Discrimination and public health
Authors: Martin Gulliford
Journal: The Lancet Public Health (2019)

The public health community has been slow to acknowledge the central role of discrimination in health inequality.1Krieger N Discrimination and health inequities.Int J Health Services. 2014; 44: 643-710Crossref PubMed Scopus (349) Google Scholar Discrimination has been defined as a set of “policies, practices, and behaviours that perpetuate inequities between socially-defined groups”.1Krieger N Discrimination and health inequities.Int J Health Services. 2014; 44: 643-710Crossref PubMed Scopus (349) Google Scholar, 2Scheim AI Bauer GR The Intersectional Discrimination Index: development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis.Soc Sci Med. 2019; (published online Jan 21.)DOI:10.1016/j.socscimed.2018.12.016Crossref Scopus (75) Google Scholar This definition identifies discrimination as a mechanism through which social stratification and its consequences are established and maintained. Discrimination is most apparent at the level of individual social interactions, but also operates at the institutional level (eg, by affecting access to employment and health care) and at the structural level, whereby societal norms can systemically disadvantage certain groups.3Krieger N Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination.Int J Health Services. 1999; 29: 295-352Crossref PubMed Scopus (730) Google Scholar For example, substantial empirical evidence shows that health inequalities affecting African Americans are to a large extent accounted for by systematic societal disadvantage among this group.4Bailey ZD Krieger N Agénor M et al.Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Summary Full Text Full Text PDF PubMed Scopus (1862) Google Scholar, 5Smith GD Learning to live with complexity: ethnicity, socioeconomic position, and health in Britain and the United States.Am J Public Health. 2000; 90: 1694-1698Crossref PubMed Scopus (163) Google Scholar In this issue of The Lancet Public Health, Sarah Jackson and colleagues6Jackson SE Hackett RA Steptoe A Associations between age discrimination and impaired health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing.Lancet Public Health. 2019; 4: e200-e208Summary Full Text Full Text PDF Scopus (58) Google Scholar report analyses of age-related discrimination among adults participating in the English Longitudinal Study of Ageing (ELSA). The population comprised 7731 participants with a mean age of 67 years in 2010–11. Respondents were asked a series of structured questions about their experiences of discrimination. Overall, 1943 (25·1%) participants reported experiences of discrimination. Perceived discrimination was more frequent in the lowest wealth quintile than in the highest (28% vs 20%). Even after adjustment for differences in age, sex, and wealth, experiences of discrimination were more frequent in people with limiting long-standing mental or physical illness than in those without these conditions, and in people who self-rated their health as fair or poor than in those with better self-rated health. During 6 years of follow-up, people who reported experiences of discrimination had increased odds of reporting new onset coronary heart disease, stroke, chronic lung disease, depressive symptoms, and limiting long-term illness, and of reporting fair or poor self-rated health. The number of discriminatory experiences showed a graded association with health status in both cross-sectional and longitudinal analyses. These results are important because they draw attention to the high frequency of perceived discrimination that older adults experience. Although the inter-relationships between age, socioeconomic status, health status, and experienced discrimination are complex, these results support the findings of other studies suggesting that discrimination not only causes short-term psychological distress, but also could have an important effect on long-term mental and physical health outcomes.7Williams DR Mohammed SA Racism and health I: pathways and scientific evidence.Am Behav Sci. 2013; 57: 1152-1173Crossref Scopus (664) Google Scholar In high-income countries, older adults represent the most rapidly expanding sector of the population.8Hazra NC Gulliford M Evolution of the “fourth stage” of epidemiologic transition in people aged 80 years and over: population-based cohort study using electronic health records.Population Health Metrics. 2017; 15: 10PubMed Google Scholar The mean age of 67 years for respondents in the ELSA study does not now represent an advanced age. Jackson and colleagues' results raise concerns about whether experiences of discrimination could be even more frequent in patients in their seventies, eighties, or nineties. Their results are also important in showing how discrimination can be directed at several aspects of an individual's identity. Discrimination on the grounds of age could be reinforced by discrimination based on female gender, lower socioeconomic status, lack of participation in employment, declining physical function, disability, and cognitive impairment. Bauer and Scheim9Bauer GR Scheim AI Methods for analytic intercategorical intersectionality in quantitative research: discrimination as a mediator of health inequalities.Soc Sci Med. 2019; (published online Jan 21.)DOI:10.1016/j.socscimed.2018.12.015Crossref Scopus (108) Google Scholar advocate the concept of intersectionality in health, which encourages researchers to avoid focusing on a single aspect of discrimination but rather to assess the experiences of groups facing multiple intersecting forms of discrimination. The extent and multifaceted nature of age-related discrimination should be investigated further. In view of demographic changes and the growing size of the elderly population, there is also a need to change public perceptions so that older people are not characterised by vulnerability but by the important contributions that they can make as citizens. Jackson and colleagues' results also challenge assumptions about how health systems should respond to older adults. Are existing arrangements institutionally ageist? One item in Jackson and colleagues' survey concerned people's experiences of receiving “poorer service or treatment than other people from doctors or hospitals”.6Jackson SE Hackett RA Steptoe A Associations between age discrimination and impaired health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing.Lancet Public Health. 2019; 4: e200-e208Summary Full Text Full Text PDF Scopus (58) Google Scholar This item raises questions about how health care should be adapted for older people. The evidence base for intervention is generally weaker for older people than for younger people, because they are infrequently included in clinical trials. Hazra and colleagues10Hazra NC Gulliford MC Rudisill C “Fair innings” in the face of ageing and demographic change.Health Econ Policy Law. 2018; 13: 209-217Crossref PubMed Scopus (9) Google Scholar expressed concern that the so-called fair-innings argument raised the possibility of reduced entitlement to health care once a “normal” lifespan was achieved. But how should the equity–efficiency trade-off be adjusted to accommodate the care of people at advanced ages? Should the founding principles of the UK's National Health Service extend to addressing the social care needs of people with dementia? The structural context for discrimination could be changing over time. Globalisation and secularisation might have made traditional forms of discrimination less salient. But the emergence of the information economy and the development of digital channels of communication could have introduced new potential for discrimination against groups who are not digitally native.11Chartered Institute of TaxationDigital exclusion. Chartered Institute of Taxation, London2012Google Scholar The observations reported by Jackson and colleagues6Jackson SE Hackett RA Steptoe A Associations between age discrimination and impaired health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing.Lancet Public Health. 2019; 4: e200-e208Summary Full Text Full Text PDF Scopus (58) Google Scholar raise a rich set of questions that merit investigation by social and behavioural scientists. Future research should aim to identify actions that can reduce problems from age-related discrimination at all levels. I declare no competing interests. Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of AgeingAmong older adults living in England, perceived age discrimination was associated with increased odds of poor self-rated health and risk of incident serious health problems over a 6-year period. These findings underscore the need for effective interventions at the population level to combat age stigma and discrimination. Full-Text PDF Open Access