Fighting an Uphill Battle: Determinants of Inequalities in the Health of a Young Alcoholic
by David Plotkin


Alcoholism has been examined in the academic realm as both a psychological impediment and mental illness. This paper sheds light on an infrequently investigated, but equally important, method of analysis – social determinants of alcoholic health inequalities. The theoretical bases used to examine this case study are two-fold in character, based upon Mel Bartley’s (2004) “Material” and “Life Course” sociological approaches. The “Material Approach” highlights how childhood income deficiencies lead to adulthood health inequalities, a contributing factor to perpetual alcohol addiction. Without an adequate education, vertical mobility becomes unattainable. The vicious cycle of poverty and addiction ensue. The “Life Course Approach” highlights how lack of affective and instrumental social support growing up perpetuates a weakened sense of self, where stress levels skyrocket and overall health plummets. It is determined that the best implemented governmental position is that of “high risk,” which would provide the individualistic and personalized care required. The conclusions reached in this paper provoke a call for debate on governmental intervention on behalf of the alcoholic. For him, the “will to succeed” must be supplemented by “the means by which to do so.”

Jack, aged 22, is a chronic alcoholic and perpetual client of Project Pride, the drug and alcohol recovery and prevention center that offers free-of-charge support to individuals and families touched by addiction, at which I volunteer on a weekly basis. Every Thursday, Jack comes in looking as ragged as ever just in time for his noon-hour AA session. Jack has followed this routine to the tee ever since I began volunteering a couple of months ago and is sure to continue doing so for years to come. How can I be so certain of this? Jack never had a chance. In the following paper, I will outline the social characteristics of Jack’s upbringing and current context that are clear determinants of his chronic alcoholism. The argumentation will be introduced within the context of Bartley’s (2004) sociological approaches to social inequalities in health, namely the Material and Life Course approaches (with emphasis on Psycho-Social hypotheses). I will then conclude as to why these determinants are unlikely to dissipate in the near future, thus promoting his perpetual failed alcoholic lifestyle.

Material Approach: Money isn’t everything, but it can help!             

Beginning at conception, Jack was already fighting an uphill battle. His mother, a crack-cocaine addict, was impregnated by one of the many sexual partners in her life at the time – which one, however, she was unsure. In and out of rehab, his mother never took good physical care of herself and little Jack was eventually born with a minor case of fetal alcohol syndrome. She never held a job long enough to prosper and Jack’s early years were spent jumping from subsidized housing to trailer parks, with a few stops on the street in between. According to Bartley (2004)’s Material Approach, “individual income determines diet, housing quality, polluted environment (and) dangerous work” (p.16). Their material lifestyle was horrific. Since Jack’s mother never had a steady income and the biological father was non-existent, all of the above-mentioned factors came under fire. Jack never finished high school. By grade 9, he was a perpetual truant, spending his days on the streets with the other delinquents, dabbling in street drugs and alcohol. At age 16, Jack secured a “job” cleaning out the filthy remains of foreclosed factories. According to Engels’ (1854) Conditions of the Working Class, Jack fell into the realm of employment stagnation. Vertical mobility in this sector of the workforce is non-existent. Constantly working in dirty, unpleasant environments without heating in the winter and adequate ventilation in the summer, it was no surprise when Jack was hospitalized for three weeks with chronic bronchitis, a condition that still ails him to this day. His stay should have been longer, but Jack had no health insurance and his Seattle-area hospital was no longer willing to care for him. Once out of the hospital, his employer had already replaced him and Jack was forced to jump from job to job, earning less than minimum wage, under the table. It is interesting to note that Jack’s work life were becoming eerily similar to his mother’s, perhaps explained by Angel & Lein (2006), when they discuss how material conditions affect intergenerational mobility.

