Health and Inequalities: An Interview with Sigrún Ólafsdóttir and Jason Beckfield

This is part of our special feature, Public Health in Europe.

While health has traditionally been considered an integral part of human well-being, rapid economic and social developments across the world have resulted in a changed understanding of how we need to assess the multiple influences on people’s health. In addition to the physical characteristics of the living environment, population health also encompasses the study of health determinants and health outcomes for certain groups of people, as well as the holistic public interventions and policies addressing economic, social, and political disparities. The distribution of health outcomes is often influenced by socially defined health determinants, such as housing conditions, income disparity, employment status, culture, etc. Thus, population health is different from public health, which is concerned with the health situation of the public at large, promoting personal level awareness of the healthier lifestyle choices.

To reduce health inequalities, understanding the communities we live in has become widely recognized. Sigrún Ólafsdóttir from the University of Iceland and Jason Beckfield from Harvard University discuss the population health from sociological perspective. They address the issues of defining populations in Europe, cross-national differences in social inequalities in health, the role of the welfare state, and the importance of addressing the root causes of health disparities. Sigrun and Jason are both guest editors of EuropeNow’s special feature, Public Health in Europe.

—Rusudan Zabakhidze for EuropeNow

EuropeNow Without doubt, health is widely recognized as the fundamental aspect of human wellbeing, and it has always been in the center of public policy debates. I’m wondering—what do you mean when you talk about population health? How is this perspective different from other approaches in broader health studies? 

Jason Beckfield The term “population health” is contested, and scholars have different ideas about what it is. I use it to refer to health beyond the individual. It is a macroscopic approach to health that concerns how health is distributed across the population, how the population is defined, what is the average health of the population, and how this average is related to health inequalities. One of the things population health is not is clinical medicine, which concerns specific individual patients. I am more interested in groups of people who have specific health issues, and the social, historical, political, and cultural factors that define populations and distribute health between and within them.

Sigrún Ólafsdóttir I am less likely to use the term population health—I prefer to refer to health in general. But when thinking about health outcomes, I always think about groups. We, sociologists, are never particularly interested in individuals. We are interested in groups of people and we can look at it at the aggregate level, which I would associate more with population health. But of course, we are also interested in individual-level health. Individual clinical diagnosis can be very useful for interdisciplinary health sciences, such as sociology, public health, or population health studies. For instance, there are large databases using health register data, including clinical diagnosis available in the Nordic countries. However, while we consider the data extremely useful, sociologists are always critical of this data. This is because sociological work has shown that many clinical diagnoses can be socially constructed. An example here would be the social construction of gender differences in the rate of heart disease.

EuropeNow Do you recall when population health research started to gain more momentum in academia?

Jason Beckfield The term population health gained currency in the last twenty years or so. It is a relatively new idea, although some of its foundational contributions date back at least to the nineteenth century. Nancy Krieger talks about this in her book, Social Epidemiology and the People’s Heath. Medical sociology, for instance, has been taking this approach to health for a long time. And I think it is only more recently that some of the other population health sciences have caught up with that perspective. For instance, epidemiology and some other fields are relative newcomers to the population way of thinking. I think in the United States, increased popularity of population health research traces back to Robert Wood Johnson Foundation, which supports relevant research on health conditions of the US population. So, we could say starting from the 1990s the focus on population health has strengthened.

EuropeNow What health issues does population health deal with more specifically? Has its understanding widened over the years?

Sigrún Ólafsdóttir Our research interests within the social sciences are always going to be linked to societal developments. One of the biggest changes that we have gone through, in many societies, is the so-called epidemiological transition. This means that, as a society, we are moving from mostly dealing with infectious diseases we either recover or die from, toward a disease profile of various chronic and mental health problems. There are people who live with a wide range of chronic conditions, including mental health problems, for decades. Consequently, how it is appropriate to study health and illness is fundamentally bound to a specific context and time period, and needs to reflect the major health concerns of a particular community, society, or a region. In general, the complexities associated with health and illness, call for multiple approaches and multiple measures of health, both at the aggregate and individual-level.  

EuropeNow What are your personal research interests? How do you contribute to scholarly literature on health?

