Poverty, Allostasis, and Chronic Health Conditions: Health Disparities Across the Lifespan

Definition

Poverty is an important social determinant of health disparities across the lifespan. Poverty also influences other life challenges such as pecuniary instability, food insecurity, housing instability, educational inequality, and limited career mobility. According to the World Bank, more than 700 million people worldwide live in global poverty, surviving on less than USD 2.15 a day. Poverty may also be viewed as a state of deprivation that limits access to resources that address basic needs (i.e., food, water, shelter, clothing, health), limiting an individual’s opportunity to participate optimally in society. A large body of research has identified a positive relationship between poverty and chronic health concerns such as heart disease, diabetes, high cholesterol, kidney problems, liver problems, cancer, and hypertension. This entry examines health disparities associated with economic status, discrimination, racism, stress, age, race/ethnicity, gender, gender identity, and nationality from a social justice perspective.

1. Introduction

The National Institute on Minority Health and Health Disparities [1] defines health disparities as the occurrence of diseases at greater levels among marginalized groups compared to a reference group. Reference groups may include race/ethnicity, gender, gender expression, socioeconomic status, nationality, religion, ableism, and age. It is important to note that health disparities reflect the preventable differences in the morbidity and mortality rates experienced by disadvantaged groups [1]. These preventable differences suggest the opportunity for a reduction in the health burden for these groups. Poverty and race/ethnicity are two important social determinants of health disparities since both are known to influence other life outcomes such as food insecurity, economic insecurity, housing instability, educational inequality, and overall well-being. This discourse utilizes a nuanced life course perspective to examine chronic health conditions influenced by environmental stressors such as poverty, racism, and discrimination, centering health and well-being as basic needs and human rights issues.

The World Bank [2] purported that more than 700 million people worldwide live in global poverty, surviving on less than USD 2.15 a day. While every country determines its poverty line, the international poverty line of USD 2.15 serves as a standard for countries to measure extreme poverty (USD 1.90/day). Poverty may also be viewed as a state of deprivation that limits access to resources that address basic needs (i.e., food, water, shelter, clothing, healthcare, education), reflecting an “environmental press”. Consequently, individuals having the necessary resources to meet their basic needs reflect a “goodness of fit”, and for this entry, such individuals function as a reference group.

Globally, children represent nearly half of the individuals struggling to survive on less than USD 2.15 a day [3]. Around the world, roughly 1 billion children are “multidimensionally poor”, indicating they lack basic necessities such as nutritious food, clean drinking water, and basic services such as transportation, housing, communication, and health systems [3]. Children experiencing environmental adversity (e.g., living in impoverished neighborhoods) have been found to experience high rates of chronic stress and chronic physical health concerns, potentially impacting future trajectories [4,5,6]. Knowledge of the factors influencing the early development of chronic health conditions provides opportunities for early interventions that could reduce adverse health and social outcomes for the global society.

McEwen and Stellar coined the term “allostatic load” to explain the poorer health outcomes experienced by marginalized groups as a result of the chronic stress resulting from experiences with racism and discrimination [7]. Extant research has identified racism and discrimination as factors in the development of chronic health concerns such as cardiovascular disease (CVD, diabetes, high cholesterol, hypertension, and cancer [4,5,7,8]). Globally, the highest rates of poverty and chronic health conditions appear to be associated with racial and ethnic groups [5,7,8]. Geronimous et al. [5] reported that the stress-influenced health burden experienced by Black/AA persons was equivalent to the wear and tear of a White person 10 years older. Geronimous proffered the term “weathering” to explain the cumulative effect of repeated exposure to social and economic adversity. Section 1.3 provides a more detailed discussion of the relationship between poverty, stress, allostasis, and chronic health concerns.

While individual countries may utilize different monetary amounts to identify poverty, the health burden for those in poverty is comparable at the individual level. Poverty exacerbates risks for marginalized groups to experience discrimination based on a number of intersecting identities, particularly as it relates to healthcare [9,10]. Healthcare inequities are deeply embedded in the healthcare system, presenting as inequality in the diagnosis, management, and treatment of the health conditions experienced by marginalized groups [11]. In some developing and industrialized nations, access to quality medical care remains a problem due to practitioner attitudes, beliefs, and behaviors [12,13]. Although poverty functions as an important social determinant of health disparities, racialized groups, historically, have been the recipients of inequitable healthcare treatment, independent of income status [5,8,10,11] This entry examines the health outcomes that occur when environmental challenges exceed an individual’s ability to cope.

