Public Health and Criminal Justice

IV. Important Public Health Studies

The following seminal public health studies reveal the impact that ecological variables have on community health and have significant implications for criminal justice. Ecological variables include such environmental factors as where one works or how much money one makes. These studies focus on the hierarchical nature of social conditions that constitute fundamental causes of poor health and posit that higher socioeconomic groups are more favorably situated to know about health risks and to possess the resources that allow them to engage in protective behaviors to avoid those risks (Link & Phelan, 1995). The findings of the Alameda Study and Whitehall Studies are synthesized in the influential Black Report.

A. Alameda Study

In 1962, academics at the University of California at Berkeley allocated funds to initiate a large ecological study of community health. The Alameda Study, which had a longitudinal, cohort design, examined the causative agents of morbidity and mortality within selected residents during the years 1965, 1974, 1983, 1994, and 1995. Researchers found that, over time, living in an impoverished area was associated with a 50% increased risk in death for all sources of mortality, even after controlling for individuallevel variables (Haan, Kaplan, & Camacho, 1987). In fact, the location of where one lived was far more important than personal lifestyle choices such as diet, smoking, and exercise. This research has since been replicated, with successive research documenting a positive, linear relationship between socioeconomic status and premature mortality (J. W. Lynch et al., 2004).

B. Whitehall Studies

The Whitehall Studies, Whitehall I and Whitehall II, were pioneered by Sir Michael Marmot and examined a particular work group: civil servants working in one area of London. Whitehall I and Whitehall II observed a large number of workers over time in order to quantify the presence of a social gradient of poor health. Civil servants were selected because this work group had nonsignificant differences in race and ethnicity, work environment, and medical benefits. However, the English civil servants could be categorized as belonging to one of five distinct work grades, which enabled researchers to collect data on social class while holding the aforementioned variables constant.

The Whitehall I study was conducted in 1967 and included 19,019 male civil servants. Whitehall I found that individuals with high employment grades were much less likely to die prematurely than men in the lowest ranks—in fact, after a 10-year period the low-ranked workers had three times the mortality rate of high-ranking workers (Ebi- Kryston, 1989). Low-grade workers also faced increased risk for coronary heart disease, cancer, accidents, homicides, and suicides when compared with high-grade workers (Marmot, 1986). In 1985, the Whitehall II study examined a new cohort of 10,314 civil servants and included female civil servants. Whitehall II reaffirmed the presence of a social gradient of health, with lower occupational rankings correlated with an increased risk of premature mortality while controlling for individual-level risk factors. Analyses of Whitehall I and Whitehall II reveal that low occupation ranking was associated with low control of work, which promotes feelings of helplessness and stress. Social gradients of health have since been confirmed in almost the entire developed world with virtually every studied disease and condition (Marmot &Wilkinson, 1999).

C. The Black Report

In 1977, The Black Report (Black, Davidson, Townsend, & Whitehead, 1993) was commissioned by English medical sociologists to report on the rising health disparities that continued in light of a socialized medical system. The working group identified four models that explain health inequalities: (1) artifact, (2) selection, (3) behaviorist, and (4) materialist/structural (MacIntyre, 1997). The artifact model suggests that the relationship between ecology and community health is primarily a product of measurement error, whereas the selection model assumes that biologically determined natural abilities lead to the allocation of social position and health. The behaviorist model argued that habits, customs, and practices of low-socioeconomic individuals produced poor health, with foremost importance placed on instances of maternal mismanagement (e.g., smoking while pregnant, inadequate prenatal care) that produce infant mortality or unhealthy offspring. The behaviorist model placed emphasis on the disease pathways of personal ignorance and irresponsible lifestyles. The materialist/structural viewpoint argues that ecological factors influence health, “independent of inherited constitution” (Szreter, 1984, p. 528). Of particular significance was the finding of The Black Report that the materialist/structuralism model possessed the greatest explanatory power in terms of health disparity. This means that, despite the contribution of genetic, behavioral, and cultural factors, the governing explanation for health inequality was material deprivation and economic stratification. No other model could justify why mortality rates in higher social classes had steadily declined while those at lower levels had stagnated or even increased.

The Black Report Committee concluded that “the availability of health care did not overcome social and economic differences,” which “were central to the explanation for the existence of health disparities” (Bundrys, 2003, p. 171). The Black Report recommended the inclusion of a comprehensive anti-poverty strategy, educational development, and equity in the distribution of resources. It is important to note that materialist/structuralism theorists would support structural changes that eliminate inequality rather than just providing interventions that ameliorate the effects. The Alameda and Whitehall Studies, coupled with The Black Report, provide valuable direction; the next section examines the contemporary state of affairs for public health and crime.

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