As well, Jack’s lack of education led to a shortage of achievable employment opportunities for him, which contributed to his alcoholic tendencies. This correlates with Virchow’s 1848 Report on the Typhus Epidemic in Upper Silesia, which emphasized that populations must be educated, so as to become upper class and attain services meant for all members of society, not just those with a transient health advantage. Tilly (2003), would also state that the inequalities present in Jack’s upbringing are a direct result of his lack of education. Education, after all, is the sorting mechanism that society uses to efficiently, albeit inequitably, distribute status and prestige, as well as the allocation of material resources. Jack barely had half a high school education, placing him on the lowest tier of any of the prestige-oriented scales.

The constant lack of stability in Jack’s life also triggered substantial psychological ailments, to be discussed in the following section, which in turn, led to even greater financial burdens. Arrested on multiple occasions for possession of illicit drugs and public drunkenness, Jack eventually found himself before a judge, released on $10,000 bail – his life savings, while awaiting a trial, adding to his vicious cycle of poverty and ensuing addiction.

All of the previous points are intuitively plausible, but considerable research has also been conducted to substantiate this intuitive causal relationship between low SES and alcohol addiction. The WHO’s International Centre for Health and Society published a document in 2003 entitled Determinants of Health: The Solid Facts, which discussed this exact issue. Alcoholic addiction “is both a response to social breakdown and an important factor in worsening the resulting inequalities in health […] and are closely associated with markers of social and economic disadvantage” (Wilkinson & Marmot 2003:24). Similar to Engels’ (1854) and Angel & Liens’ (2006) assertions regarding the vicious cycle of deteriorated social conditions, this report concludes that “alcohol dependence leads to downward social mobility” (p.24). As for material SES, Pittman & Snyder (1962) concluded, based on their own research, that “middle class individuals tend to be underrepresented in the alcoholic population” (p.237), contrary to the staggering number of lower class individuals, while “urban adults have been found more likely than rural adults to drink and drink compulsively” (p.238). Jack is both lower class and urban-dwelling – when he has a dwelling to live in – that is. Research in this area is continuously pursued, but the results are overwhelmingly strong in their support of the direct correlation between material deficiency and drug and alcohol addiction.

Life Course Approach: What’s my Plan B?

“Life course epidemiology is the study of long-term biological, behavioural, and psychosocial processes that link adult health and disease risk to physical or social exposures acting during gestation, childhood, adolescence, earlier in adult life, or across generations” (Kuh & Ben Shlomo 2004:3). For the purposes of this paper, let us examine the social exposures Jack came into contact with during his adolescence, the crux of his alcoholism, with emphasis placed on his psycho-social processes.

Age is a key characteristic of addiction. Biddle et al. (1980) conclude from their research on adolescent drinking patterns, that parents “affect adolescents through normative standards (and) peers through modeling behavior” (p.235). Growing up, Jack had very little affective or instrumental support. His mother was too busy being drunk and stoned to help her son through any of the psychological rigors of adolescence. As well, she never achieved the means necessary to provide him with anything from chicken soup when he had the flu to the minimum educational opportunities that should have been provided. His peers, the truant children he spent his days with, were lost causes just like him and simply reinforced the perverted norms he had been internalizing since birth. Jack had no “Plan B.” When all else failed, who was there to turn to? Without role models, adolescents turn to other instruments of cultural learning, most notably, television. Whenever the opportunity presented itself, Jack would spend hours glued to the TV.

“In order to influence teenagers to drink, the media portrays drinking as a form of camaraderie” (Marshall 2001: 50), something which this teen was greatly lacking. As well, Engels et al. (2009) argue that “when people associate a specific cue or event to a specific behavioral pattern, this might become habitual and automatic behavior” (p.1), as drinking had become habitual and automatic for Jack. Had he been in school like the majority of kids his age, or had he had positive role models in his life to counter this “intoxication = fun” perception, perhaps his alcoholic tendencies could have been stymied.