1.1. Medical Racism

The inequitable health care provided to certain groups is reflected via medical racism: the systematic racism against people of color within the medical system [14,15,16]. In order to fully grasp the healthcare disparities occurring as a result of medical racism, it is imperative to explore global modern-day and historical examples to understand the pervasiveness of this practice. Emanating from historical roots to the modern day is the widely acknowledged medical practice involving the belief that Black persons have a higher pain threshold and tougher skin than White persons, a misconception that continues to influence current medical practice [17]. A number of studies have revealed that Black patients are less likely to receive pain medication compared to White patients, even when presenting with the same symptoms [17,18]. This false belief in biological differences between the races contributes to patterns of unequal treatment and inadequate care for people of color (POC) [19]. A British study on pain treatment provided to British mothers of mixed heritage revealed that Black, Asian, and mixed-heritage mothers received different levels of pain medication compared to White mothers [18]. While the United Kingdom (UK) is reported to have the lowest maternal mortality rates in the world, this statistic is not applicable to women of color. According to the House of Commons’ Women and Equalities Committee, the maternal mortality rate for Black women is four times higher than that for White women [20].

The Tuskegee Syphilis Study represents one of the most notorious examples of medical racism in the United States (US), starting in 1932 and continuing for 40 years. In this study, 600 Black men—399 with syphilis and 201 without—were misled by researchers from the US Public Health Service and the Centers for Disease Control and Prevention. They were told they were receiving free healthcare for their “bad blood” [21,22]. In reality, they were not treated for syphilis, even after penicillin became the standard treatment in 1947. By the end of the study, only 74 of the uninformed participants were alive: 28 died of syphilis; 100 died of related complications; 40 wives had been infected; and 19 children were born with congenital syphilis [22].

The final example of medical racism rests with the forced sterilization of Indigenous women in the Canadian provinces of Alberta, Saskatchewan, and British Columbia. Canada’s 1928 Sexual Sterilization Act allowed persons residing in government-run institutions to be sterilized without their knowledge or consent. Extant research indicates that 74% of Aboriginals presented to the Eugenics Board for sterilization were sterilized compared to 60% of all patients presented [23]. Forced sterilization was supported as a method for limiting the reproduction of “unfit” Indigenous persons. This practice was supposed to have ended in the 1970s, yet a bill to criminalize forced sterilization was introduced to Parliament in 2024 [24]. Awareness of historical and current instances of medical racism may lead to mistrust of medical professionals and enhance opportunities for a heightened stress response.

Accompanying instances of medical racism is the geographical distribution of healthcare facilities in racial/ethnic communities. In the US, predominantly Black and Hispanic/Latinx neighborhoods are often underserved, with fewer hospitals, clinics, and pharmacies, leading to limited access to essential healthcare services [25]. These disparities are a direct result of historical redlining and discriminatory zoning practices that left marginalized communities with fewer resources, thus constraining their ability to address their basic needs. Current and past healthcare practices appear to support the value of bias-free, culturally informed healthcare for the global society [26,27].

1.2. Basic Needs and Human Rights

Maslow’s [28] theory on human motivation describes how the inability to meet basic needs such as food, water, shelter, clothing, and healthcare may hamper a person’s ability to address higher-level needs. The first four levels of basic needs represent deficiency needs, while the fifth, self-actualization, represents a growth need. When basic needs are not met, self-actualization may not occur, rendering these individuals unable to achieve personal growth or contribute positively to society. Entitlement to basic needs is supported by the United Nation’s Universal Declaration of Human Rights [29] that “everyone has a right to a standard of living adequate for health and well-being”. Despite this pronouncement, opportunities to experience basic human rights continue to be influenced by income inequality, discrimination, and social structure since economically disadvantaged individuals rarely have a voice in neighborhood conditions, the services they receive, or the income provided via work or income transfer programs. The inability to have basic needs addressed and to experience basic human rights exacerbates risks for chronic stress, increasing the health burden for marginalized persons. Maslow’s theory provides the foundation to understand person-centered responses to unmet basic needs, as well as the potential impact on societal well-being.