Sigrún Ólafsdóttir My research interests are at the intersection of medical, political, and cultural sociology. Some of the issues I have focused on are health inequalities, health services research, health policy, mental health, medicalization, the stigma of mental illness, and social inequalities. In most of my work, I use a cross-national approach as my key interest is in understanding how larger institutional arrangements, historical trajectories, and cultural traditions impact individual lives, including our health and illness. For instance, I am a part of a research team, led by my former PhD advisor, Bernice Pescosolido, focusing on stigma toward mental illness around the globe. There was a belief in the medical community—and even the broader community—that the solution to stigma was to get the public to believe that mental illnesses are diseases just like any other diseases. However, research showed that the American public bought the narrative of a biological model of mental illnesses, however, it did not make them hold less stigmatizing attitudes. When we extend this to a cross-national perspective, we do find that attitudes vary significantly across contexts, and are likely to be culturally bound. For example, Icelanders are more likely to attribute the causes of mental illness to social, rather than individual causes, and they along with Germans, generally hold the less stigmatizing attitudes. A striking finding from our work is that while Icelanders are rather unlikely to associate mental illness with dangerousness, Americans are quite likely to do so. We can wonder what it is about those two societies that produces those different findings.

Jason Beckfield I am a sociologist as well. My current work focuses on cross-national differences in social inequalities in health. There is a new field of comparative research that shows how social inequalities in health vary quite a lot across different national contexts. One branch of my work focuses on Western Europe and the welfare state, which is arguably the major stratifying institution in many western European countries. In the US, I focus more on cross-state and cross-county differences. I am also interested in health inequalities in the Global South. One of the questions I have been working on with some graduate students is the issue of whether improving average population health necessarily comes at the cost of widening health inequalities. The reason you might be tempted to think that is things that improve individual health can often be captured first by people in socially advantageous positions. So, sometimes health inequalities widen with new health interventions. But looking at countries in Global South that had steep declines in under-5 mortality rates, we found is that as average health improved, inequalities actually declined at the same time. It turns out that one of the explanatory factors was the growth of the education system and the expansion of public health programs that were delivered as a citizenship right.

EuropeNow Could you elaborate more on the intersection of social justice and health inequalities in the European context?

Jason Beckfield One of the things I am interested in is the “Nordic Paradox,” the idea that Nordic countries despite extremely strong or at least comparatively strong welfare and healthcare systems, still have large social inequalities in a range of different health outcomes. I worked on this question together with colleagues led by Clare Bambra, in a big project called “Health Inequalities in the European Welfare States.” We found that the Nordic Paradox is overblown. We found little evidence for such a paradox. This caused us to rethink how we conceive of the relationship between the welfare state and population health in the first place. If the Nordic Paradox concept is less helpful, then what do we replace it with? We have developed an institutional theory of population health that we think does a better job. The objective of this theory is to explain population health, including cross-national differences in social inequalities, in terms of institutional arrangements, including citizenship rights, labor markets, gendered state institutions, migration policies, and other things that organize the “rules of the game.”

Sigrún Ólafsdóttir This is something that I have been thinking about for a long time. I read somewhere that Nordic people are born with the love of equality in their blood, and while I do not necessarily believe that, social inequalities first became one of my main interests when I moved to the United States. It was quite eye opening to move there and experience first-hand, just how large the social inequalities are and how great their implications are for health inequalities. My original interest was understanding whether and how different welfare states may reduce health inequalities through policies and safety nets. One of my first papers on the topic compared the United States and Iceland, two capitalist societies with fundamentally different relationship between the state, the market and medicine. One of my findings there was that parents, regardless of marital status, have better health in Iceland than in the US. This may, of course, be related to the variations in family policies across the two contexts, but also the cultural context surrounding lone parenthood in Iceland, compared to the United States. Seeing how much societies can choose, or not choose, to interfere in inequalities makes it clear that health inequalities are about social justice—they are about what kind of inequalities we are willing to accept in our societies, what kind of resources, including access to health care, we give to different societal groups, and how we interfere in equality of opportunities, as well as equality of outcomes. In my mind, there is no doubt that the Nordic societies are the societies with the greatest emphasis on correcting inequalities, and it is our work, as researchers, to empirically evaluate how that impacts health inequalities within and across countries. 

EuropeNow So far, we have mostly referred to population health at the state level, but what about smaller groups within the state in terms of health outcomes and access to healthcare? How do recent trends in migration challenge population health in Europe?

Jason Beckfield Migrant health inequalities are very interesting objects of study because they involve so many complicated processes that only very deeply multidisciplinary perspectives can grapple with. Transnationalism for instance has potentially a large impact on the health and wellbeing of populations. Histories of migration are also very interesting because they create situations where you have to be very careful in constructing groups of migrants for comparison purposes. Germany is a great case for this. It means something different to be first-generation Turkish migrant, versus a second-generation migrant, versus an asylum seeker. All these groups have very different experiences that shape their population health, in part because of the way in which the state incorporates them. In fact, we have found in new work that the manner in which welfare states incorporate migrants into the polity has pretty robust effects on health. So, what we call political incorporation matters for health and for health inequalities.