Jack also found himself perpetually stuck in the “fight or flight” biological response to his life-long stressors. Lacking in social support and a steady job, his stress levels must have been off the charts. Always having to worry about how his next meal would be paid for, induced the “fight” responses of his body, causing blood pressure to rise systematically, without ever feeling the soothing effects of the “flight” response, in which one’s body slowly returns physiological functioning to normal levels, after discontinuation of the stressful situation. In response to this constant stress, Jack turned to the only available coping mechanism – alcohol, the drug that “offers a mirage of escape from adversity and stress, but only makes their problems worse” (Wilkinson & Marmot 2003:8).

Another element of Jack’s life that contributed to his inevitable alcoholism was the fact that his mother was the closest alcoholic in his life. “Research has shown that when father becomes an alcoholic it is different to when mother becomes an alcoholic. Father brings shame and disrepute in the family; women evoke sympathy and understanding” (Marshall 2001:60). To this day, however, Jack does not blame his mother for his troubled youth full of poverty and the unbearable stress of not knowing what tomorrow would bring. He blames “the system.”

Jack believes that the system has failed him in the sense that no one cares whether he’s sober or passed-out-drunk, working or unemployed, living or dead. He lacks a defined status. The neighborhood he grew up in taught him to distrust those who have the power to help him. Social capital was a non-existent entity in his upbringing. He lacks the understanding of such concepts as risks and rewards, as the only jobs he ever had were low-status and menial, while the only home life he had was filled with frustration and pain. 

The “Will to Succeed” Needs a Budget

To conclude, I wish to emphasize a few key points. Lack of a supportive family, the primary agent of socialization, cannot be stressed enough as contributing to Jack’s alcoholism. However, what is also an essential social fact is that “children of alcoholics are significantly more anxious and depressed than their counterparts from non-alcoholic families” (Marshall 2001:59). Even if, by some improbability, Jack had been able to break through the material obstacles to improve his overall health, he would not have been capable of conquering the psychological traumas hammered into him by his alcohol-centric childhood. The underlying mechanism eternally holding him back is his low SES. He has no income to pay for counseling. He has no social support networks to fall back on in his times of withdrawal. All he has are his alcoholic buddies to be there for him, beer in hand, when he comes crashing down.

From a policy perspective, Jack needs a high-risk approach to be adopted by his government. This approach allocates funding and resources to those individuals most likely to become victims of alcoholism, as established by certain criteria (as opposed to the population-approach, which targets the common catalysts towards alcoholism, that all members of society might face, such as workplace depression). Coming from a background of family alcoholism, Jack would fall under the “high-risk” category. By adopting this perspective, governments could ensure that Jack gets the specific care he needs, as opposed to simply attending general AA meetings, geared towards anyone and everyone. He needs to be cleaned up, free of charge, and integrated back into normal society with the financial and psychological support which are essential to keeping his stress levels down. He needs to be placed in affordable subsidized housing with medical and psychiatric check-ups on a regular basis. He needs a whole lot of support – support which the current governmental policies are not providing. Jack still lives with his ailing mother, slowly dying from liver disease and dementia. While there is no one stepping up to take care of him, as an alcoholic, he is the one stepping up to care for his mother, who should be in a palliative care facility. All the while, Jack tries as much as possibly to attend these weekly AA meetings, hoping that they might spark some possibility of overcoming his lifelong addiction. Jack undoubtedly has the will, but sorely lacks the adequate means to succeed.

It is clear that Jack’s circumstances are based on social determinants, many of which have been discussed in this paper, and not, for example, genetics. Perhaps biology has played a part in shaping his mind into acting and behaving in a certain fashion. But, given support networks and the economic means to combat those tendencies, Jack could most certainly put up a good fight. I believe that Jack is stuck in Engels’ “vicious cycle.” Poverty leads to stress, which he copes with via alcohol. He is then forced to clean up his life, when he hits rock-bottom. After his little money is spent on detoxing and psychological counseling, Jack falls back into the same cycle of poverty and stress, culminating with the soothing effects of alcohol on his system.



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