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Social Pathways
to Health
Vulnerability
Implications for Health
Professionals
Dula F. Pacquiao
Marilyn “Marty” Douglas
Editors
123
Social Pathways to Health Vulnerability
Dula F. Pacquiao
Marilyn "Marty" Douglas
Editors
Social Pathways to
Health Vulnerability
Implications for Health Professionals
Editors
Dula F. Pacquiao Marilyn "Marty" Douglas
Schools of Nursing School of Nursing
University of Hawaii, Hilo, HI University of California San Francisco
Rutgers University San Francisco, CA
Newark, NJ USA
USA
ISBN 978-3-319-93325-2 ISBN 978-3-319-93326-9 (eBook)

https://doi.org/10.1007/978-3-319-93326-9
Library of Congress Control Number: 2018957083
© Springer International Publishing AG, part of Springer Nature 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Expensive health care is not unique to the USA; costs are rising around the
world as technological advances and an aging population have driven up the
price for everyone. But nowhere are costs rising as fast as in the USA where,
in 2016, health care consumed 18% of our national GDP, $3.3 trillion. That is
$10,348 of health care spending in a single year for every woman, man, and
child in the USA. Our medical industry is approximately the size of Brazil’s
economy, the seventh largest in the world.
Given the amount of money that the USA sinks into health care, one would
imagine that we would be the healthiest nation on earth. However, this is far
from true; in terms of health, the USA compares poorly to other developed
countries. A 2013 Organization for Economic Cooperation and Development
(OECD) study found that across 13 high-income countries, Americans had
worse outcomes than their peers. Of the countries studied, the USA had the
lowest life expectancy at birth (78.8 years compared to an OECD median of
81.2), the highest infant mortality rate (at 6.1 deaths per 1,000 live births in
comparison to an OECD median of 3.5). The prevalence of chronic disease
was higher in the USA: 68% of Americans age 65 or older had at least two
chronic conditions (in comparison to 33% in the UK and 56% in Canada).
And, more than 1/3 of Americans were obese in 2012: this was about 15%
higher than the next-highest country.
There are other reasons why our health care is more expensive: adminis-
trative costs, costs of drugs in the USA, waste, medical error, the practice of
defensive medicine (i.e., when a provider recommends testing or treatment
that may or may not be the best option for the patient, but protects the pro-
vider against potential legal action), and overspecialization of the provider
workforce. However, perhaps the biggest reason is the fact that as a nation we
predominantly invest in downstream factors—care for the individual once
they have experienced alterations in physiological and biological functioning.
While focusing primarily on acute care and disease-based care, we have
ignored the fact that wellness and prevention of disease occurs at the upstream
(policies and the determinants of health—environmental, social, economic)
and midstream levels—psychosocial factors, health-related behaviors, and
the role played by the healthcare system.1 To improve population health and
1
Bharmal, N., Derose, K.P., Felician, M., & Weden, M.M. Understanding the Upstream
Social Determinants of Health. Rand Health. May, 2015. https://www.rand.org/content/
dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf.
v
vi Foreword
prevent vulnerable populations from experiencing serious illness, we must

invest substantially more in understanding and overcoming social determi-
nants of health and the challenges vulnerable populations face.
We cannot improve population health outcomes or control the rising cost
of health care until we address these determinants of health—the conditions
in which people are born, grow, live, work, and age. The World Health
Organization reminds us that “these circumstances are shaped by the distribu-
tion of money, power and resources at global, national and local levels and
that these social determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health status seen within
and between [neighborhoods, populations, and] countries.”2 Social disadvan-
tage, risk exposure, and social inequities are a central causal role in poor
health outcomes and thus represent important opportunities for improving
health and reducing health disparities.
The OECD study mentioned previously found that the USA—possibly as
a result of high health spending—crowds out other forms of social spending,
spends substantially less on social services than peer countries. According to
OECD, “A growing body of evidence suggests that social services aimed at
social determinants play an important role in shaping health trajectories and
mitigating health disparities.” Redressing this imbalance is a needed step
toward a population health approach.
Population health moves us from “reactive responses to an individual’s
health needs towards outcomes-based proactive approaches to a given popu-
lation with attention directed toward larger, socially grouped needs and pre-
vention efforts while reducing disparity and variation in care delivery.”3
Population health broadens the traditional medical delivery system by encom-
passing the wide range of factors that affect health that are not yet integrated
into our healthcare delivery model. These activities include not only preven-
tion, health education, and wellness but also care coordination, in-patient and
out-patient health risk assessment, patient engagement, greater use of pri-
mary care, and patient-centered care. But it also recognizes the role of the
healthcare provider as advocate in determining public policy that addresses
factors that affect health and access to health whether it is the cost of drugs,
advocating for policies that reduce administration or defensive medicine,
supporting patient access to information to make well-informed health-
related decisions, ensuring access to education and community safety, and
improving air and water quality and healthy housing.
This book provides a comprehensive look at the social determinants—
what they are, how they manifest, how they should be measured and studied,
and how they can be addressed to achieve equity. It highlights the link
between health and social disadvantage in which neighborhood conditions,
working conditions, education, income and wealth, and race/ethnicity and
racism all create stress, which is a causal factor of disease as brought to light
2
WHO. About Social Determinants of Health. http://www.who.int/social_determinants/
sdh_definition/en/.
3
Milken Institute School of Public Health, George Washington University. What Is
Population Health? April 27, 2015. https://mha.gwu.edu/what-is-population-health/.
Foreword vii
through the growing understanding of epigenetics. It provides an understand-

ing of the link between health and social inequities stemming from sociode-
mographic factors, such as class and immigration status, gender, and sexual
orientation. They remind the practitioner of the need for data to understand
health outcomes and disparity and provide approaches for monitoring and
measuring social determinants and programs addressing social determinants.
And significantly, they present broad frameworks of action for addressing
social determinants and disparities and in integrating these approaches into
clinical practice, education, research, and administration.
I applaud Drs. Pacquiao and Douglas’s approach of reinforcing the multi-
ple pathways to health vulnerability. My hope is that this book is more than a
reservoir of knowledge but a call to action. Achieving a culture of health and
overcoming health disparities requires our professional role to go beyond
direct patient care. We must actively support or participate in evaluation and
impact research that highlights the evidence base for interventions and mod-
els of care that address social determinants and ultimately improve health
outcomes and reduce healthcare costs. We must actively participate in policy
development to reimagine health care and improve health and in changing
broad socioeconomic public policies that make a difference for underserved
and vulnerable communities. We must be advocates so that social determi-
nants of health are reflected within national standards and within education
curricula. And we must be leaders in ensuring that in our approach to care we
engage our organizations, ourselves, and others to ensure the needed partner-
ing between health care, social services, private industry, nongovernmental
organizations, and civil society.
Susan W. Salmond, EdD, RN, ANEF, FAAN

School of Nursing
Rutgers, The State University
of New Jersey
Newark, NJ, USA
Preface
This book is intended for students, faculty, and professionals interested in

health and health promotion for communities and populations. This book
uses specific social determinants of health as its organizing framework. This
approach is in contrast to many books that are organized around different
vulnerable population groups and their specific illnesses (e.g., diabetes, HIV).
It promotes an in-depth understanding of the social and environmental repro-
duction of cumulative disadvantages that create poor health in vulnerable
populations. This presentation helps ground readers in the universal processes
contributing to population health inequities and shifts the focus to population
health promotion that goes beyond individual-level and disease-centered
interventions. This approach is critical to broadening the perspectives of
health by professionals whose practice is mostly limited to individual encoun-
ters with sick individuals within organizations.
The content is organized using specific social determinants of health and
their influence in creating health vulnerability in populations. By using this
approach, the authors attempt to explicate the root causes of poor health and
the mechanisms by which they produce differential health statuses across
population groups. Corrective remedies addressing health inequities must be
grounded in reducing or preventing the social structural factors and processes
contributing to poor health. By focusing on the social and environmental
explanations of the different patterns of disease distribution, readers are able
to direct their attention toward macrosocial, structural, and upstream forces
that have greater health impact. Addressing social determinants of health has
greater impact on population health compared to individual-level approaches
that are focused on disease conditions using the biomedical paradigm.
The book is informed by constructs, theories, and research from different
disciplines including the social sciences, environmental sciences, public
health, medicine, ethics, and nursing. Chapter authors have a multidisci-
plinary background with doctoral preparation and experience in population
health promotion. The book is organized in four units: (a) social, economic
and political determinants of health, (b) natural and built environmental fac-
tors influencing health, (c) methodological considerations in examining
health determinants, and (d) approaches to address social and environmental
determinants of health. We aim to provide a comprehensive single reference
for students, faculty, and practitioners in health. Each chapter presents
cutting-edge theories, research, and strategies drawn from the different disci-
plines. Each chapter is supplemented by selected seminal research pertinent
ix
x Preface
to the health determinants being presented. A list of additional resources is

provided in relevant chapters to obtain further information on the topic.
Reflective questions are designed to provoke readers to engage in further
examination of the critical issues presented.
The challenge of population health promotion is that it requires broad-
based social and political advocacy in order to achieve sustainable long-term
changes, particularly for the most vulnerable. The ethical principles of social
justice, human rights, and empowerment are integrated in each chapter to
sensitize readers toward actions that might achieve meaningful changes in
people’s lives, particularly for the disadvantaged and vulnerable.
Health promotion requires multisectoral and interdisciplinary collabora-
tion with active participation by the people and communities. The book’s
content is purposely enriched by the breadth of knowledge, research, and
experience from the various disciplines. This is critical as population health
necessitates broad-based efforts beyond a single discipline or specialty. It
requires a global perspective of problems that transcend individual-level con-
text because of their connections with societal, governmental, economic,
political, and institutional structures. A more global approach to the discus-
sion is used to expand the understanding of similar and diverse perspectives
as well as interventions to universal problems such as social inequalities, dis-
crimination, poverty, inadequate resources, and marginal environments.
We are deeply indebted to the contribution of our colleagues at Rutgers
University School of Nursing, especially the graduates of the PhD program in
urban systems, whose collaborative work with the editors have strengthened
the content and application of this book. We value their individual and collec-
tive expertise in making this project a reality. Together, we have gained a
greater understanding of health determinants—a must for all healthcare pro-
fessionals, academicians, researchers, and students. We hope to share our
journey toward a broader and deeper enlightenment of the social determi-
nants of population health with other health professionals, and we wish to
engage them in strategizing solutions to address the challenges of population
health promotion.
Newark, NJ; Hilo, HI Dula F. Pacquiao

San Francisco, CA Marilyn "Marty" Douglas
Contents
Part I Social, Economic and Political Determinants of Health
1 “Place” and Health�� 3

Dula F. Pacquiao
2 Poverty, Discrimination, and Health�� 23
Sharese N. Porter
3 Politics, Economics, and Health�� 55
Dula F. Pacquiao
4 Disempowerment and Migrant Populations�� 73
Rubab I. Qureshi
Part II Natural and Built Environmental Determinants of Health
5 The Built World and Health�� 107

Phoebe Del Boccio
6 Epigenetics: The Process of Inheriting Health Disparities�� 143
Yuri T. Jadotte
Part III Methodological Considerations in the

Examination of Health Determinants
7 Social Epidemiology�� 159

Peijia Zha
8 Program Evaluation�� 181
Peijia Zha
Part IV Approaches to Address Social and Environmental

