Within and across all societies, some people live longer and healthier lives than others. Although many of us intuitively think of health as a very important good, general theories of justice have hitherto paid little attention to its distribution. This is a thesis about what we owe to one another, as a matter of justice, in view of our unequal levels of health. The first part of the thesis addresses the problem of social justice in health. I argue that the basic institutional framework of society must be arranged so as to ensure an egalitarian distribution of the 'social bases of health,' that is, the socioeconomic conditions that shape our opportunities for a healthy life. Inequalities in health, including those caused by differences in individual lifestyles, are only fair when people have been given fair opportunities. This egalitarian approach to the social bases of health must be complemented by a sufficientarian concern for meeting all basic health needs, regardless of whether these originate in unfair social arrangements. The second part of the thesis takes up the problem of global justice in health. Although I argue against the idea that domestic principles of justice can be simply replicated on a global scale, I emphasise the fact that there are a number of international institutions and practices that shape people's opportunities for health. One of these is the state system - the division of the world into sovereign states - which I argue grounds the idea of the human right to health. I also examine two more specific examples of global practices that contribute to global inequalities in health, namely global trade in tobacco and the global labour market for healthcare workers. Both of these, I suggest, must be restricted in light of their impact on health levels worldwide.

This medical anthropology dissertation is an intersectional study of the illness experiences of African-American women living with the chronic autoimmune syndrome systemic lupus erythematosus (SLE), commonly known as lupus. Research was conducted in Memphis, Tennessee from 2013 to 2015, with the aim of examining the healthcare resources available to working poor and working class women using public sector healthcare programs to meet their primary care needs. This project focuses on resources available through Tennessee’s privatized public sector healthcare system, TennCare, during the first phases of the Patient Protection and Affordable Care Act (ACA). A critical medical anthropological analysis is used to examine chronically ill women’s survival strategies regarding their daily health and well-being. The objectives of this research were to: 1) understand what factors contribute to poor women’s ability to access healthcare resources, 2) explore how shared illness experiences act as a form of community building, and 3) document how communities of color use illness narratives as a way to address institutionalized racism in the United States. The research areas included: the limits of biomedical objectivity; diagnostic timeline in relation to self-reported medical history; effects of the relationship between socio-economic circumstance and access to consistent healthcare resources, including primary and acute care, as well as access to pharmaceutical interventions; and the role of non-medical support networks, including personal support networks, illness specific support groups, and faith based organizations. Qualitative methods were used to collect data. Methods included: participant observation in support groups, personal homes, and faith based organizations, semi-structured group interviews, and open-ended individual interviews. Fifty-one women living with clinically diagnosed lupus or undiagnosed lupus-like symptoms participated in individual interviews. Additionally twenty-one healthcare workers, including social workers, Medicaid caseworkers, and clinic support staff were interviewed in order to contextualize current state and local health programs and proposed changes to federal and state healthcare policy.

Cette thèse porte sur la mesure et la compréhension des inégalités des chances en santé c'est-à-dire aux inégalités attribuables à des facteurs ne relevant pas de la responsabilité individuelle, tel que le milieu d'origine. Nous portons un intérêt spécifique à la contribution des comportements de santé dans la construction de ces inégalités. Nous développons notre analyse à travers trois axes : (i) la mesure de l'importance respective des conditions de vie dans l'enfance, du niveau d'éducation et des comportements de santé dans l'explication des inégalités de santé ; (ii) l'analyse des mécanismes en jeu dans la transmission intergénérationnelle des comportements de santé avec l'exemple du tabagisme et des habitudes de soins ; (iii) la mesure des différences entre pays européens dans les inégalités des chances en santé. Les analyses empiriques combinent des données prospectives d'une cohorte britannique ainsi que des données rétrospectives issues d'une enquête française et d'une enquête européenne. Les résultats soulignent la contribution aux inégalités de santé des conditions de vie dans l'enfance et du niveau d'éducation de façon directe et de façon indirecte par les comportements de santé. / This thesis focuses on the measurement and the understanding of inequality of opportunity in health which are inequalities related to factors beyond the individual responsability, such as the individual's social background. We focus on the contribution of health-related behaviors in the construction of these inequalities. Our analysis is based on three topics: (i) the measure of the respective contribution of early-life conditions, education and lifestyles to health inequality ; (ii) the analysis of the intergenerational transmission of health-related behaviors with the example of smoking and health care habits ; (iii) the measure of cross-country differences in inequality of opportunity in health with a European perspective. Empirical analysis are conducted with both prospective data using a British cohort and retrospective data using a French study and a European study. The results emphasize the contribution of early-life conditions and education to health inequality both directly and indirectly through lifestyles.