Sigrún Ólafsdóttir I would like to talk about this issue more broadly. Within sociology, class, race, and gender related inequalities have always been important. However, what I think has changed is an ever-increased emphasis on studying these inequalities not separately but together. It is relatively new for certain European countries to have an influx of immigrants from various countries. This is one of the most pressing societal issues in general, but also clearly applies to health and wellbeing. In the European context, it is challenging to operationalize race and ethnicity, and one of the main lessons from our research with Elyas Bakhtiari was just how complex it is to define race and ethnicity, and how different ways of measurement produce different results. But perhaps the most important finding was that a stronger welfare state benefits the health of all groups in societies, but only specific migration policies and cultural attitudes do anything to reduce health inequalities between natives and immigrants. Therefore, the welfare state may be a key institution to improve health, but if we are serious about addressing health inequalities, we need to address what is producing the societal inequalities that then have health implications.

EuropeNow In your opinion, is health prioritized enough in Europe? What are the existing challenges of how we deal with population health?

Sigrún Ólafsdóttir I think health can never be prioritized enough because it is the most fundamental asset human beings can have. But to a certain extent, I think most European countries spend a great deal on the health care system. It is usually the largest spending category of the state. But in many countries, medicine is getting a disproportionately large portion compared to other health disciplines, or even other approaches we could use to improve health. We might be prioritizing fixing health problems at the expense of addressing the causes of such problems. We can relate this back to studies done in the UK in the late 1960s on the importance of relative poverty and health. One of the implications here is that you can address the health needs of people if they have access to the medical system, but if you send some groups back to the same dire conditions, we will do little to address health inequalities. We can use this as a lesson for health inequalities based on immigration status—we can address the health needs of immigrants, but we also need to think about what broader social conditions may be creating those inequalities in the first place.

Jason Beckfield I am quite worried about European population health from an American perspective. Over the past thirty years, the record of population health, at least in North-West Europe, has been enviable. So much so that a recent, high-profile National Academy of Sciences report tried to explain the enormous mortality disadvantage the US population has, relative to the European population, as well as the populations of other rich democracies. I think the gap will close, but for the wrong reason: instead of the US catching up to Europe, many European countries are “catching down” to the US. And I think that is primarily because in many European nation states, you have increasing acceptance of the idea that state should serve the market and the state should use market tools. If there is anything we know about population health in the US, as it relates to the organization of the health system, it is that market logic for the health system does not work. And it is really frightening to me as an American to see so many European welfare states trying out market tools and applying them to the health system.

Population health is not traditionally a huge area of concern for Europeanists. And I think that needs to change—in large part because people who specialize in health research including epidemiologists and public health scholars have over the last ten years especially discovered that a lot of biological factors and healthcare-oriented factors that they have been focusing on are not the most important determinants of population health. Instead, the most important drivers of population health are societal. These drivers include institutions and identities, policies and social inequalities, and historical transformations. I think the field of health research can also be useful to social scientists, so this is a fruitful new domain for collaboration.

Sigrún Ólafsdóttir is a Professor and the chair of sociology at the University of Iceland. Her research is at the intersection of medical, political, and cultural sociology. The main areas of research are health inequalities, health services research, health policy, mental health, medicalization, stigma of mental illness, and social inequalities. Most of her research uses a cross-national perspective, as one of her primary goals is to understand how larger societal arrangements impact individual outcomes, attitudes and behavior.

Jason Beckfield is Professor of Sociology at Harvard University. His research investigates the institutional causes and consequences of social inequality. His new books include Political Sociology and the People’s Health (2018, Oxford University Press) and Unequal Europe: Regional Integration and the Rise of European Inequality (2019, Oxford University Press).

Rusudan Zabakhidze is a visiting fellow at the Council for European studies. She is pursuing an international master’s degree in Security, Intelligence and Strategic Studies (IMSISS), which is a collectively run program by the University of Glasgow, Dublin City University, and Charles University in Prague. Rusudan has a BA in international relations from Tbilisi State University. Her research interests mostly revolve around but are not limited to the politics of Central and Eastern Europe, NATO, and civil-military relations.

 Published on June 11, 2019.

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