Determinants of Health
9 Building Community Social Capital�� 207

Ellen S. Lieberman
10 Practices to Address the Social Determinants of Health�� 237
Dula F. Pacquiao and Marilyn "Marty" Douglas
Index�� 247
xi
Editors and Contributors
Editors
Dula F. Pacquiao, EdD, RN, CTN-A, TNS School of Nursing, University

of Hawaii at Hilo, Hilo, HI, USA
School of Nursing, Rutgers University, Newark, NJ, USA
Marilyn "Marty" Douglas, PhD, RN, FAAN School of Nursing, University
of California, San Francisco, San Francisco, CA, USA
Contributors
Phoebe Del Boccio, MS, PhD Robert Wood Johnson Barnabas Health,
Multiple Sclerosis Center, Livingston, NJ, USA
Marilyn "Marty" Douglas, PhD, RN, FAAN School of Nursing, University
of California, San Francisco, San Francisco, CA, USA
Yuri T. Jadotte, MD, MPH, PhD School of Nursing, Rutgers University,
Newark, NJ, USA
School of Public Health, Rutgers University, Newark, NJ, USA
Northeast Institute for Evidence Synthesis and Translation, Rutgers
University, Newark, NJ, USA
School of Medicine, Stony Brook University, Stony Brook, NY, USA
Ellen S. Lieberman, MA, MS, PhD Douglass Residential College, Rutgers
University, New Brunswick, NJ, USA
Dula F. Pacquiao, EdD, RN, CTN-A, TNS School of Nursing, University
of Hawaii at Hilo, Hilo, HI, USA
School of Nursing, Rutgers University, Newark, NJ, USA
Sharese N. Porter, MPH, PhD, CHES Department of Family and
Community Health Sciences, Rutgers University, Cooperative Extension,
New Brunswick, NJ, USA
xiii
xiv Editors and Contributors
Rubab I. Qureshi, MBBS, MD, PhD Division of Nursing Science, School

of Nursing, Rutgers University, Newark, NJ, USA
Peijia Zha, MA, PhD Division of Nursing Science, School of Nursing,
Rutgers University, Newark, NJ, USA
Part I
Social, Economic and Political
Determinants of Health
“Place” and Health
1
Dula F. Pacquiao
Pierre Bourdieu’s theory of practice identified the nature and highly unconscious predispositions.
relationship between social structure and human The secondary habitus is built on the primary
behaviors in reproducing social class distinctions habitus and results from one’s education and life
in society through the interplay of three elements: experiences. The primary habitus and secondary
field, capital, and habitus in shaping unconscious habitus can be combined into one single dynamic
human behaviors [1]. The interplay of these ele- habitus that is constantly reinforced and modified
ments leads to strategies or practices that aim to by life experiences [3]. The internalization of
achieve greater capital. Human interactions are field-specific rules enables the agent to anticipate
best understood in their respective social space future tendencies/predispositions and opportuni-
(fields), a network of social positions that have ties. Conflicts between agents are principally
been based on historically generated systems of about relative positions within the field to maxi-
shared meaning. Habitus is one’s agency to think mize capital; hence, individual strategies in con-
and behave based on one’s position (doxa) in the formity with the rules of the interactions are
social field, which depends on one’s economic, critical. It is the structure of objective relations
cultural, and social capital. Rules are not formal- between the agents in a field that defines domi-
ized, but rather are tacit in nature and internalized nant and dominated positions and determines
by the agents in order to demonstrate appropriate what agents can do or which practices are possi-
practices and strategies in the social field [2]. ble. This doxa forms one’s sense of place and the
The habitus is acquired during primary (comes feeling of what is possible within a social field
from family during childhood) and secondary [3].
socialization. The resulting primary habitus or Positions in the respective fields are gained
class habitus is rather stable and results from through capital. Economic capital is related to a
internalizing the parents’ modes of thinking, feel- person’s fortune and revenues that can be mone-
ing, and behaving derived from their social posi- tized and institutionalized in property rights; this
tion in the social space. The primary habitus is form of capital can be more easily transformed
the embodiment of history, internalized as second into other types of capital. Cultural capital, as the
primary cause for status and relative positions
within a social field, is transferred by family and
D. F. Pacquiao education and may be institutionalized in the
School of Nursing, University of Hawaii at Hilo, forms of educational qualifications. Incorporated
Hilo, HI, USA
or embodied cultural capital can be a durable sys-
School of Nursing, Rutgers University, tem of dispositions and intellectual qualifications
Newark, NJ, USA
© Springer International Publishing AG, part of Springer Nature 2019 3

D. F. Pacquiao, M. K. Douglas (eds.), Social Pathways to Health Vulnerability,
https://doi.org/10.1007/978-3-319-93326-9_1
4 D. F. Pacquiao
or human capital that is achieved by the individ- sists of discourses and cultural values that encour-
ual himself. Objectivized cultural capital exists age structures of exploitation and hegemony
in the form of material objects that are transfer- through policies and economic systems. Class
able in their physical state. Institutionalized cul- oppression goes beyond economic structures; to
tural capital takes the form of a certificate of maintain its hegemony, it requires the support of
cultural competence through a formalized aca- noneconomic institutions and culture, such as the
demic qualification that is socially sanctioned by family, legal/judicial system, government, reli-
an institution [4]. gious institutions, businesses, community organi-
Social capital represents a person’s entirety zations, schools, and mental health systems that
of social relations—one’s network of actual or are all organized in ways that maintain and repro-
potential resources that can be legitimized by the duce social class differences. Meritocracy, the
family, group, or class membership—and allows cornerstone of capitalist ethics, is propagated in
access to material and non-material resources, these institutions, emphasizing that some indi-
information, and knowledge [4]. Social capital viduals and groups are more important, smarter,
can be institutionalized, such as an administra- working harder, and more deserving than others.
tive title, and requires efforts for its creation and Conversely, the working class and poor are
maintenance. Symbolic capital is related to judged less intelligent, less capable, lazy, and less
honor and recognition that is not an independent deserving than those who earned their way.
type of capital, but an acknowledgment of capi- Therefore, these groups deserve their low eco-
tal by one’s peer competitors in a specific field. nomic position because of their personal short-
Thus, in a social field, economic, social, and cul- comings and irresponsible behaviors. Classist
tural capital is converted to symbolic capital that meritocratic discourses permit rationalization of
is worthy of being pursued and preserved. existing social disparities and class oppression as
Symbolic capital reflects the external and inter- part of the natural order [6].
nal recognition or the value accorded by the sys-
tem and its actors [5].
Sociology of “Place”
Classism Bourdieu’s theory is instructive in understanding

the concept of place, social class differences, and
According to Barone, “classism is the systematic differential access to societal power and
oppression of one group by another based on eco- resources. Sociologists such as Geiryn [7]
nomic distinctions based on one’s position within emphasized the significance of place as the locale
the system of production and distribution” ([6], where all social events happen and have three
p. 6). Classism differs from other kinds of social linked features: geographic location, material
oppression, such as racism and sexism, because forms, and socially constructed meanings. Places
its basis is in the economic system itself; it is are made through human and institutional prac-
rooted in the economic system of capitalism, tices to represent something of value that is
which is structured on the basis of classes. meaningfully interpreted, narrated, and under-
Capitalism is founded on three economic institu- stood. Place attachment involves emotional, sen-
tions: private ownership, hierarchical organiza- timental bonds between people and places that
tion of businesses, and the division of labor. are brought together in the material forms on the
Working interdependently, these three institu- geographic site and the meanings people invest in
tions produce a class-based system of domination them [7]. A sense of place is the ability to locate
and subordination. things on a cognitive map and the attribution of
Classism operates on multiple ecological meaning to a built form or natural spot. However,
levels, including cultural and political, indirect values and meanings are malleable and may be
systems, intergroup, and personal. Classism con- contested in another time.
1 “Place” and Health 5
Places ensconce structural patterns of social criminals. Criminals tend to live close to the
inequalities and differences through emplace- locations of their crimes, often on the same
ment or psychosocial processes, such as power, block or in the same neighborhood [11].
control and collective action, and the material Crimes in place tend to be more expressive
forms that are designed, built, and used. and violent, whereas crimes in space tend to be
Emplacement occurs when a group has estab- more instrumental and acquisition oriented.
lished a particular location as its own and erects Expressive crimes tend to be less planned, less
boundaries that reinforce its unique identity. concerned with risk of capture, aggressive in
Thus, places have the power or capacity to domi- nature, and target trespassers. Instrumental
nate and control people or things through geo- crimes tend to be more planned, in pursuit of
graphic location, built form, and symbolic material gain, and target either properties or
meanings [8]. strangers [12]. Lersch and Hart [13] noted that
Places reflect and reinforce the social hierar- expressive crimes are more emotional and likely
chy by extending or denying life chances to to be committed closer to the offender’s home,
groups located in salutary or detrimental spots. whereas instrumental crimes are committed out-
Residents of segregated urban neighborhoods side a buffer zone to lessen the chances of detec-
that have deteriorated physically, socially, and tion. Gang locales tend to have high violent crime
culturally because of exodus of middle-income rates as gang members try to maintain control
minorities and discriminatory real estate prac- over their turfs from outsiders and nonmember
tices face enormous difficulty in improving their residents [11]. Therefore, crime prevention
conditions [9]. Places can bring people together requires different strategies based on space-place
in engagement or estrangement through its built differences and the types of crimes that are likely
form. A highway or railroad can cut off contact to be committed within [14].
among the people, while safe, open public spaces
can foster interaction. Places can be objects of Place Attachment
collective action and can inhibit or promote broad Place attachment may be influenced by tenure of
participation of the people [10]. residence. Renters tend to have a more cosmo-
politan attitude toward the rented space, while
Place and Crime resident homeowners have stronger ties to the
Places are normative landscapes for human con- place. Place attachment facilitates a sense of
duct. Certain behaviors such as graffiti and security and well-being, defines group boundar-
openly gay behaviors are tolerated or accepted ies, and stabilizes memories [15]. Loss of place
in certain places. Informal and formal social has devastating implications for individual and
control is territorialized. The geographic loca- collective identity, memory, history, and psycho-
tion and architectural arrangement of spaces can logical well-being [16]. Such is the experience of
promote or retard crimes. Tita et al. [11] found the homeless, inmates coming out of prisons, and
that hard-core urban gangs have identifiable those discharged from mental institutions. One
physical spaces that are geographically defined can be displaced even without moving, such as
in which they impart meaning and identity and the loss, marginalization and isolation experi-
transform into places. Violent predatory gangs enced by Native Americans [17] and coal mining
are more likely to prosper in areas with weak- families in West Virginia [18].
ened social control and underclass features.
Neighborhoods with emplaced collective effi- lace, Slavery and Indigeneity
P
cacy characterized by mutual trust and willing- Several authors have pointed out the Eurocentric
ness to act against outsiders or potential bias of Marx’s treatise on capital by neglecting
offenders are more effective in preventing the contradictions inherent in the conceptualiza-
occurrence of crimes. Repeat crime addresses tion of capital-labor and capital-nature based on
are far more predictive of crime than repeat slavery and the destruction of indigeneity. Marx
6 D. F. Pacquiao
conceptualized capital as different from labor lace and Health Inequity

