Structural Foundations of Health

January 26, 2026

Today’s Question

Why do some populations experience better health than others?

The Scale of Health Disparities

1. The Social Gradient

1. The Social Gradient

Health improves at each step up the economic ladder—not just rich vs. poor

1. What Creates the Gradient?

Material

• Housing quality
• Neighborhood safety
• Resource access

Psychosocial

• Chronic stress
• Sense of control
• Social support

Behavioral

• Context shapes choices
• Coping mechanisms
• Access to healthy options

2. Structural Inequities

2. What Are Structural Inequities?

Systematic disadvantages built into social, economic, and political systems

• Not individual behaviors
• Embedded in institutions
• Unfair and avoidable
• Persist unless actively dismantled

2. Historical Example: Redlining

Federal policy (1930s-1968) denied mortgages in Black neighborhoods

2. Health Impacts Today

• Higher pollution exposure
• Food deserts
• Chronic stress
• Lower home values
• Less wealth for health

2. Contemporary Inequities

• Education: School funding tied to property taxes

• Criminal Justice: Mass incarceration, employment barriers

• Labor Market: Occupational segregation, wage gaps

• Healthcare: Insurance gaps, provider distribution

3. Social Context

3. Social Capital

Bonding

• Within-group
• Family, close friends

Bridging

• Between-group
• Diverse networks

Linking

• To institutions
• Access to power

All three types affect mental health, safety, and resource access

3. Discrimination & Health

3. Three Forms

• Interpersonal: Everyday experiences

• Institutional: Policies and practices

• Structural: Systemic patterns

3. Health Pathways

• Direct stress response → cortisol, inflammation

• Differential treatment in healthcare

• Limited opportunities in education and employment

• Cumulative burden over lifetime (weathering)

4. Economic Context

4. Income vs. Wealth

• Income (flow)

Wages enable current consumption:

• healthcare access
• healthy food
• safe housing

• Wealth (stock)

Assets provide security:

• buffer against shocks
• intergenerational transfers

4. Job Quality Matters

Beyond just having a job:

• Wages and benefits
• Schedule control
• Physical demands
• Autonomy and security

Example: Service workers without paid sick leave work while ill

5. Environmental Context

5. Built Environment

5. Environmental Justice

Low-income communities and communities of color disproportionately exposed to environmental hazards

5. Health Impacts

• Respiratory diseases (asthma, COPD)
• Cancer clusters
• Cardiovascular disease
• Mental health effects

6. Housing

6. Housing as Health Determinant

• Direct effects

Quality: lead, mold, pests

Crowding: disease transmission

Safety: injuries, violence

Stability: eviction stress

• Indirect effects

Affordability: less for food, healthcare

Location: job access, schools

Segregation: concentrated poverty

6. Lead Exposure Example

Pre-1978 housing concentrated in low-income areas causes irreversible cognitive damage

Synthesis

Key Takeaways

• Health disparities stem from structural inequities—not individual failings

• The social gradient operates through material, psychosocial, and behavioral pathways

• Social, economic, and environmental contexts interact to shape health

• Housing is a fundamental determinant with direct and indirect effects

Wednesday Preview

• Policy as a health determinant
• Labor conditions
• Community vs. population health assessments
• Group exercise: Identifying determinants in real communities

Read Chapter 4 (sections on determinants)

Thank you!