This study explores the experiences of General Practitioners (GPs) and patients in the management of type 2 diabetes in contemporary Australia. I focus on the way the socioeconomic position of patients is a factor in that experience as my underlying interest is in exploring how health inequalities are understood, approached and handled in general practice. The study is thus a practical and grounded exploration of a widely debated theoretical issue in the study of social life, namely the relationship between the micro day-to-day interactions and events in the lives of individuals and the broad macro structure of society and the position of the individual within that. There is now wide acceptance and evidence that people’s social and economic circumstances impact on their health status and their experiences in the health system. However, there is considerable debate about the role played by primary medical care. Nevertheless, better theoretical understanding of the importance of psychosocial processes in generating social inequalities in health suggests medical care may well be important, as such processes are crucial in the care of chronic illnesses such as diabetes which are now such a large part of general practice work. I approach this study through an exploration of patient centred clinical practice. Patient centredness is a pragmatic, idealised prescriptive framework for clinical practice, particularly general practice. Patient centredness developed in part in response to critiques of biomedicine, and is premised on a notion of a more equal relationship between GP and patient, and one that places importance on the context of patients’ lives. It contains an implicit promise that it will help GP and patient engage with and confront social disadvantage.

Objetivos: Estudiar el efecto de los factores de riesgo social, añadidos a la falta de conocimiento del español, en relación con el incumplimiento del control prenatal en gestantes inmigrantes africanas y autóctonas en Cantabria. Comparar la asociación entre la falta de control prenatal y la morbilidad neonatal en gestantes inmigrantes africanas frente a autóctonas. Metodología: Estudio de cohortes retrospectivo. Se identificaron 231 gestantes inmigrantes africanas en todo Cantabria, con fecha de parto entre el 01/01/2007 y 31/12/2010. La muestra de la población autóctona se obtuvo mediante muestreo simple aleatorio. El muestreo se realizó estratificando por los Centros de Salud de origen de las gestantes inmigrantes incluidas en nuestro estudio. Se predefinió un ratio 1:3 gestante inmigrante: autóctona. Cómo principales variables de estudio se recogieron: el conocimiento insuficiente del idioma (no saber hablar español), la derivación de la embarazada a la trabajadora social (TS) por detección de factores de riesgo social. El grado de control de embarazo se estimó a través del Índice Kessner (IK) y de un Índice Propio (IP), categorizándose en cumplimiento adecuado versus incumplimiento. Como variables principales de morbilidad neonatal se recogieron: bajo peso (<2.500 gr. al nacimiento) y parto pretérmino (por debajo de las 37 semanas de gestación). Mediante Regresión logística no condicional se estimaron Odds Ratios (OR), junto con sus Intervalos de Confianza al 95% (IC95%). Para estudiar interacción, la asociación entre el idioma y grado de control prenatal se estratificó en función de la derivación de la embarazada a la TS, incluyendo asimismo el término de interacción en los modelos logísticos. Resultados: El 84% de las gestantes africanas no sabía hablar español. El 47% fueron derivadas a la TS. La prevalencia de incumplimiento del control prenatal fue del 2 76-78% en función del índice analizado (Kessner o Propio) en inmigrantes frente al 22-27% en autóctonas (p< 0,001). El conocimiento insuficiente del español en africanas no derivadas a la TS, se asoció al incumplimiento de forma más débil y no significativa (ORc incumplimiento ORc IK 1,31; ORc IP 1,66). Por el contrario, en gestantes derivadas a la TS, la asociación para el idioma se reforzó alcanzando significación estadística (ORc incumplimiento IK 8,98; ORc IP 6,94). El término de interacción fue estadísticamente significativo (p interacción= 0,026) para el incumplimiento basado en el IK. En ambos colectivos se encontraron asociaciones positivas tanto para parto pretérmino (OR IK africanas=8,74; OR autóctonas=3,00) como para bajo peso (OR IK bajo peso africanas=6,81, OR autóctonas=3,00). Los resultados se mantuvieron al ajustarse por edad y detección de riesgo social por parte de la matrona. Al clasificar el incumplimiento en intermedio e inadecuado se obtuvieron patrones dosis respuesta estadísticamente significativos (p< 0,01): OR IK incumplimiento inadecuado