Commentary by Robert Perlman on a BBS article by Pepper and Nettle
Socioeconomic disparities in health are persistent, complex, and seemingly intractable problems. Disparities in access to health care play a role but can’t be a major cause of health disparities, since there are prominent disparities in the United Kingdom and other countries with national health services, where the barriers to accessing health care are much lower than in the United States. One of the facile explanations offered by people who wish to deny or minimize the social determinants of disease is to blame the victims. Indeed, poor, marginalized, or disadvantaged people are more likely to engage in unhealthy behaviors—they are more likely to smoke, to use illicit drugs, and to engage in unsafe sex, and they have poorer diets and exercise less than do more privileged people. Last year, Gillian Pepper and Daniel Nettle published a Target Article in Behavioral and Brain Sciences, “The behavioural constellation of deprivation: causes and consequences” (paywall), that turns this “blame the victim” explanation on its head. Peer commentaries and the authors’ responses have recently been posted on the journal’s Web site (paywall). Pepper and Nettle have made a strong argument that socioeconomic disadvantage promotes a cluster of behaviors, which they refer to as “the behavioral constellation of deprivation,” that include savings and financial decisions, and reproductive and childrearing decisions, as well as the unhealthy behaviors mentioned above. All of these behaviors entail tradeoffs between present benefits and future costs. Disadvantaged people discount the costs or benefits of future events, and so are less future-oriented than are more privileged people. Pepper and Nettle argue—again, convincingly—that this temporal discounting by disadvantaged people is a response to the reality that they live in dangerous or unpredictable environments and have less control over their future, and so have a lesser likelihood of securing deferred rewards than do more privileged people. In their view, the behavioral constellation of deprivation represents a “contextually appropriate” (I would say understandable) response to the ecology of poverty and disadvantage.
Pepper and Nettle use extrinsic or uncontrollable mortality risk to illustrate their argument. Extrinsic mortality is clear cut, relatively easy to measure, and definitive—death precludes the possibility of gaining future rewards. Extrinsic mortality is one measure of the dangerousness or uncertainty of the environment and is an important factor in evolutionary life history theory. Populations that suffer high levels of extrinsic mortality evolve fast life courses, in which they discount the value of their long-term survival and fertility, and so devote energy to early growth and reproduction at the expense of bodily maintenance. Moreover, animals have evolved a developmental plasticity that enables us to adjust our life courses in response to the quality of our environment; again, animals that develop in dangerous or unpredictable environment exhibit earlier sexual maturity and reproduction. The behavioral time preferences that Pepper and Nettle discuss develop in concert with the physiological time preferences that have been addressed by life history theory. Since we would expect behavioral predilections and energy allocations to go hand in hand, however, their reference to behavioral and physiological discounting as “a double disinvestment in future health” sounds like an unfortunate relic of Cartesian dualism.
If the behavioral constellation of deprivation were only a short-term response to deprivation, it would be damaging enough. But Pepper and Nettle go on to show how these behaviors become embedded during development, such that small initial differences produce larger disparities later in life, and they discuss feedback mechanisms that result in the intergenerational transmission of these behaviors. The idea that deprivation can lead to the intergenerational transmission of poor health and shorter life expectancies is one of the most important—and disturbing—implications of their work. It may take several generations to undo the consequences of poverty. On the other hand, their analysis suggests that creating environments in which disadvantaged people are safer and more secure will improve health even in the face of socioeconomic disparities.
There is more that I wish Pepper and Nettle had done. For example, women suffer much lower rates of death by homicide than do men, and socioeconomic gradients in health are shallower for women than for men. Do women and girls show different degrees of temporal discounting than do men and boys? And I wish they had cited Aristotle, who was the first person to distinguish between extrinsic and intrinsic causes of death. But these are quibbles. What Pepper and Nettle have demonstrated is that, instead of blaming disadvantaged or marginalized people for their unhealthy behaviors and their poor health, we should recognize that we, privileged people who have more control over our lives, our futures, and our communities, have constructed a niche in which disadvantaged people are predisposed to short, unhealthy, and, all too often, unfulfilling lives. If we care about socioeconomic disparities in health, we have to acknowledge our responsibility in creating an environment that maintains these disparities and seek ways to ameliorate these problems. And that is plenty for one article!