P
and inherently in conflict with each other (own- Places are where social inequalities are opera-
ing class vs. laborer). Slaves do not fall within tionalized and can determine the differential
the Marxist concept of labor as they had no exposure to social determinants of health by indi-
agency and were forced into free labor. In fact, viduals and groups. WHO [24] defines social
slaves were viewed as part of capital by slave determinants of health as the conditions in which
owners. By ignoring slavery, Marx also failed to people are born, grow, live, work, and age that are
recognize the racial basis of modern economy shaped by the distribution of money, power, and
and capitalism that divided the world based on resources at global, national, and local levels and
race and created the racialized economic infra- which are mostly responsible for health inequi-
structure and superstructure [19, 20] that estab- ties. Health inequities refer to the unfair and
lished the legacy of a marginalized, subordinated avoidable differences in health status seen within
place of these groups in society. Another contra- and between countries. Social determinants
diction is the forcible dispossession of indige- include the economic and social conditions that
nous populations from their natural territories. influence the health of individuals, communities,
Colonists were motivated by summarily destroy- and nations. These conditions determine the
ing the origin and identity of indigenes and tak- extent to which a person or group possesses the
ing over their prized territories to enhance physical, social, and personal resources to iden-
capital. According to Anaya, indigenous com- tify and achieve personal aspirations, satisfy
munities, peoples, and nations are “those that needs, and cope with the environment [25].
have a historical continuity with pre-invasion Scientists generally recognize five determi-
and pre-colonial societies that developed on nants of population health: (1) genes and biology
their territories and consider themselves distinct (sex and age), (2) health behaviors (e.g., smok-
from other sectors of the societies now prevail- ing, drug use), (3) social environment or social
ing on those territories, or parts of them” ([21], characteristics (discrimination, socioeconomic
pp. 2–3). status), (4) physical environment or total ecology,
The legacy of slavery and destruction of indi- and (5) health services or medical care [26]. The
geneity created long-term consequences through last three factors account for 75% of population
the process of thingification of the personhood of health and contribute to the social patterning of
the colonized that is beyond commodification health, disease, and illness as well as influence
and the pursuit of capital [22]. It was aimed individual behaviors. Experts have argued that
toward the annihilation and dehumanization of the degree of access to health-care services only
the colonized using racialized mechanisms of accounts for 10% of premature deaths. For exam-
discrimination and control through social coer- ple, the United States in 2005 had the highest per
cion, violence, and humiliation. These groups capita and total health expenditures but ranked
were subjected to the processes of dispossession, 36th among men and 42nd among women in life
extraction, and forced relocation depriving them expectancy at birth in the world [27]. Life expec-
of their personhood, which was built through the tancy did not reflect differential access to health-
continuity and mutuality between humans and care coverage.
nature (ancestral land). Loss of connection with Delivery of health services alone is ineffective
nature could not be expressed by any measure in promoting health equity because of the failure
nor substituted by any other value. This was the to address the social and environmental factors
central argument by the Native American Yavapai that determine poor health. People do not get sick
and the Andean people of Peru to the building of randomly but rather in relation to their living,
dams in their ancestral lands. The relationship working, environmental, social, and political
between humans and nature underlines indige- contexts, as well as due to biological and envi-
nous resistance that is beyond the logic of capital ronmental factors that are unevenly distributed in
[19, 23]. the population [28]. While health is affected by
much more than access to health care, health-care and creates a higher distribution of risk exposure
financing is a social determinant because it for them than for the rest of the population” ([31],
reflects the same distribution of disadvantage or p. 218). A vulnerable group is a disadvantaged
advantage as other social determinants [29]. segment of the community requiring greater con-
Health inequities are attributed to systemic sideration because of limited capability to protect
inequality in the allocation of resources and themselves from intended or inherent risks and
power. They are the consequences of social injus- their inability to make informed choices [32].
tices and unfair distribution of goods, services, Vulnerability is created by multiple and cumula-
and privileges across populations. Social deter- tive risks experienced through the life course
minants of health pertain to the quantity and that may not be directly related to health, such as
quality of a variety of resources that a society low socioeconomic status and discrimination.
makes available to its members, such as income, Exposure to multiple risk factors and a greater
food, housing, employment, and health and social number of comorbidities are more frequent in
services. Equity refers to fairness in the distribu- vulnerable populations, i.e., persons with low
tion of goods and services based on need. Needs income, the less educated, racial and ethnic
are not necessarily equal [28]. Therefore, equal minorities, aboriginal peoples, those who experi-
opportunity or equal allocation of resources that enced discrimination and violence, etc. According
ignore differences in needs, generally fail to to Phelan and Link [33], risk factors and their
achieve equity of outcomes. Social justice has accumulation are the expression of fundamental
become the focus for addressing health inequities causes linked to one’s position in the social struc-
by emphasizing a collective societal moral obli- ture that generates exposure to other risks.
gation to create equity or fairness in the alloca- Four selected theories are presented to explain
tion of risks and rewards to everyone. the social pathways toward vulnerability. These
Social injustice does not arise solely from dis- evidence-based theories illustrate the cumulative
tribution of goods and services but also in the disadvantages from social determinants that con-
allocation of non-distributive aspects of well- tribute to the buildup of lifetime risks of poor
being [30]. Well-being is affected by the nature of health in vulnerable populations.
a person’s social relationships with others. In the
case of social injustices, these relationships
impose systemic constraints on the development Life Course Theory
of well-being and can have profound and perva-
sive adverse effects on all aspects of well-being. Life course theory stipulates that early life adver-
People who are victims of social subordination, sities create an accumulation of disadvantages
violence, discrimination, and stigma often expe- that persist into adulthood and later life.
rience lack of respect and lack of attachment and Significant life course events and transitions
determination, which are essential aspects of across the lifespan are found to create a cumula-
well-being. Justice needs to integrate the tive impact on individuals and ultimately on their
distributive and non-distributive aspects of
health and well-being [34]. Exposure to clusters
well-being. of multiple negative life course factors at critical
life transition periods, particularly during a
child’s development, has lasting consequences on
Social Pathways to Vulnerability an individual’s physical and mental health [35].
The timing and length of exposure to disadvan-
A vulnerable population is a “subgroup or sub- tages create differential impacts on health. These
population who, because of shared social charac- differential exposure effects persist even when
teristics, is at a higher risk for [health] risks risk factors and diseases change over time [36].
because of their position in the social strata, Four principles of life course theory explicate
which exposes them to contextual conditions, the processes that build accumulation of multiple
8 D. F. Pacquiao
risks and disadvantages. The first principle, long- eral distress, anxiety, and mental health disorders
term temporal patterns, posits that present life that can persist into middle and later adulthood
and health status are affected by earlier circum- [47]. Children of depressed parents tend to
stances. Socioeconomic status (SES) shapes an exhibit both more internalizing and externalizing
individual’s exposure and experience of psycho- problem behaviors and have more problems with
social and physical health risks. People with low defiance and cognitive ability, similar to children
socioeconomic status (SES) experience poorer of parents with schizophrenia. Mentally ill par-
health than those with higher SES [37, 38] as ents tend to be emotionally unavailable to their
higher SES is associated with access to resources children, often overemotional, and are more
such as knowledge, money, power, prestige, and likely to use authoritarian parenting practices.
beneficial social connections that enable people Cold, uncaring families produce long-lasting
to avoid risks and adopt protective strategies to emotional problems in children [48]. There is a
decrease illness and death [39]. Growing up in clear relationship between accumulated lifetime
poverty is associated with an elevated risk of trauma and psychiatric disorder and psychologi-
experiencing violence and low academic achieve- cal distress [41]. Childhood abuse is associated
ment [40], greater exposure to chronic stress with early menarche; both are associated with
related to poor living conditions, low job security partner violence during adolescence [49].
and financial difficulties [41], increased engage- The fourth principle, human agency, refers to
ment in smoking and physical inactivity, and the the long-term consequences of one’s ability to
likelihood of being obese. control life events. While individuals may have
The second principle, intersection of biography choices and control of their actions, there are
and history, emphasizes the significance of his- broad sociocultural factors such as low SES that
torical context and events on health and well- limit human agency [43]. Health outcomes may
being. Contextual factors include features of the vary from a combination of individual choices
neighborhood environment, e.g., housing, avail- and contextual opportunities and constraints. In
able health services, schools, recreation, and job general, people with higher SES have more
opportunities, and the collective characteristic of capacity to be effective self-agents and have bet-
neighborhood residents including SES, shared val- ter mental health. People with higher self-esteem,
ues and norms, and mutual commitment [42]. mastery, and efficacy are better equipped to
George [43] found a link between combat experi- weather the impact of stressful experiences and
ence during World War II and the incidence of have lower levels of depression and anxiety dur-
post-traumatic stress disorder (PTSD), substance ing stressful events [50].
abuse, anxiety disorders, and other mental health
problems 60 years later. Higher divorce rates in the
twentieth and twenty-first centuries are associated Ecosocial Theory
with increased prevalence of poverty and adverse
mental health among divorced women and lower Krieger’s ecosocial theory [51] proposes that
life expectancy among divorced individuals com- human beings literally incorporate, biologically,
pared to their married counterparts [44]. Parental their material and social world, from in utero to
divorce is found to be more detrimental on chil- death through the process of embodiment, that in
dren’s health than parental death [45]. turn shapes the patterns of distribution of health
The third principle, linked lives, stipulates that and disease in society. The causal pathways of
health is affected by one’s social networks. There embodiment are operationalized by the life and
is more prevalence of divorced, single mothers work conditions of people that are differentially
among those with lower SES; conversely, moth- structured by social inequalities, thus creating the
ers with higher education and income are more production and reproduction of social and bio-
likely to maintain stable marriages [46]. Parental logical inequities among individuals and popula-
divorce during childhood is associated with gen- tions [51]. Diverse, concurrent, and interacting
pathways to embodiment determine the cumula- nomic, immune, and metabolic systems. The
tive exposure, susceptibility, and resistance of immediate response to different stressors is medi-
populations to social and economic deprivation, ated by a coordinated reaction to the brain’s eval-
hazardous ecosystem, social trauma, or inade- uation of the threat [55], which in turn activates
quate health care. These pathways of embodi- the sympathetic-adrenal-medullary (SAM) axis
ment occur in multiple levels (individual, to release catecholamines such as epinephrine to
neighborhood, regional or political jurisdiction, improve cardiac output and tissue oxygenation
national, international, or supranational) and in by accelerating the heart rate and respiratory rate
multiple domains, e.g., home, work, school, and and by increasing cardiac stroke volume and
other public settings. Accountability and agency blood pressure to shift blood flow to major
for rectifying social inequalities involve institu- organs. Catecholamines release pro-inflamma-
tions, communities, households, individuals, and tory cytokines to prevent infection and tissue
scientists who need to integrate social inequali- damage. These mechanisms are involved in the
ties in their methods and explanations of epide- fight or flight response.
miologic patterns ([51], p. 225). Patterns of By contrast, chronic stress can promote and
disease distribution cannot be explained by dis- exacerbate pathophysiology through the same sys-
ease mechanisms alone but must account for tems that are dysregulated. Brain regions such as
social inequalities underlying the different epide- the hippocampus, prefrontal cortex, and amygdala
miological patterns across time and places ([51], respond to acute and chronic stress and show
p. 937). changes in morphology and chemistry that are
Studies of racial residential segregation in the largely reversible if stress is not prolonged [55].
United States have shown that concentration of Prolonged activation of the stress response sys-
poor Blacks in neighborhoods with overcrowded tems however can disrupt the development of
housing, low-quality health services and schools, brain architecture and other organ systems and
violent and polluted environments, and limited increase the risk for stress-related disease and cog-
availability of affordable healthy foods [52] cre- nitive impairment well into the adult years [56].
ate cumulative health risks and limited opportu- A more long-term response to chronic stress is
nities for economic mobility. These conditions mediated by the hypothalamic-pituitary-adrenal
perpetuate social and environmental injustices (HPA) axis, which releases hormones called glu-
that ultimately result in poor health. Inequality in cocorticoids. Glucocorticoids cause increased
living standards, working conditions, and envi- metabolic activity in order to provide energy and
ronmental exposures of the dominant and subor- also manage the parasympathetic nervous system
dinate classes create health differences among and the level of physiological arousal.
racial and ethnic groups [53]. Glucocorticoids inhibit production of pro-inflam-
matory cytokines, although the relationship
between these two substances has been observed
Allostatic Load Theory as nonlinear in nature [54]. A decline in parasym-
pathetic activity also occurs in allostatic load,
Allostatic load is the “wear and tear” effects on resulting in less regulation of the sympathetic
the physical and mental well-being associated effects of increased heart rate, blood pressure,
with exposure to chronic, unmitigated stress [54]. and cardiac activity [55].
It is the cost of adaptation to cumulative stress Stress can alter health-related behaviors such
originating from repeated stress, but it may also as smoking, alcohol use, sleep, diet, and exercise,
result from lack of adaptation or a prolonged which in turn increase the risk of high allostatic
inadequate stress response. It is likely to develop load. If the stress response remains high for a
when acute stress responses become chronic. long time, subclinical dysfunction can progress
Acute stress responses promote adaptation and into disease due to the malfunction of multiple
survival through neural, cardiovascular, auto- systems. Cardiovascular disease may result from
10 D. F. Pacquiao
stress-related amygdala hyperactivity, contribut- and increased incidence of preterm births [55,
ing to hypertension. Elevated inflammation and 59]. The effects of chronic stress on the brain are
cortisol hormone levels may decrease cell sensi- linked with high-risk behaviors and impaired
tivity to insulin, leading to the development of decision-making.
metabolic disorders such as diabetes. Elevated
inflammation and cortisol levels may also pro-
mote neurodegeneration, leading to cognitive Historical Trauma
decline and dementia. Inflammation and meta-
bolic abnormalities cause shortening of a region According to Sotero [60], populations that were
of repetitive DNA at the end of chromosomes, historically subjected to long-term mass trauma,
causing cellular aging [56]. such as colonialism, slavery, wars, genocide,
Events in early life produce long-term effects incarceration, etc., exhibit a higher prevalence of
on the activity of systems producing hormonal disease even several generations after the original
stress mediators. Low birthweight and various trauma occurred. In these cases, mass trauma was
types of early life trauma may influence stress deliberately and systematically inflicted on a tar-
hormone responsiveness over a lifetime. There is get population over an extended period of time by
consistent elevation of stress hormone activity in a subjugating dominant group, creating a univer-
abused children. History of sexual and physical sal experience of the trauma and destruction of
abuse in childhood is a risk factor not only for the people’s history and cultural identity. This
PTSD but also for hippocampal atrophy and destruction results in a legacy of physical, psy-
cognitive impairment in adulthood. Adolescents chological, and socioeconomic vulnerability
with PTSD and a history of childhood physical across generations. Historical trauma integrates
and sexual abuse were found to have elevated uri- (a) the link between disease and physical and
nary catecholamines compared to both non-trau- psychological stressors from the social environ-
matized children with over-anxious disorders and ment; (b) the influence of political, economic,
healthy groups [54]. Maltreated children with and structural determinants of health on disease
PTSD revealed the presence of smaller intracra- prevalence; and (c) the multilevel ecological
nial and cerebral volumes compared to a matched dynamics of history and life course factors in dis-
control group; in addition, electroencephalo- ease causation [51]. The psychological and emo-
graphic abnormalities were found in children tional consequences of trauma experiences are
with a history of psychological, physical, and transmitted to subsequent generations through
sexual abuse [57]. Neglect and trauma in child- physiological, environmental, and social path-
hood are associated with low serotonin levels and ways, thus establishing the intergenerational
increased risk for hostility, aggression, substance cycle of the trauma response. The overt legitimi-
abuse, and suicide [54], as well as increased mor- zation of subjugation may discontinue overtime,
tality and morbidity from a variety of disorders but its legacy remains in the form of racism,
during adult life, such as depression, suicide discrimination, and social and economic disad-
related to substance abuse, cardiovascular dis- vantage. They may also experience loss of lan-
ease, and extreme obesity [58]. guage and culture, poverty, discrimination,
Studies of chronic stress associated with expe- injustice, and social inequality [61].
riences of discrimination, marginalization, and Traumas such as the soul wound from historical
lack of control over one’s life circumstances cre- and contemporary discrimination among Native
ate a “wear and tear” effect on the body or allo- women influence their health and mental health
static load that is linked to sustained high levels outcomes. Disempowerment of Native women
of cortisol and other stress hormones that increase was specifically a primary goal of the colonizers,
one’s susceptibility to chronic diseases such as with the intent of destabilizing and, ultimately,
hypertension, cardiac disease, diabetes, cancer, exerting colonial domination over each indigenous
nation [62]. For example, the British decreased the sure time, lower levels of physical activity, higher
power of Cherokee women, a traditionally matriar- prevalence of underlying illnesses, higher blood
chal society, by “educating” Cherokee males in pressure, and shorter height.
European ways, encouraging marriage to non- The Whitehall Studies revealed the social gra-
Native women, and privileging mixed-blood male dient for a range of different diseases: heart dis-
offspring in nation-to-nation negotiations. During ease, some cancers, chronic lung disease,
the 1970s, the Indian Health Service oversaw the gastrointestinal disease, depression, suicide,
nonconsensual sterilization of ~40% of Native sickness absence, back pain, and general feelings
women of childbearing age [63]. of ill-health. After controlling for these risk fac-
Sotero [60] describes the legacy of vulnerabil- tors, the lowest social grade continued to have a
ity of Native Americans that began during the greater relative risk for cardiovascular disease
European colonization. The introduction of mortality compared to the highest grade. The
infectious diseases such as measles and small Whitehall Studies confirmed that access to
pox had a devastating impact on Native health-care services does not guarantee equity of
Americans, decreasing the immunity of those health outcomes and suggested that health status
exposed and their unborn children to other infec- is more significantly shaped by life conditions.
tious diseases such as tuberculosis, hepatitis, and Marmot [66] labeled this health gradient as the
influenza. Food scarcity and starvation resulted social status syndrome. The lower individuals are
from recurrent epidemics and government poli- in the social hierarchy, the less likely they are
cies, exposing the population to an abundant sup- able to meet their needs for autonomy, social
ply of unhealthy processed food. These events integration, and participation.
led to metabolic and behavioral adaptations that White et al. [67] conducted a review of articles
started a pattern of poor physical and mental published from 1998 to 2011 to describe the
health that has plagued Native Americans to mechanisms that shape health-care access, utili-
this day. zation, and quality of preventive, diagnostic,
therapeutic, and end-of-life services across the
ocial Status Syndrome
S life course in the United States. Racial and ethnic
The seminal Whitehall I [64] and Whitehall II stud- residential segregation is a key factor driving
ies [65] of British civil servants found a social gradi- place-based health-care inequities, stemming
ent in health among Caucasians who were not poor from limited opportunities for employment and
and had equal access to health services. Each step education, and high concentrations of poverty.
downward in their socioeconomic status was corre- Neighborhoods characterized by economic and
lated with a proportional decline in their health sta- social disadvantage experience health-care dis-
tus. Whitehall I examined cardiovascular disease parities because of difficulty attracting primary
prevalence and mortality rates of more than 18,000 and specialty care physicians and have inade-
white males between the ages of 20 and 64 for more quately funded and poorly organized health-care
than 10 years using a prospective cohort design. infrastructure, higher rates of adverse patient
Whitehall II examined morbidity in 10,308 safety events, and poorer access to preventive
white men and women using a longitudinal, health services. Poorer health status is associated
prospective cohort study of employees in the
with higher levels of segregation.
London offices of the British Civil Service. Higher
mortality from all causes, including coronary artery
disease, and lower life expectancy were observed Health of Indigenous Populations
among those in the lower grades of employment as
compared to those in higher grades. Lower status Indigenous peoples have come to be known as the
was associated with higher prevalence of significant “Fourth World” or “nations without states” who
risk factors including obesity, smoking, reduced lei- are found in many countries. The position and
12 D. F. Pacquiao
health status of the “Fourth World” are strongly tancy, is significantly worse than that of the main-
affected by the country where they are located. stream populations of those countries. New
Poor health associated with poverty, malnutrition, Zealand, the United States, and Canada saw
overcrowding, poor hygiene, environmental con- major health improvements for indigenous popu-
tamination, and prevalent infections is widespread lations up to around the 1980s, leading to an
among the nearly 400 million indigenous people appreciable narrowing of the gap in life expec-
worldwide. These are compounded by limited tancy between indigenous and mainstream popu-
access to adequate clinical care, health promotion, lations. However, between the 1980s and the end
and disease prevention services. As some indige- of the century, a slowing or stalling of indigenous
nous groups transition from traditional to modern health improvements measured by life expec-
lifestyles, they develop lifestyle diseases, such as tancy showed that the gap between these groups
obesity, cardiovascular disease, type 2 diabetes, failed to close significantly. In Canada the gap
and exposure to toxic pollutants in their environ- narrowed to 5.2 years for women and 7.4 years
ment as well as physical, social, and mental disor- for men but even widened in New Zealand
ders linked to the misuse of alcohol and other (10 years in 1999), Australia (17 years in 2001),
drugs [68]. and the United States (6 years in 1998) [72].
The Inuit population occupies territories from A comparison of health statuses of indigenous
the easternmost tip of Russia in the west to populations of New Zealand and the United
Greenland in the east, governed by Denmark, States with those of dominant populations of
United States, Canada, and Russia. Among the these countries revealed that in nearly every
circumpolar Inuits near the Arctic, the incidence health status indicator assessed, disparities (both
of infectious diseases has declined considerably absolute and relative) were more pronounced for
but is still high compared with western societies. Maoris than for American Indians/Alaska Natives
Chronic diseases such as diabetes and cardiovas- (AIANs). Both indigenous populations suffered
cular disease are on the rise, while accidents, sui- from disparities across a range of health indica-
cides, violence, and substance abuse are major tors. However, no disparities were observed for
patterns of ill health. Social, environmental, and AIANs in regard to immunization coverage.
lifestyle changes are major determinants of health Ethnic health disparities were more pronounced
among the Inuit [69]. in New Zealand than in the United States [73].
In Australia, the health gap between indigenous In Canada, social exclusion of aboriginal pop-
and nonindigenous populations accounted for ulations is evident in the differences in their
59% of the total burden of disease for Indigenous sociodemographic and health status as compared
Australians in 2003. Noncommunicable diseases to non-aboriginal populations. Compared to non-
explained 70% of the health gap: tobacco (17%), aboriginal Canadians, First Nations aboriginal
high body mass (16%), physical inactivity (12%), people earn much less income, have twice the
high blood cholesterol (7%), and alcohol (4%). rate of unemployment, are more likely to live in
While the 26% of Indigenous Australians residing crowded conditions, and are much less likely to
in remote areas experienced a disproportionate graduate from high school. Aboriginal Canadians
amount of the health gap (40%) compared with live the shortest lives among all other groups in
those in non-remote areas, the majority of the Canada and have higher rates of infant mortality,
health gap affects residents of non-remote areas suicide, major depression, alcohol, and child-
[70]. Endean et al. [71] reported high prevalence hood sexual abuse than non-aboriginal Canadians
of dental caries among the children and higher [74].
rates of edentulism among adult Indigenous peo- Latin America and the Caribbean have over
ples in Northwest South Australia. 400 different indigenous groups and a total popu-
The Australian Department of Health [72] lation of 45–48 million people [75]. Household
reported that the health of Indigenous peoples in surveys conducted in Latin America by the
First World countries, measured by life expec- United Nations Development Programme in
1994 revealed consistently larger proportion of have at least a bachelor’s degree in comparison to
indigenous people living below the poverty line 33% of non-Hispanic Whites. The median house-
compared to nonindigenous populations in hold income for AIANs was $37,353, as com-
Bolivia (64.3% vs. 48.1%), Guatemala (86.6% pared to $56,565 for non-Hispanic Whites; 26%
vs. 53.9%), Mexico (80.6% vs. 17.9%), and Peru lived at the poverty level, as compared to 11% of
(79.0% vs. 49.7%). The surveys also found low non-Hispanic Whites [79].
quality of construction materials for building In terms of health coverage, 47.5% had private
houses and less availability of potable water, insurance, 38.1% had Medicaid, and 22.6% were
plumbing, and other services among indigenous uninsured. AIANs frequently encounter issues
groups as compared to the nonindigenous popu- that prevent them from receiving quality medical
lations. Indigenous status was strongly correlated care, including cultural barriers, geographic iso-
with lower educational attainment and literacy lation, inadequate sewage disposal, and low
level [76]. income. Some of the leading diseases and causes
In India, data analysis of population-based of death among AIANs are heart disease, cancer,
data from the 1998–1999 Indian National Family unintentional injuries (accidents), diabetes, and
Health Survey found that indigenous groups stroke. They have a high prevalence and risk for
experienced excess mortality even after adjusting mental health problems and suicide, obesity, sub-
for economic standard of living and were more stance abuse, sudden infant death syndrome,
likely to smoke and drink alcohol compared to teenage pregnancy, liver disease, and hepatitis.
nonindigenous groups. Within the Indigenous In 2012, the infant death rate was 60% higher
people, those in the bottom income quintile had than the rate for Whites; AIANs were twice as
higher odds for mortality compared to those in likely to have diabetes as Whites. The Pima tribe
the top fifth quintile. Smoking, drinking alcohol, of Arizona has one of the highest diabetes rates
and chewing tobacco also showed graded associ- and serum cholesterol levels in the world. AIANs
ations with socioeconomic status within also have disproportionately high death rates
Indigenous groups [77]. from unintentional injuries and suicide. In 2012,
A study of indigenous groups in Malaysia the tuberculosis rate for AIANs was 6.3 per
showed urbanized groups with significantly 100,000 as compared to 0.8 for White Americans
higher mean body weight, body mass index, total [79].
cholesterol, and higher prevalence of obesity and Currently, there are 573 federally recognized
hypercholesterolemia compared to the rural- AIAN tribes and more than 100 state recognized
dwelling groups. The health effects were attrib- tribes, but there are also tribes that are neither
uted to changing dietary habits, lifestyles, and state nor federally acknowledged. State recogni-
socioeconomic factors brought about by urban- tion does not confer federal recognition but fed-
ization [78]. erally recognized tribes are also state recognized.
Based on data from 2012, the Office of Federally recognized tribes are provided health
Minority Health [79] reports an estimated and educational assistance by the government
5.2 million people who were classified as agency, Indian Health Service (IHS), which oper-
American Indian and Alaskan Native (AIAN) ates a comprehensive health service delivery sys-
alone or in combination with one or more other tem for approximately two million AIANs. IHS
races, comprised 2% of the total US population funds 33 urban Indian health organizations in cit-
with 1.5 million (30%) under the age of 18. Only ies throughout the Unites States, providing medi-
22% of AIANs lived on reservations or other trust cal, dental, sexually transmitted disease
lands compared to 60% in metropolitan areas. prevention, pharmacy, optometry, mental health,
Twenty percent of AIANs spoke a language other home health community, and social services. In
than English at home; 82% of AIANs aged 25 addition, alcohol and drug abuse prevention, edu-
and over have at least a high school diploma, as cation and counseling, and nutritional education
compared to 92% of non-Hispanic Whites; 17% are also provided [79].
14 D. F. Pacquiao
icronesians: A Case Study of Health