parto pretérmino africanas=16,98 (IC95% 0,96-299,23), OR IK incumplimiento inadecuado bajo peso africanas 12,95 (IC95% 0,72-232,38). Conclusiones: La falta de control prenatal fue mayor en gestantes inmigrantes africanas. En este colectivo, la derivación de la embarazada a la TS interaccionaría con el idioma aumentando el riesgo de incumplimiento del control prenatal. Nuestros resultados apoyan que el conocimiento insuficiente del español es el principal factor asociado al incumplimiento en gestantes africanas, pero únicamente en presencia de factores de riesgo social que motivan la derivación de la embaraza a la TS. Asimismo sugieren que la falta de control prenatal se asocia a un mayor riesgo de morbilidad fetal en ambos colectivos, si bien el efecto del incumplimiento sobre la morbilidad neonatal parece ser mayor en gestantes inmigrantes africanas que en autóctonas, pudiendo suponer una fuente de desigualdades en salud. / Objetives: To study the effect of social risk factors, added to the lack of knowledge of Spanish, related to the lack of adherence to prenatal care in African immigrant women and native-born in Cantabria. To compare the association between lack of prenatal care and neonatal morbidity in African immigrant women and native-born in Cantabria. Methodology: Retrospective cohort study. We identified 231 pregnant African immigrant women in Cantabria with delivery dates between January 1st, 2007 and December 31st, 2010. The native-born population sample was obtained by simple random sampling, which was stratified by health centers of reference of the pregnant African immigrants included in our study. A ratio 1:3 was established pregnant immigrant: native-born. The main studying variables were collected: insufficient knowledge of Spanish (not to be able to speak Spanish), and the referral of the pregnant woman to a social worker (SW) due to social risk factors. The degree of the pregnancy control was estimated by Kessner Index (KI) and an Own Index (OI), being categorized in proper compliance versus noncompliance. The main neonatal morbidity variables were collected: low weight (<2500 g. at birth) and preterm birth (less than 37 weeks in gestation). Odds ratios (OR) were estimated by non-conditional logistic regression along with their Confidence Intervals at 95% (CI95%). To study interaction, the association between language and degree of prenatal control was stratified according to the referral to the SW, including the interaction term in the logistic models. Results: 84% of pregnant African women did not know how to speak Spanish. 47% were referred to a SW. The prevalence of the lack of adherence to prenatal care was 76-78% depending on the analyzed index (Kessner or Own) in immigrants compared to 22-27% in native-born (p <0.001). In Africans who were not referred to a SW, the association between their insufficient knowledge of Spanish and inadequacy of prenatal care was weak and not significant (OR for KI=1.31; OR for OI=1.66). On the contrary, in pregnant women who were referred to a SW, the association for the language was strengthened and yielded statistical significance (OR for KI=8.98; OR for OI =6.94). The term of interaction (language*referral to a SW) was statistically significant (p interaction=0.026) for the lack of adherence based on the KI. 4 In both groups, positive associations were found for both preterm delivery (OR = 8.74 African, native-born OR = 3.00) and for low birth weight ones (OR = 6.81 underweight African, native-born OR = 3.00). The findings held when adjusted for age and social risk detection by the midwife. By classifying the lack of adherence to prenatal care as intermediate and inadequate, statistically significant dose response patterns were obtained (p <0.01): OR KI inadequate preterm African = 16.98 (95% CI 0.96 to 299.23), OR KI inadequate low birth weight African 12.95 (95% CI 0.72 to 232.38). Conclusion: Lack of prenatal care was higher in African immigrant women. In this group, the referral of the pregnant woman to a SW would interact with language barriers, thus increasing the risk of lack of adherence to prenatal care. Our results support the idea that insufficient knowledge of Spanish is the main factor associated with the lack of prenatal care in African immigrant women, but only in the presence of social risk factors that motivate the referral of the pregnant woman to a SW. Furthermore, our results suggest that the lack of prenatal care is associated with an increased risk of fetal morbidity in both groups, although the effect of the lack of prenatal care on neonatal morbidity appears to be higher in African immigrant women than in native-born. As a consequence, this could be a source of health inequalities.

