with incentives like the “community benefit” incentive, hospitals have little reason to reduce their high utilization:

“Hopkins, UMMC and other hospitals collected $84 million over the three years ending in 2015 to treat acutely ill Baltimore asthma patients as inpatients or in emergency rooms, according to the news organizations’ analysis of statewide hospital data. Hopkins and a sister hospital received $31 million of that.” (Washington Post, “Hospitals find asthma hot spots more profitable to neglect than fix.” 4 December 2017)

I consider this a disability issue because (1) the prevalence of disability is higher in Black and Latinx populations. Per 2013 BRFSS data, 29 percent of non-Hispanic Black adults, and 25.9 percent of Latinx adults reported having a disability, compared with 20.6 percent of white adults (CDC, 2015).

And (2) environmental exposures in the home are a key facet of health. In addition to grappling with a lack of accessible and affordable housing, people with disabilities may also have to contend with unhealthy home environments. There are individual-level solutions that can be provided in the space of the hospital, and there are community-level interventions to address environmental exposures that trigger respiratory responses, such as trash cleanup to reduce rodents and insects, removal of old carpets, and the reduction of secondhand smoke.

“Science has shown it’s relatively easy and inexpensive to reduce asthma attacks: Remove rodents, carpets, bugs, cigarette smoke and other triggers. Deploy community doctors to prescribe preventive medicine and health workers to teach patients to use it. ” (Washington Post, “Hospitals find asthma hot spots more profitable to neglect than fix.” 4 December 2017)

These interventions can also extend to housing policy, including protections for renters.

Post-recession (post-2008), “recovery” has been uneven. The wealthiest households have seen a growth in their net worth, while the so-named “middle class” has not returned to pre-recession levels. Moreover, as economic geographer Desiree Fields (2017) has found, single-family rental homes have become an asset class driving the growth in net worth among the wealthiest. The subprime loan & foreclosure crisis has left people to grapple with cascading consequences including housing insecurity while foreclosed homes and/or homes with delinquent property taxes are auctioned off for as little as $1 (Chicago is a good example of this practice- lots in the majority Black and Latinx South and West sides are being auctioned off for $1).

References:

Kraus, Lewis. (2017). 2016 Disability Statistics Annual Report. Durham, NH: University of New Hampshire. URL: https://disabilitycompendium.org/sites/default/files/user-uploads/2016_AnnualReport.pdf (accessed 16 December 2017)

Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, People with a disability less likely to have completed a bachelor’s degree on the Internet at https://www.bls.gov/opub/ted/2015/people-with-a-disability-less-likely-to-have-completed-a-bachelors-degree.htm (visited December 16, 2017).

Shakespeare, T. (2013). The Social Model of Disability. In The Disability Studies Reader, ed. L.J. Davis. 4th edition. Routledge, New York City, NY. Pp. 214-221

Washington Post, “Hospitals find asthma hot spots more profitable to neglect than fix.” 4 December 2017. URL: https://www.washingtonpost.com/national/health-science/hospitals-find-asthma-hot-spots-more-profitable-to-neglect-than-fix/2017/12/01/0d804ce2-b806-11e7-be94-fabb0f1e9ffb_story.html?tid=ss_tw&utm_term=.ad3a42192fd7 (visited 16 December 2017)

Fields, D.J. (2017) Constructing a new asset class: Property-led financial accumulation after the crisis. Economic Geography. pp 1-23 http://www.tandfonline.com/doi/abs/10.1080/00130095.2017.1397492?tokenDomain=eprints&tokenAccess=HZGvxXArF7p6cmN37EB2&forwardService=showFullText&doi=10.1080%2F00130095.2017.1397492&doi=10.1080%2F00130095.2017.1397492&journalCode=recg20

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