M relocate to other nearby islands, including those
Vulnerability that were previously considered uninhabitable.
The people were unwittingly exposed to nuclear
The plight of Micronesians (the people of radiation because of the shift in the wind direc-
the Federated States of Micronesia (FSM), the tion, resulting in a legacy of stillborn babies,
Republic of Palau and the Republic of the birth defects, sterility, cancer, and other maladies.
Marshall Islands) illustrates placed-based health Hundreds of Micronesians were also recruited to
inequities rooted in social inequalities that tran- work in highly contaminated areas, allegedly
spire not only in their own country but also inter- without adequate protection.
nationally. Micronesians have suffered After gaining its independence in 1986, the
cumulative disadvantages that resulted in their sovereign islands entered into a Compact of Free
vulnerability at home and as a migrant group in Association (COFA) with the United States that
the United States. As many as one-fifth of was later amended in 2004. Today, most of the
Micronesians live outside their home countries, islands of Micronesia are independent states,
mostly in Hawaii, Guam, and the western coast except for the US territories of Guam and Wake
of the United States, and as far away as Arkansas Island and the US Commonwealth of the Northern
[80]. Mass emigration has been prompted by lack Mariana Islands [83]. Under the terms of COFA,
of jobs, health problems, and destruction of their the United States has full authority and responsi-
natural environment from rising water levels, bility for the defense and security of the region,
nuclear contamination, overfishing, and sewage but this agreement can be changed or terminated
pollution. Migration to the United States has by mutual agreement. COFA citizens can live,
been motivated by the promise of a better life, work, study, and join the Armed Forces in the
health care, education, job opportunities, and United States without a visa [84].
governmental assistance, as well as reunification In 1996, the US government changed the sta-
with family members who have settled in the tus of Micronesians to non-qualified aliens, mak-
United States [80]. ing them ineligible for federal public assistance
Micronesians were ruled by a succession of including medical care, which escalated emigra-
colonial powers for over four centuries with the tion from the islands. Because the state of Hawaii
consequent loss of their traditional and suste- continued health-care assistance for poor
nance practices, as well as the development of Micronesian migrants through the state-funded
health problems. Following World War II, the Medicaid program, it became their favored desti-
islands of Micronesia became part of the UN nation [83]. The Department of Health and
Trust Territory of the Pacific Islands, adminis- Human Services used to allocate $30 million
tered by the United States as the trustee of the (equivalent to <10% of its total annual funding)
Pacific Islands. The United States has gained annually to different states to help defray
military and strategic opportunities by setting up expenses for COFA migrants. Approximately
military bases and performing nuclear weapons $10 million was earmarked for Hawaii, which
testing [81]. Between 1946 and 1958, the islands spent ten times that amount on services for this
became an open-air nuclear testing area for at population [86]. In 2008, Micronesian migrants
least 67 nuclear tests using over 7200 Hiroshima- made up <1% of the state population but used
sized bombs. The contamination was equivalent over 20% of its social services. In 2010, the
to 108,496 tons of atmospheric nuclear weapons Department of Health and Human Services
as compared to the 36 tons used during the entire reduced health-care benefits for COFA migrants,
World War II [82]. The largest test in March 1954 giving them a cheaper and more limited program
yielded 15 megatons, more than 1000 times the than the one available to US citizens. A class
strength of the bomb that destroyed Hiroshima. action suit filed by COFA migrants gained a fed-
The once idyllic atolls were transformed into eral judge’s decision in December 2010 to restore
radioactive craters forcing the local people to full medical benefits effective January 2011, but
the decision was appealed by the state in 2012. In ulation between 35 and 64 years old, 80% are
April 2014, the US Ninth Circuit Court of overweight and 50% are obese; 50% of those
Appeals ruled that the state has no constitutional over 50 years suffer from type 2 diabetes.
obligation to fill the gap left in 1996 when Compared to the United States, the FSM has tri-
Congress cut health funding for COFA migrants. pled the prevalence of diabetes [87]. The leading
The court ruled that the Micronesian people are causes of morbidity and mortality among
nonimmigrant aliens whose numbers are increas- Micronesians are cardiovascular disease, diabe-
ing because of lack of economic opportunity and tes mellitus, chronic obstructive pulmonary dis-
health care in their home islands. In May 2011, ease, and cerebrovascular disease. The high rates
legislators from Hawaii urged the US govern- of type 2 diabetes and cardiovascular disease
ment to conduct medical screening of COFA have been attributed to the destruction of their
migrants to prevent entry of individuals who are natural environment, coral reefs, and agricultural
likely to become a public charge [86]. lands from nuclear and sewage contamination.
Under the Affordable Care Act of 2010, COFA The importation of food commodities into the
migrants are eligible to purchase health insurance islands by the United States, such as canned
through the state’s health insurance exchange. meats, white flour, sugar, and rice, accompanied
Most Micronesian migrants, however, have little their transition from subsistence farming to a sed-
education, speak little or no English, and face entary lifestyle [88].
social challenges, such as unemployment, pov- Cancer is the second leading cause of death
erty, poor living conditions, and lack of transpor- among Micronesians. In 2007, preliminary
tation, which impede their ability to find steady results from the Pacific Cancer Initiative discov-
employment and access social services and the ered 26 cancers associated with nuclear weapons
health-care systems [82]. Today, many testing. Radiation exposure maybe associated
Micronesians are flocking to homeless shelters with a 95% lifetime risk for thyroid cancer [89].
and struggling to make ends meet. Gastric and liver cancer rates are high along with
Micronesian migrants in Hawaii have numer- other types of cancers found in developing
ous health problems including communicable countries, such as prostate, breast, lung, and oral
and chronic diseases, such as obesity, diabetes, cancer. Ionizing radiation exposure is a well-doc-
cardiovascular disease, and cancer. Many are on umented risk factor in most malignancies, but
renal dialysis and receiving chemotherapy treat- latent radiation carcinogenesis is complex and
ment. They have lower rates of immunization difficult to definitively trace [90]. The full conse-
compared to those of other groups. They have quences of nuclear testing are unknown, espe-
reported encountering open resentment, blatant cially among the descendants of those who were
racism, and discrimination in health care and exposed. Nuclear-related cancers have not been
general society [86]. fully expressed and are predicted to increase in
In Micronesia, smoking and alcoholism are the future [83].
major problems; many lives are lost to drunk- Infectious diseases such as tuberculosis, hep-
driving [86]. Suicide is the leading cause of death atitis B, and syphilis are endemic in Micronesia.
for young men aged 15–29, which is among the The region has the highest rate of Hansen’s dis-
highest in the world and more than ten times that ease, with most cases being diagnosed in Hawaii
of American men of the same age. The Republic [91]. The region is also plagued by outbreaks of
of Palau has the highest rates of schizophrenia in cholera and dengue fever. Micronesians suffer
the world. The average life expectancy in from increasing rates of sexually transmitted
Micronesia is 65 compared to 77 years in the infections including chlamydia, gonorrhea,
United States [83]. Chronic diseases including syphilis, and HIV/AIDS. HIV/AIDS rates for
diabetes, hypertension, heart disease, cancer, Micronesian migrants in Hawaii remain low;
strokes, and obesity are major health problems however, there is concern over their reluctance
which are projected to increase. Among the pop- to seek screening and treatment in the absence
16 D. F. Pacquiao
of ongoing symptoms [88]. In 2007, the preva-