The incidence of adverse birth outcomes, such as low birth weight and preterm births, has steadily risen in recent years in Canada. Despite the fact that numerous individual and neighbourhood risk factors for low birth weight and preterm births have been identified and various person-oriented intervention strategies have been implemented, uncertainties still exist concerning the role that place and space play in determining adverse birth outcomes. In order to succeed in producing community-oriented health policy and planning guidelines to reduce both the occurrence and inequalities of adverse birth outcomes, the research presented in this thesis provides an approach to examining the pathways of various socio-economic, environmental, and psycho-social risks to LBW and preterm births. Using a modified multilevel binary-outcome mediational analysis method, case studies are conducted within three public health units in Ontario, namely the Wellington-Dufferin-Guelph Health Unit, the Windsor-Essex County Health Unit, and the Halton Region Health Unit. Different pathways are investigated given the available data and the theoretical assumptions of three health inequality pathway models, namely the behavioural model, the psycho-social model, and the materialist model, and the geographical and planning perspectives of health inequalities. A local spatial analysis process is also used to identify spatial clusters of incidence and to assess possible associated reasons in order to support public health polices and planning in community-oriented health interventions. Using Bayesian spatial hierarchical analysis and spatial clustering analysis, local clustering of high risks of adverse birth outcomes and spatial variations of associated individual risks within the study areas are identified. The analysis is framed around five hypotheses that examine personal vs. spatial, compositional vs. contextual, psycho-social vs. material, personal vs. cultural, and global vs. local effects on the determinants of adverse birth outcomes. The results of testing these hypotheses provide evidence to assist with multi-component multi-level community-oriented interventions. Possible improvements of current prenatal care policies and programs to reduce the spatial and social inequalities of adverse birth outcomes are suggested. Potential improvements, including early stage prenatal health education, local healthy food provision, and cross-sector interventions such as the combination of social mixing strategies with bottom-up community-based health promotion programs, are also suggested.

The aim of the present thesis is to examine various aspects of the school-class structure and their links to health in a life-course perspective. The empirical studies are based on two longitudinal data materials of cohorts born in the 1950s, followed up until middle age. In the first study, the overall status distribution in the school class was shown to be associated with both minor psychiatric disorder in childhood and self-rated health in adulthood. Thus, ill-health was more common among individuals who attended school classes less equal in terms of status. The second study demonstrated that it was more common among those who had fewer mutual friendships in the school class to report poorer health as adults. Socioeconomic career emerged as the primary explanation for men while, for women, these findings were largely unaccounted for by any of the included child and adult circumstances. Findings from the third study suggested the child’s status position in the school class, i.e. peer status, to be related to a wide range of health outcomes in adulthood. In particular, lower peer status was linked to an excess risk of mental and behavioural disorders, cardiovascular diseases and diabetes. Childhood social class did not confound these associations to any large extent. The fourth study examined two types of social isolation in the school class: marginalisation (low peer status) and friendlessness. Hospitalisation due to any disease was more common among marginalised children compared to among non-isolates, whereas no corresponding association was found for the friendless. For both types of isolates, the number of hospitalisations was greater than among non-isolated individuals. Of the studied childhood factors, scholastic ability emerged as an important mechanism. In sum, this thesis points to the relevance of the school class for health development across the life course and to the complexity of pathways through which influences of the school class may operate. / At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 1: Submitted. Paper 2: Accepted.