1.3. Stress, Allostasis, and Chronic Health Concerns

Allostasis is the process by which the body responds to stress and works to regain balance or homeostasis. This is accomplished through the release of cortisol. Anyone can experience stress, but many reactions are generally time-limited rather than long term or indefinite. The release of cortisol allows the body to adapt to the stressor and return organ systems to “normal” levels [5,7,8]. Contrarily, repeated or ongoing exposure to stressors prevents the body from regaining homeostasis, allowing the continued release of cortisol and other hormones that may ultimately damage organs and tissues [5,7,8]. High cortisol levels can lead to inflammation, Type 2 diabetes, and high blood pressure, as well as significant health disparities for marginalized groups [30,31]. The related concept of allostatic load represents a measure of cumulative stress that leads to chronic health conditions such as allostatic heart failure, allostatic kidney failure, and allostatic liver failure [5,7,8].

1.4. The Challenge for the Global Society

As global society considers the well-being of all people, it is important to consider the health impact of poverty, discrimination, and structural inequities. Health disparities must be viewed from a social justice lens to accurately assess how poverty, racism, and healthcare disparities are maintained and to identify possible solutions that will benefit the global community. The well-being of a society’s people is critical to the well-being of that society. To this end, this entry will explore income and race-/ethnicity-related health trajectories from infancy to older adulthood. For each developmental stage, case examples are provided to illustrate the universal impact of poverty, discrimination, and a host of other social forces on micro- and macro-level health outcomes around the world.

2. Infant and Toddler Health Disparities

Poverty affects child development and well-being via the stress experienced growing up in an indigent home environment. Children from disadvantaged backgrounds experience many stressful opportunities, primarily as a result of their reliance on adults to provide safety and stability. Unlike adults, children have fewer options to avoid or escape traumatic experiences in their home life. One of the largest investigations into child abuse and health outcomes later in life was the CDC-Kaiser Permanente Adverse Childhood Experiences (ACEs) study conducted by Felitti et al. [32]. This study identified a strong relationship between exposure to abuse and/or household dysfunction and risk factors for several leading causes of death in adults: cancer, diabetes, and heart disease. ACEs are potentially traumatic events that occur during childhood (0–17 years) and include physical, sexual, and verbal abuse; neglect; witnessing violence; substance abuse in the family; mental illness in the family; having an incarcerated family member; and parental separation. ACEs result in toxic stress that affects brain development, immune systems, and stress-response systems. Toxic stress is a type of chronic stress that shuts down areas of the brain as a defense mechanism for the child’s uncontrollable fear [32].

The Council on Community Pediatrics reported that poverty has a significant effect on birth weight, infant mortality, chronic illness, nutrition, and injury [33]. Allostasis (the body’s attempt to regain balance) is the primary mechanism by which poverty affects child development and influences risks for early developmental, physiological, and mental health challenges [4]. Children who experience poverty during their early years are at-risk for adverse health outcomes throughout their lifespan [33].

Longitudinal studies function as useful resources for comprehending health pathways, allowing researchers the opportunity to assess exposure-related changes to different events and subsequent health outcomes. One longitudinal study with 1135 children reported a relationship between early environmental adversity and poverty to resting or basal level cortisol in infants and children from 7 months to 48 months [4]. Significant stress effects were reported for poor housing quality, African American ethnicity, and low caregiving behavior to higher levels of salivary cortisol [4]. This research suggests the possibility of early cognitive impairment for African American children. Another study revealed that the length of time children live in poverty was associated with elevated AL during early adolescence, suggesting a cumulative stress effect [34]. Combined, the two studies appear to suggest that African American children who live a significant portion of their life in impoverished neighborhoods have a greater chance of experiencing some degree of cognitive impairment.

Poverty affects the health and well-being of children via the toxic effects of stress on the brain during the critical stages of development [32]. This phenomenon represents a global public health issue. Since children are the future, all efforts should be directed to do everything necessary to ensure their mental and physical well-being. Despite its status as a superpower, child poverty in the US is greater than many of the Organization for Economic Cooperation and Development (OECD) countries with similar resources [35]. During 2022, Costa Rica had the highest share (28.2%) of children living in poverty, followed by Turkey at 22%, then Chile, Spain, and the United States at 20.5%, with Finland having the lowest child poverty share at 3% [35]. Child poverty rates appear daunting, especially for developed nations such as the US.