lence rate of tuberculosis in the FSM was Box 1.1 Research Box
133/10,000 individuals (four cases of multidrug Reference: Burgess CP, Johnston FH,
resistance) and highest among those 18–34 years Berry HL, McDonnell J, Yibarbuk D,
of age. In Hawaii during the period of 2004– Gunabarra C, Mileran A, Bailie RS. Healthy
2008, 84.4% of new cases of tuberculosis among country, healthy people: the relationship
Pacific islanders involved migrants from between Indigenous health status and “car-
Micronesia [90]. ing for country”. Med J Aust.
Colonization and social inequalities perpetu- 2009;190(10):567–72 [92].
ated since after World War II combined to create Study Purpose: Examine associations
cumulative disadvantages among Micronesians between “caring for country” and health
through many losses: physical environment, outcomes of indigenous populations in
livelihood, cultural traditions, and practices for Australia. “Caring for country” involves
sustenance. Their lives have been transformed to activities promoting relationships between
a state of inferiority, disempowerment, and Indigenous peoples and their ancestral
dependence on aid from the United States for lands and seas, which they believe promote
survival. Their patterns of morbidity and mortal- ecological, spiritual, and human health.
ity manifest the embodiment of social inequali- Method: Cross-sectional study of 298
ties that promoted their cumulative exposure, indigenous adults aged 15–54 years
susceptibility, and lack of resistance to stressors recruited from the remote Arnhem Land
throughout their life course. Their needs are community in Australia’s Northern
multiple, complex, and overwhelming that Territory. Volunteer participants were
require external agency and accountability to recruited from homelands, township resi-
compel measures such as cleaning up their envi- dences, workplaces, public spaces, and
ronment, building the infrastructure to support community council buildings between
their basic needs, safeguarding their basic rights March and September 2005 via an outreach
as human beings, and restoring their dignity as a program of preventive health checks.
people. They have suffered place-based inequi- In addition to self-reported sociodemo-
ties both in Micronesia and in places they graphic data (primary place of residence,
migrated to in search of a better life and health education, income, diet, physical activity,
care. and smoking), the following variables were
measured:
Implications for Health • Caring for country comprised six core