The incidence of adverse birth outcomes, such as low birth weight and preterm births, has steadily risen in recent years in Canada. Despite the fact that numerous individual and neighbourhood risk factors for low birth weight and preterm births have been identified and various person-oriented intervention strategies have been implemented, uncertainties still exist concerning the role that place and space play in determining adverse birth outcomes. In order to succeed in producing community-oriented health policy and planning guidelines to reduce both the occurrence and inequalities of adverse birth outcomes, the research presented in this thesis provides an approach to examining the pathways of various socio-economic, environmental, and psycho-social risks to LBW and preterm births. Using a modified multilevel binary-outcome mediational analysis method, case studies are conducted within three public health units in Ontario, namely the Wellington-Dufferin-Guelph Health Unit, the Windsor-Essex County Health Unit, and the Halton Region Health Unit. Different pathways are investigated given the available data and the theoretical assumptions of three health inequality pathway models, namely the behavioural model, the psycho-social model, and the materialist model, and the geographical and planning perspectives of health inequalities. A local spatial analysis process is also used to identify spatial clusters of incidence and to assess possible associated reasons in order to support public health polices and planning in community-oriented health interventions. Using Bayesian spatial hierarchical analysis and spatial clustering analysis, local clustering of high risks of adverse birth outcomes and spatial variations of associated individual risks within the study areas are identified. The analysis is framed around five hypotheses that examine personal vs. spatial, compositional vs. contextual, psycho-social vs. material, personal vs. cultural, and global vs. local effects on the determinants of adverse birth outcomes. The results of testing these hypotheses provide evidence to assist with multi-component multi-level community-oriented interventions. Possible improvements of current prenatal care policies and programs to reduce the spatial and social inequalities of adverse birth outcomes are suggested. Potential improvements, including early stage prenatal health education, local healthy food provision, and cross-sector interventions such as the combination of social mixing strategies with bottom-up community-based health promotion programs, are also suggested.

This research utilizes an intersectionality framework to examine the complexity of social location and its effects on women's health. By examining connections among the state, processes of globalization, and the production of health inequalities for poor women in a rural community in southern Veracruz, Mexico, the research highlights the nexus of nationality, class, and gender. Four interconnected contexts are explored: (1) women's increasing paid and unpaid labor in the context of a poverty of resources brought on by sustained economic crisis; (2) the maintenance of reproductive labor as the responsibility of women; (3) the development of migrant "illegality" and its consequences for the well being of women who are consistently anxious about the lives of their migrant family members and the stability of remittances that sustain the household, and (4) the increasing neoliberalization of public health care that includes the heightened surveillance of women's hygienic activities and chronic underfunding of public health resources. Using an ethnographic methodology including interviews, case studies, and participant observation, the research explores the daily lives of wives and mothers of transnational migrants as well as those women who, although they do not have migrant family members, live within the context of transnationalism because it pervades the community. In addition, all women in the research confront the inadequacy of public health services because most never have the resources to utilize private health services. The research makes three important contributions to medical anthropology and the social sciences. First, it contributes to ongoing debates concerning the potential uses of the intersectionality framework in anthropology and related social sciences. Second, it contributes to border studies by elaborating an example of productive ways that the border can be theoretically extended to include examinations of the lives of migrant family members living far from the border. Third, it critically examines a public health insurance program that has the potential to fulfill Mexico's constitutional right to health care for all citizens and to be a model for global health care policy. By doing so, it provides a basis for future study and development of progressive health care policy in Mexico and beyond.

The paper studies class inequalities in health over the ageing process in a comparative perspective. It investigates if health inequalities among the elderly vary between European welfare state regimes, and if this variation is age-dependent. Previous comparative research on health inequalities have largely failed to take age and ageing into account, and have not investigated whether cross-country variation in health inequalities might differ for different age categories. Since the elderly belong to the demographic category most dependent on welfare policies, an ageing perspective is warranted. The study combines fives data rounds (2002 to 2010) from the European Social Survey. Multilevel techniques are used, and the analysis is stratified by age, comparing the 50-64 year olds with those aged 65-80 years. Health is measured by self-assessed general health and disability status. Two results stand out. First, class differences in health are strongly reduced or vanish completely for the 65-80 year olds in the Social democratic welfare states, while they remain stable or are in some cases even intensified in almost all other welfare states. Second, the cross-country variation in health inequalities is much larger for the oldest (aged 65-80 years) than is the case for the 50-64 year olds. It is concluded that welfare policies seem to influence the magnitude of health inequalities, and that the importance of welfare state context is greater for the elderly, who are more fragile and more reliant on welfare policies such as public pensions and elderly care.