Health and Social Stratification

One could argue, quite cogently, that social stratification clearly delineates human activity and behavior on multiple levels in a society. Linking social stratification to health issues constitutes a structural approach to understanding health issues at the local and global, public and private sector levels. It also means understanding the ways in which patients' and health care providers' choices are circumscribed (Anagnost, 1995; Morsy, 1995; Navarro, 1981; Pearce, 1995; Singer, 1990). At the individual level, as Gramsci (1971) argues, the healer, like the priest, is a mediator between the elite and the non-elite, and health and disease are defined by the elite for the purposes of controlling the non-elite. Others have described healing systems as the meeting ground between the elites and the proletariat (Waitzkin, 1979) and as "the locus of hegemony" (Csordas, 1988). Medicine often defines the "Other" as diseased or unhygienic, and in doing so, places it under medical control, the realm of the elites (Comaroff & Comaroff, 1992; Douglas, 1966).

Because health is negotiated at so many different levels, it is important not only to identify the different levels but also to understand their interaction. What are the tools available to anthropology to examine the structural determinants of health care? Health care at the macro level is determined by the confluence of politics, economics, and ideology. Such interactions determine the path governments choose in determining health standards, in providing health for their populous, and in endorsing one health care system over another. The macro, structural, is separated from the micro, experiential, phenomena only as matter of analysis (Singer, 1990, p. 191). In practice, individual and structural features work simultaneously to determine health decision-making.

As Morsy states, "the political economic orientation forces anthropology to redefine its field of inquiry in global processual and relational terms" (Morsy, 1990, p. 27). As such, the political economy of health addresses the issue of power in the production of health. For example, in Egypt uzr is described as a sickness that preys upon young brides and younger sons in the family. The disease is understood as being induced by the powerless-ness of these familial positions, and the sick role is seen as an embodiment of this inefficacy. In a Nigerian example, the uncertain political future of the nation-state has prompted people to utilize simultaneously a variety of health solutions, including reliance upon familial "therapy managing groups" and a renewed interest in faith healing and indigenous medicine, in addition to the state-supported biomedical system (Pearce, 1993). Wilkerson further demonstrates the linkage between social position and health. He writes about a study of electoral wards in Northern England in which death rates were four times higher in the poorest 10% of the wards, as in the richest 10% (Wilkerson, 1996, p. 53). He writes, "numerous studies have shown health differences are not confined to differences between the poor and the rest of society, but instead run across society with every level of society having worse health than the one above it" (Wilkerson, 1996, p. 53).

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