Professionals activities: time on country, burning of
annual grasses, gathering of food and
Health advocacy for vulnerable indigenous groups medicinal resources, participation in
and those who experienced historical trauma from ceremonies, protecting sacred areas, and
dispossession of their ancestral land, forced relo- producing artwork using a four-point
cation to other lands, and continuing marginaliza- ordinal response scale through an inter-
tion and disempowerment requires macrosocial viewer-administered questionnaire.
approaches to stop the cycle of cumulative disad- • Actual measurements were taken of par-
vantages and poor health. Correction of health ticipants’ height, weight, waist circum-
inequities needs increased awareness, political ference, and body mass index; blood
commitment, and recognition rather than govern- pressure; urinary albumin and creati-
mental denial and neglect of these serious and nine; and non-fasting blood samples
complex problems. Indigenous people should be
giving them active control and participation in

(HbA1c, glucose, HDL, LDL, and programs designed for them [93]. Indigenous
cholesterol). knowledge and perspectives are distinct from
• History of type 2 DM based on medical biomedical measures for health outcomes and
records and confirmed by oral glucose western individual ethos. According to Durie
tolerance test. Five-year cardiovascular [94], indigenous knowledge cannot be verified by
disease risk was calculated based on the scientific criteria nor adequately assessed by sci-
Framingham Study. ence since it is built on distinctive philosophies,
• Psychological distress measured by methodologies, and criteria. In New Zealand,
Kessler Psychological Distress Scale. Maori researchers have been able to apply the
methods and values of Maori indigenous systems
Results: Participants were stratified by to foster a more comprehensive understanding of
residence in either townships or homelands. health and illness by indigenous populations.
Pearson correlation revealed significant Remedies should be informed by their own con-
associations between sociodemographic ceptualization of health and should restore the
characteristics and health behaviors within connection between humans and nature and
groups and clinical outcomes. Multivariate among their own people [95]. Elder [86] has
regression analysis revealed significant aptly recommended that “if lives are lived in spe-
associations between caring for country cific historical times and places, by changing his-
participation, health behaviors, and clinical torical times and places, people can change the
outcomes. An interquartile range rise in the way they live their lives.”
weighted composite of caring for country Changing the life conditions of marginalized
score was significantly associated with fre- and socially oppressed people requires multi-
quent physical activity, better diet, lower level social strategies and political advocacy and
BMI, less abdominal obesity, lower systolic empowerment. Health is a political issue, and the
BP, less diabetes, low HbA1c, and lower remedies for social determinants of poor health
CVD risk. are achieved by political means. Advocacy for
Implications: Study reveals the impor- legislative, funding, and policy changes may
tance of integrating indigenous health require a broad-based coalition to sway public
beliefs and practices in health promotion, opinions. For Micronesians, litigation can com-
which may be uniquely different from the pel the US government to reallocate fair com-
premises of biomedical sciences. The spe- pensation for damages done to the people and
cial connections between aboriginal people their homeland by nuclear contamination perpe-
and their ancestral places should be incor- trated by the US military [96]. Litigation can be
porated in public policy and public health pushed by a broad coalition of academicians,
promotion. Caring for country affirms this scientists, community advocates, and the
connection that is pervasive in the world- Micronesian government. Support by mass
view of indigenes about health and media to increase public awareness of their his-
well-being. tory and continued suffering is needed to influ-
ence public opinion and regard for the
Micronesian people.
encouraged, trained, and enabled to become Environmental injustices are best addressed
increasingly involved in overcoming these by vigilant monitoring and research documenting
challenges. the negative impact of lack of regulation and the
Closing the health gap between indigenous pursuit of profits by big businesses. Cleaning up
and nonindigenous populations needs the inte- of the Micronesian ancestral land and seas
gration of their indigenous cultural meanings and requires political and legal action. Restoring their
18 D. F. Pacquiao
sovereignty, cultural identity, and control over the cumulative exposure, susceptibility, and
their lives can restore their meaningful existence resistance to risks by individuals, communities,
by moving from a state of dependence to a more and populations in different ecological con-
autonomous and productive life. There should be texts. All these causal pathways affect indige-
an obligation by the federal government to pro- nous and disempowered groups who suffered
mote educational achievement and gainful historical mass trauma.
employment of Micronesian migrants and AIANs Place-based health inequities are linked to
by facilitating their access to quality schools, historical classism and social inequalities that
residential environments, and empowering social accumulate risks and disadvantages in vulnera-
connections with their own people and outside ble populations. Macrosocial or upstream
support. approaches are needed to stop the cycle of vul-
Health educators should use theories, research nerability by shifting the emphasis from indi-
methods, and interpretations that can shed light vidual and disease-based measures to focusing
on the association between social inequities and on population health promotion. Health is not
health. Policies and programs should be exam- merely the absence of disease but rather the
ined for their impact on vulnerable populations; capacity of the people to control their life con-
outcomes evaluation must include comparative ditions to achieve health. Macrosocial initia-
measures between vulnerable groups and other tives address the social determinants of
groups. Multidisciplinary theories and perspec- disadvantages that result in poor health. Health
tives should be used to guide the study design and advocacy for indigenous and vulnerable popu-
interpretation of findings in order to bring a better lations must be informed by social justice and
understanding of the social determinants and human rights principles. The right to health is
place-based health inequities. intimately linked with other human rights as
human rights are indivisible. Physical and men-
tal health are impacted by chronic stress from
Conclusion unsafe environments, poverty, and discrimina-
tion. Therefore, health promotion must attend
A society’s economic, political, and social rela- to the living and working conditions of popula-
tionships affect how the people live and the tions rather than just the illnesses. Human
condition of their environment; these relation- rights protection and social justice demand pro-
ships shape patterns of disease distribution. tection of the vulnerable in society. Social jus-
Societal distribution of health and illness can- tice upholds the collective obligation to redress
not be separated from a society’s economic and inequalities especially for the vulnerable whose
political ecology. Social determinants of poor capacity to confront multiple risks and disad-
health are operationalized in places by the vantages is constrained [97].
social inequalities that produce different out- Disadvantaged groups in society have shared
comes in population health. Life course theory social characteristics that are different from
emphasizes that the timing, length, and context powerful groups. Advocacy for the vulnerable
of exposure to social disadvantages or advan- must be informed by their valued traditions and
tages influence a population’s present and unique identities. Culturally competent advo-
future physical and mental well-being. cacy preserves their self-worth and pride
Allostatic load theory elucidates how unmiti- because it is built on mutual respect, apprecia-
gated, place-based social stressors create wear tion of differences, and grassroot empowerment.
and tear effects on the body, with negative con- Health professionals working with disadvan-
sequences on physical and mental health. taged groups must promote their active partici-
Ecosocial theory emphasizes that societal pat- pation and sense of achievement from which
terns of health and disease represent the empowerment, autonomy, and self-advocacy
embodiment of social inequalities that structure can flourish [98].
Exploring the Variety of Random
Documents with Different Content
The earliest guns were simply tubes, not cast, but built of strips of
iron or wood held together by rings. They were breech-loaders, the
charge being placed in a loosely-fitting chamber. How the chamber
was secured and the gun fired are still undecided. The guns were
usually innocent of trunnions and were fastened lengthwise upon
wooden beams which could be propped up to give them the desired
elevation. It has been recorded that in one of the earliest siege
operations at which this primitive artillery was employed, both sides
were so interested in the operation of firing that they ceased
exchanging missiles and defiance, and even stopped their personal
combats, until after the discharge, when, being much relieved that
the stone bullet had inflicted no damage on the assailed castle wall
and had wounded no one, they resumed hostilities in the old-
fashioned way. In those days one discharge per gun per diem was
regarded as sufficient. It was customary to load the piece overnight
and fire it in the morning, from which it may be surmised that its
moral effects were greater than the material destruction caused.
Artillery would have to be in a more advanced stage to justify its use
at sea, for no vessels could afford to carry guns which could only be
used so infrequently. Nevertheless, the moral effects of gunfire were
so evident, especially when weapons were made more powerful and
able to inflict serious material damage, that the adoption of the new
arm for naval war could not be long delayed, and the time soon
arrived when both national and private vessels of any size carried
one gun or more. By the middle of the fifteenth century guns on
board ship had become common.
The illustration of the model[14] of a ship of the period 1486-1520
gives a very good idea of what the warships of that time were like.
Although the vessel carried guns, the bow and arrow were still relied
upon. The archer’s panier on the mast had given place to the deep
circular top. Castles, however, were provided fore and aft for the
archers, and were useful alike for affording them protection and
accommodation and a place of vantage whence to discharge their
arrows. The vessel is of the same type as the Spanish caravel of the
early sixteenth century. From this it may be inferred that the
Spaniards went to the north for the designs of their hulls, but
preferred to retain the rig with which they were most familiar, the
Spaniards depending largely on lateen yards and sails, whereas the
model is square-rigged but without the top-sails she ought to carry.
A feature of the sea-going Atlantic vessels of this time was their
great beam in proportion to their length. They also had an
extraordinary amount of “tumble home,” or sloping of the sides
above the water line towards each other. Ships of the type
represented by the model were much in advance of those upon
which artillery was first carried.
Galleys were the first to be equipped with guns, the weapons being
upon the upper deck and fired above the bulwarks. Some galleys,
particularly in the Mediterranean, carried only one gun forward, a
bow chaser. The desire to carry more guns and to fire them over the
sides led to the raising of the sides of the vessel; and in order to
avoid the strain to the ship’s structure when the guns were fired, the
weak point apparently being the connection between the sides and
beams, the sides were given an inclination inboard, or tumble home,
the connecting beams being thus shortened. The practice was
carried to such an absurd extent that the beam of a Venetian galleon
—as such vessels now began to be called—at the deck might be
only half that of the vessel at the water line. The narrower deck
space left less room on which to place the stern castle, which
instead of being an addition became a structural part of the ship,
provided with three and sometimes four decks, all carrying cannon.
A MEDITERRANEAN WAR GALLEY.
From an Old Print.
SHIP OF WAR, 1486-1520.
From a Model in the Museum of the Royal United Service Institution.
On the Atlantic coasts the problem of cannon was solved in its own
way. Guns were placed broadside and fired over the bulwark. But the
disadvantages of this method were so obvious, especially when an
enemy returned the fire, that portholes in the bulwarks were devised
through which the guns could be discharged. A French shipbuilder at
Brest, named Decharges, is said to have been the inventor of
portholes, and also to have designed some other improvements. His
portholes, however, were so small that the muzzles of the guns could
only just protrude. It was impossible to give them any traverse, that
is, to train or aim them.
The general adoption of artillery led to numerous modifications in the
shape of the ships; they were built of greater dimensions, were more
fully masted and rigged, and could show a considerable press of sail.
It was also considered advisable that ships should be built especially
for war purposes, the French taking the lead after the battle of La
Rochelle.
If Henry V.’s warlike enterprises proved harmful to the development
of English commerce, there is no denying that shipbuilding made
some progress in his reign, though very little is known of the details
of the construction of the vessels. From lists of the ships employed in
his expeditions, it appears that his fleets included “Great Ships,” the
largest of which was the Jesus of 1,000 tons, the others being the
Holigost, 760 tons; Trinity Royal, 540 tons, and Christopher Spayne,
600 tons; there were also “cogs,” which were rather smaller;
carracks, which were probably foreign built and were prizes of war,
the construction of these vessels not having been then begun in
England; ships, barges, and ballingers, the last being barges. The
last three classes were no doubt impressed merchant vessels,
ranging from 500 tons in the case of the ships to 80 tons in the
ballingers. In regard to the “Great Ships,” it is reported[15] that Henry,
observing the superiority of the Castilian and Genoese ships, caused
some very large vessels, called “dromons,” to be built at
Southampton, “such as were never seen in the world before,” says
an old writer erroneously, “three of which had the names of the
Trinity, Grace de Dieu, and Holy Ghost.” Although called dromons it
does not follow that they were similar to the dromons in earlier or
contemporary use in the eastern Mediterranean. The name was
given to the latter because of their size and speed, and it is very
likely that Henry V.’s vessels were so named for similar reasons.
Long galleys, called ramberges, were also used about this time, and
the English are said to have become very expert in their
management.
Most of the large English armed ships of the middle of the fifteenth
century were Spanish or Genoese built. A ship was then in existence
carrying four guns on the broadside, fired apparently through ports in
the bulwarks. She was fitted with four masts and a bowsprit, and had
a high forecastle similar to that provided in Italian ships of that
period, but seemingly more a part of the structure of the ship than
was that of the latter. The mainsail bears the arms of the Earl of
Warwick.[16]
A remarkable ship in the history of naval building was the Great
Harry, sometimes confounded with the Henry Grace de Dieu. The
Great Harry was commenced for Henry VII., and is regarded by
many as the first ship of the British Royal Navy. No doubt the fact
that Henry lived for many years in Brittany, which was then
remarkable for its maritime activity, gave him a greater interest in
shipping than most of his predecessors on the throne professed.
It was a proud day for England, had he but known it, when, in the
year 1488, he ordered the Great Harry, for she marked the first
serious attempt of an English sovereign to render the state not
wholly dependent upon the merchants and the ports whenever he
decided upon an expedition abroad, by providing a vessel which
should be at the disposal of the state whenever required. For the first
time in the history of England, for the building of a national ship, the
axes swung as the trees were felled, and the blows resounded
through the forests; the forges roared for the formation of the iron
bolts and nails, and the hammers on the anvils rang as they beat
them into shape; the tools of the carpenters hissed as they fashioned
the knees and ribs and beams and planks; the looms whereon the
sailcloth was woven hummed in the industrial chorus; for this was
the first ship of England a nation, the first sign that Britannia was
really awaking at last to the fulfilment of her maritime destiny. He did
not live to see this vessel completed, and she was finished in Henry
VIII.’s reign. Henry VII. also ordered the Regent and the Sovereign.
The Great Harry is said to have been the first two-decked vessel
built in England, and the only ship with three masts in the whole
squadron. She was accidentally burnt at Woolwich in 1553.[17]
The Regent was about 1,000 tons, and carried two hundred and
twenty-five small guns, called serpentines. She had four masts and a
bowsprit, and was launched at Rotherhithe. She was not of English
design, but, like a few before her and many since, was modelled
after a French vessel. The Sovereign, a somewhat smaller ship,
carried one hundred and forty-one serpentines. The year 1512 saw
the end of the Regent. She was the flagship of the English in a
notable battle, and was opposed by the great French ship, Marie de
la Cordeliere, which was provided at the expense of Anne of Brittany,
then Queen of France. This ship is stated to have carried one
thousand two hundred fighting men, exclusive of mariners; at this
time there were nine hundred on board, according to Derrick, who
probably bases his statement on the report that she foundered with
all hands numbering nine hundred.
An English description of the engagement states that, “All things
being ... in order, the Englishmen approached towards the
Frenchmen, which came fiercely forward ... and when they were in
sight they shot ordnance so terribly that all the sea coast sounded of
it.” One of the English ships “bowged,” or rammed, the Cordeliere,
and when at last the Cordeliere was boarded, “a varlet gunner, being
desperate, put fire in the gunpowder.”[18] The French writer, Guerin,
also quoted by the same authority, in his version, says: “In the midst
of this general French attack there was to be noted above all others
a large and beautiful carrack, decorated superbly and as daintily as a
queen. She of herself had already sunk almost as many hostile
vessels as all the rest of the fleet, and now found herself surrounded
by twelve of the principal English ships.... From the top of a hostile
vessel there was flung into her a mass of fireworks. Then, sighting
the Regent, she, like a floating volcano, bore down, a huge
incendiary torch, upon her, pitilessly grappled her, and wound her in
her own flaming robe. The powder magazine of the Regent blew up,
and with it the hostile ship ... while the Cordeliere, satisfied, and still
proud amid the disaster, and a whirl of fire and smoke, vanished
beneath the waves.” The English version, if less vivid, is also less
imaginative.
EMBARKATION OF HENRY VIII. ON THE “GREAT HARRY.”

From the Painting by Volpe at Hampton Court Palace. Photograph by W. M.
Spooner & Co.
(click image to enlarge)
To replace the Regent, and to emulate Francis I. of France, who had
built a ship called the Caracon (afterwards burnt at Havre), carrying
one hundred guns, Henry ordered the Henry Grace de Dieu, of the
same tonnage, 1,000 tons, but carrying one hundred and twenty-two
guns. It is disputed whether she was built at Erith, as usually stated,
or whether she was launched at Deptford and completed at Erith.
Her launch took place in 1515. Historians differ as to what became of
this vessel. One version is that she rolled incessantly and steered
badly, and, having been built rather for magnificence than use, only
made one voyage and was disarmed at Bristol and suffered to
decay. If this be so, it affords an explanation of the discrepancies in
the illustrations of the Henry Grace de Dieu, as it is permissible to
suppose that another vessel bearing that name was constructed to
take its place and that the newcomer afterwards became known as
the Edward. The Henry Grace de Dieu was sometimes called the
Great Harry, but must not be confused with Henry VII.’s ship bearing
that name. The Henry Grace de Dieu was renamed the Edward after
the accession of the next monarch. She had four pole masts; the
foremast was placed almost over the stem, an arrangement which
must have made her pitch deeply and recover slowly; the mainmast
was at the break of the after deckhouse or sterncastle; the mizen or
third mast was midway between the mainmast and the stern, and the
fourth, or second mizen, was at the extreme stern, as far aft as it
was possible to place it. Her forecastle overhung her bows by 12 feet
or so, an arrangement which must have made her very
uncomfortable in anything like a sea. She is asserted to have been
the first four-masted vessel. There was also a fifth mast, if it may so
be called, which slanted forward like an immense bowsprit. The first,
second, and third masts had two round tops each, and the fourth
mast one top, these being for the archers. Her sails and pennants
were of damasked cloth of gold. Her armament comprised twenty-
one heavy brass guns, and numerous smaller pieces of various
types; but when she passed into the possession of Edward VI. she
had nineteen brass guns and one hundred and one of iron.
GREAT SHIP OF HENRY VIII.

(From a drawing by Holbein.)
As already stated, the great majority of the ships built for mercantile
purposes were intended to be able to give a good account of
themselves if they should be assailed by a hostile vessel, a
contingency which was not at all unlikely in the days when ships
roved the seas under the protection of letters of marque and made
“mistakes” as to the nationality of the prize when the prospective
booty might be held to justify the error. Before the nations took to
building vessels especially for war every merchant was liable to have
his traders requisitioned for war purposes, and even up to the end of
the nineteenth century the inclusion of armed merchantmen in
national forces was not uncommon. Letters of marque were permits
granted to ship owners whose vessels had been despoiled by the
subjects of another nation to recoup themselves at the cost of any
vessels belonging to that nation which they could capture, and to
continue to do so until the losses were made good. Naturally they
found this profitable, much more so indeed than ordinary trading,
and did not hesitate to set a low value upon all captures when
casting about to find an excuse for another expedition. Piracy, too,
was rife, and as at sea every shipmaster was a law unto himself
unless there was someone at hand to enforce a change of views, the
shipmaster or merchant turned pirate usually nourished exceedingly
until captured red-handed, when his shrift was like to be a short one.
As an instance of the license to which this liberty was extended, may
be mentioned the Barton family who, in the fifteenth century, had
granted to them letters of marque to prey upon the Portuguese in
retaliation for the murder of John Barton, who was captured and
beheaded by Portuguese. His sons conducted the enterprise with
such thoroughness that they were able to pay their Scottish Royal
master so well that they were never interfered with by him, and when
he entrusted them with the task of reducing the Flemish pirates who
levied toll on Scottish commerce, they sent him a few barrels filled
with pickled human heads to show that they were not idle. The fame
of this Scottish family became world wide, for they had now a
powerful fleet and traded and fought and captured where they would,
so that the reputation of the Scottish navy was great. One of the
ships of the Barton family, the Lion, was second in size and
armament only to the Great Harry itself. The death of Sir Andrew
Barton is commemorated in a well-known ballad.
When vessels with two and more decks were constructed, the lower
ports were cut so near the water that when the vessel heeled, or
even a moderate sea was running, the guns could not be worked.
The ports of the Mary Rose, which was the next largest ship to the
Regent, at one time, and had a tonnage variously stated at 500 and
660 tons, though afterwards surpassed by the Sovereign, 800 tons,
Gabriel Royal, 650 tons, and Katherine Forteless, or Fortileza, were
but 16 inches above the water. She was lost, in 1545, through the
water entering her lower ports when going about off Spithead, and
her commander and six hundred men went down with her; the Great
Harry had a narrow escape from a similar disaster at the same time.
A report on the Royal Navy in 1552 makes interesting reading. The
fleet was overhauled, and twenty-four “ships and pinnaces are in
good case to serve, so that they may be grounded and caulked once
a year to keep them tight.” This is endorsed, “To be so ordered, By
the King’s Command.” Other seven ships were ordered to be
“docked and new dubbed, to search their treenails and iron work.”
The Mrs. Grand, a name which no longer adorns the “Navy List,” a
vessel carrying a crew of two hundred and fifty men, and having one
brass gun and twenty-two iron guns, lying at Deptford, was
recommended to be “dry-docked—not thought worthy of new
making”; so she was ordered “To lie still, or to take that which is
profitable of her for other Ships.” Six others were stated in the report
—a document seemingly the work of a naval reform party—to be
“not worth keeping,” but they were ordered “To be preserved, as they
may with little charge.”
Queen Elizabeth, whose patriotism and naval enthusiasm were
about equally in evidence, was careful of her men and ships, raised
the pay of her officers and seamen, and took steps generally to have
the navy and the naval resources strengthened and conserved. She
seems to have had twenty-nine vessels in 1565. She also
encouraged merchants to build large vessels, which could be
converted into warships as occasion required. The exigencies of
trading over sea, however, were such that many of the vessels
required little to be done to them in the way of conversion. Vessels
were also rated at from 50 to 100 tons more than they measured.
BREECH-LOADING GUN RECOVERED FROM THE

WRECK OF THE “MARY ROSE.”
In the Museum of the Royal United Service Institution. A spare chamber
is shown in the front.
“The Queen’s Highness,” a contemporary historian writes,[19] “hath
at this present already made and furnished, to the number of One
Hundred and Twenty Great Ships, which lie for the most part in
Gillingham Road. Beside these, her Grace hath other in hand also;
she hath likewise three notable Galleys, the Speedwell, the
Tryeright, and the Black Galley, with the sight whereof, and the rest
of the Navy-Royal, it is incredible to say how marvellously her Grace
is delighted. I add, to the end that all men should understand
somewhat of the great masses of treasure daily employed upon our
Navy, how there are few merchant ships of the first and second sort,
that being apparelled and made ready to sail, are not worth one
thousand pounds, or three thousand ducats at the least, if they
should presently be sold. What then shall we think of the Navy-
Royal, of which some one vessel is worth two of the other, as the
shipwright has often told me.”
Queen Elizabeth had, in 1578, twenty-four ships ranging from the
Triumph, of 1,000 tons, built in 1561, to the George, of under 60
tons.
When the Spanish Armada arrived in the Channel in 1588, the
British fleet, which numbered one hundred and ninety-seven vessels,
included thirty-four belonging to the state. The remainder were ships
of various kinds and sizes, mostly small, hired by the state or
provided by private owners, and fitted out hastily for war purposes by
their owners or the ports. The Cinque Ports, it should be
remembered, which furnished a considerable number, were obliged
by Henry VIII., in return for certain privileges, to supply him with fifty-
seven ships, each containing twenty-one men and a boy, for fifteen
days once a year at the ports’ expense, and it often happened that
the ports had to find a greater number of vessels. After the fifteen
days they received state pay. A similar arrangement held good at the
time of the Armada. The largest ships in the English force are
sometimes stated to have carried fifty-five or sixty guns, and one
may have carried sixty-eight guns. The armament of the Triumph,
which was the heaviest armed English vessel, comprised four
cannon, three demi-cannon, seventeen culverins, eight demi-
culverins, six sakers, and four small pieces. The Elizabeth Jones, of
900 tons, built in 1559, carried fifty-six guns, and the Ark Royal, Lord
Howard’s flagship, launched in 1587, had fifty-eight guns and a crew
of four hundred and thirty men, her tonnage being 800. The principal
royal ships and the number of guns they carried were, as far as can
be ascertained accurately: Ark Royal, fifty-five guns; Lion, thirty-
eight; Triumph, forty-two; Victory, forty-two; Bonaventure, thirty-four;
Dreadnought, thirty-two; Nonpareil, thirty-eight; Rainbow, forty;
Vanguard, forty; Mary Rose, thirty-six; Antelope, thirty; and
Swiftsure, forty-two. The Spanish ships were rather floating
fortresses packed with soldiers, and desiring to come to close
quarters so that the fight should be of the hand-to-hand description
to which they were accustomed. The English ships were smaller, and
though more numerous, of little more than half the total tonnage of
the Armada, and were, on the whole, more lightly armed. Still, a
large number of the English vessels carried what were long, heavy
guns for those days, and they used them at short range when they
assumed a windward position and attacked the Spanish rear,
inflicting great damage and throwing the enemy into confusion. This
defeat definitely established the cannon as the principal weapon for
warfare afloat, and inaugurated a new era in the history of the
world’s fighting navies.
THE “ARK ROYAL,” THE ENGLISH ADMIRAL’S FLAGSHIP.
From a Contemporary Print.
(click image to enlarge)
Of the merchant ships engaged, the largest were the Leicester,
sometimes called the Galleon Leicester, and the Merchant Royal,
each of 400 tons. The great galleys and galleasses of the Armada
were not the largest ships afloat by a great deal, for they were far
exceeded in size by many contemporary merchantmen in the
Mediterranean.
The Queen’s ships were sometimes employed upon peaceful and
ambassadorial errands. The voyage of the Ascension to
Constantinople shows a definite attempt to spread English prestige
in distant seas by means of English trade openings, instead of by the
diplomacy of the day, a prominent feature of which was the discovery
of means and opportunities of raiding a state having much portable
riches and not sufficient power to protect them.
The Ascension, in which Queen Elizabeth sent her second present
to the Sultan of Turkey, left London in March, 1593, and arrived in
August, 1594. She was “a good shippe very well appointed, of two
hundred and three score tunnes (whereof was master one William
Broadbanke, a provident and skilfull man in his faculties).” Some
days after the arrival when the wind suited, “our shippe set out in
their best manner with flagges, streamers, and pendants of divers
coloured silke, with all the mariners, together with most of the
Ambassador’s men, having the winde faire, and came within two
cables’ length of this his moskyta,[20] where (hee to his great content
beholding the shippe in such bravery) they discharged first volies of
small shot, and then all the great ordinance twise over, there being
seven and twentie or eight and twentie pieces in the shippe.”[21]
The early part of the seventeenth century, when James I. was king,
saw a remarkable advance in shipbuilding, thanks to Phineas Pett,
who dropped the somewhat haphazard rule-of-thumb methods of
ship construction and introduced a more or less scientific system of
measurement and estimate of weights. In 1610, the Prince, or Prince
Royal, of 1,400 tons, and mounting sixty-four guns, was launched.
She is described as “Double-built,” which has been supposed to
mean that she had an outer and inner skin and an additional number
of beams, etc. This may afford a partial explanation of the fact that
though seven hundred and seventy-five loads of timber were
estimated to be necessary for her construction, one thousand six
hundred and twenty-seven loads were used. Also, as the ship only
lasted fifteen years, a possible further explanation of the discrepancy
may be found in the suggestion that much of the timber supplied and
included in the larger amount was unfit for use. The Prince Royal
was “most sumptuously adorned, within and without, with all manner
of curious carving, painting and rich gilding, being in all respects the
greatest and goodliest ship that was ever built in England.” In 1624
this ship had two cannon-petro, six demi-cannon, twelve culverins,
eighteen demi-culverins, thirteen sakers, and four port-pieces.
THE “SOVEREIGN OF THE SEAS.”
From the Model in the Royal Naval College Museum, Greenwich.
THE “PRINCE ROYAL.”
Designed by Phineas Pett.
By permission of the Elder Brethren of Trinity House.
Good sea fighters as the English had proved themselves to be, they
yet were behind the Dutch and French as naval architects. Sir Walter
Raleigh, an outspoken critic of the King’s ships and of English
merchant vessels, comparing the latter with those of the Dutch,
nevertheless admitted that some progress had been made in English
shipping. “In my own time,” he writes, “the shape of our English ships
hath been greatly bettered. It is not long since the striking of the
topmast hath been devised. Together with the chain pump, we have
lately added the Bonnet and Drabler.... To the courses we have
devised studding sails, top-gallant sails, spritsails and topsails. The
weighing of anchors by the capstan is also new. We have fallen into
consideration of the length of cables, and by it we resist the malice of
the greatest winds that can blow. We have also raised our second
decks.” The last improvement was one of the most important, for the
space between the decks was cramped, and the lower deck was not
much above the water level. The raising of the decks gave the ships
more freeboard and increased their seaworthiness, rendered the
lower tier of guns more effective by enabling them to be used with
less danger from water entering the ports, and gave the men working
the guns on the lower tier more head room.
A list of the ships of King Charles, dated 1633, is of more than usual
interest, says Derrick, “this being the earliest list of the Navy I have
met with, wherein any part of the ships’ principal dimensions are
inserted.... This is the first list in which any nice regard seems to
have been paid to the tonnage of the Ships. Previous to 1663, the
tonnage of almost every Ship seems to have been rather estimated
than calculated, being inserted in even numbers.”
A natural development of the Prince Royal was the Sovereign of the
Seas. These two vessels may be regarded as marking the first and
second stages in the final period of transition from the old style of
warship to the wooden walls. She was a remarkable vessel in
national as well as naval history, for she played not a small part in
the agitation over the question of ship-money, which had such a
tremendous influence on the nation’s development.
“This famous vessel,” Heywood states in his publication addressed
to the King, “was built at Woolwich in 1637. She was in length by the
keel 128 feet or thereabout, within some few inches; her main
breadth 48 feet; in length, from the fore end of the beak-head to the
after end of the stern, a prora ad puppim, 232 feet; and in height,
from the bottom of her keel to the top of her lanthorn, 76 feet; bore
five lanthorns, the biggest of which would hold ten persons upright;
had three flush decks, a forecastle, half-deck, quarter deck, and
round house. Her lower tier had thirty ports for cannon and demi-
cannon, middle tier thirty for culverines and demi-culverines, third tier
twenty-six for other ordnance, forecastle twelve, and two half-decks
have thirteen or fourteen ports more within board, for murdering
pieces, besides ten pieces of chace-ordnance forward and ten right
aft, and many loop-holes in the cabin for musquet-shot. She had
eleven anchors, one of 4,400 pounds weight. She was of the burthen
of 1,637 tons.... She hath two galleries besides, and all of most
curious carved work, and all the sides of the ship carved with
trophies of artillery and types of honour, as well belonging to sea as
land, with symbols appertaining to navigation; also their two sacred
majesties’ badges of honour; arms with several angels holding their
letters in compartments, all which works are gilded over and no other
colour but gold or black. One tree, or oak, made four of the principal
beams, which was 44 feet, of strong serviceable timber, in length, 3
feet diameter at the top and 10 feet at the stub or bottom.
“Upon the stem head a Cupid, or Child bridling a Lion; upon the
bulkhead, right forward, stand six statues, in sundry postures; these
figures represent Concilium, Cura, Conamen, Vis, Virtus, Victoria.
Upon the hamers of the water are four figures, Jupiter, Mars,
Neptune, Eolus; on the stern, Victory, in the midst of a frontispiece;
upon the beak-head sitteth King Edgar on horseback, trampling on
seven kings.”
The Sovereign of the Seas was the largest vessel yet built in
England, and though she was intended as much for show as use,
she became, when she was reduced a deck and a lot of this
ornamental flummery was removed, one of the best fighting ships in
the navy, and was in nearly all the chief engagements in the war with
Holland, and proved herself a very serious opponent, as the navy
records show.
It was about this time that ships were first rated or classified
according to their size and efficiency as fighting units. About this time
also, a new type of vessel, the frigate, was introduced into the navy.
The frigate is not a British invention, but, so far as this country is
concerned, was copied from the French by Peter Pett, son of
Phineas Pett, who saw one in the Thames. He built, in 1649, the
Constant Warwick to the order of the Earl of Warwick, who intended
her for a privateer, but sold her.
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Rubab I. Qureshi, MBBS, MD, PhD Division of Nursing Science, School

© Springer International Publishing AG, part of Springer Nature 2019 3

Classism Bourdieu’s theory is instructive in understanding

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BREECH-LOADING GUN RECOVERED FROM THE

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