2.1. Case Example: Finland: Low Child Mortality Rates and the Baby Box

In 2022, Finland’s infant mortality rate was 1.422 deaths per 1000 live births, and the under-5 mortality rate was 2.3 deaths per 1000 live births [36]. Finland’s child mortality rate declined from 37.846 deaths per 1000 in 1950 to 1.381 deaths per 1000 in 2023 [37]. The highest child mortality rates occurred at a time when Finland’s birth rate was declining, presenting a double dilemma. To address this concern, the government-sponsored Baby Box, or maternity package, was implemented to reduce infant mortality rates and enhance the fertility rates of Finnish women. The Box was provided free to new mothers and functioned as an incentive to connect pregnant women with prenatal care. The Box was implemented to ensure that each baby had an equal start in life. It included diapers, food, clothing, toys, blankets, books, and bedding, enhancing opportunities to meet the baby’s basic needs. The Box also functioned as a crib as it also contained a mattress that fit securely inside. Paid maternity leave provides an opportunity for Finnish parents and infants to experience a “goodness of fit”. The Baby Box program impacted both micro- and macro-level outcomes. Finland’s population is primarily White: This suggests that much of Finland’s population is more likely to experience privilege rather than disadvantage. The Baby Box program addresses the developmental needs of Finland’s future citizens through the allocation of in-kind and monetary resources, reducing opportunities for health disparities.

2.2. Case Example: Haiti: High Child Mortality Rates and the Bonbon tè aka Mud Cookie

The majority of Haitian children live in poverty and are deprived of basic needs such as clean drinking water, food, sanitation, education, and healthcare, representing an “environmental press”. The World Bank [2] projects Haiti’s poverty rate to be 29.2% for the international poverty line and 58% for USD 3.65 per day, with nearly 3 million Haitian children in need of humanitarian support [3]. Haitian children experience chronic health conditions such as malnutrition, cholera, and early-onset heart disease. Heart disease is the No. 1 cause of death in Haiti [38]. One Haitian child in fourteen will die before the age of five [39]. For 2024, Haiti’s infant mortality rate is projected to be 46.869 deaths per 1000 live births, with the under-5 mortality rate projected at 56.5 deaths per 1000 live births [39].

Due to extremely high poverty rates, natural disasters, and internal conflicts, food is scarce, forcing many Haitian children to satisfy their hunger by eating mud cookies (Bonbon tė). These environmental conditions elevate Haitian children’s stress, resulting in allostasis. Some Haitians view the mud cookies as nutritious due to the perceived mineral content. Mud cookies do contain differing amounts of iron, potassium, and zinc, but these nutrients are not bioavailable because they are locked inside silicates. Eating dirt increases risks for parasites, heavy metal poisoning, and gastrointestinal problems. Haiti is the poorest country in the Western Hemisphere and has a predominately Black population comprising largely descendants of African slaves. This suggests the likelihood of racial discrimination and heightened risks for Haitian children to experience economic and social disadvantage, adverse childhood experiences, and the denial of basic needs and human rights. As an under-resourced country, Haiti does not have the funds to enhance the healthy development of its youngest citizens as Finland.

3. Children’s Health Disparities

The most paramount issues shaping child health inequities are due to the widespread prevalence of impoverished living conditions. The lack of economic resources leads directly to food access barriers, as well as deterring access to high-quality food with nutrient density. UNICEF [40] reported that 181 million children live in severe food poverty—roughly 1 in every 4 children globally—with the highest rates of severe poverty located in South Asia (38%). Although the deaths of children under 5 have been decreasing over time (60% since 1990), the World Health Organization reported that 4.9 million died before their 5th birthday [41].

Some of the most significant child health challenges include infectious diseases, respiratory infections, pneumonia, diarrhea, and malaria [42]. Asher and colleagues [43] note that asthma is “the most common non-communicable disease in children”, with prevalence varied but rising in low- and middle-income countries. On a daily basis, 1 billion children “are exposed to excessively high levels of air pollution”, and 920 million are without access to clean drinking water [44]. It is estimated that over 81 million children are affected by asthma [45]. Nearly 37 million children under age 5 are overweight, and 160 million are living with obesity [46]. Obesity is inextricably related to physical health, mental health, and well-being. Importantly, limited access to healthcare prevention, treatment, high-quality food, and clean drinking water may be exacerbated by rising forms of economic inequality and the climate crisis [44].

Case Example: First Nations Children (Canada, New Zealand, Australia)

Despite entry into the 21st century, histories of colonization and oppression continue to have a significant impact on the health and well-being of First Nations Peoples, resulting in chronic stress and allostasis. First Nations children continue to be constrained by inequalities in housing, education, employment, and healthcare, with poverty playing a pivotal role in their inability to access needed resources. In Canada, it is estimated that 47% of First Nations children live in poverty. In Australia, half of Indigenous children live in poverty, and in New Zealand, 14.5% of Māori children and 19.5% of Pacific Islander children live in poverty [47]. First Nations children 17 years or under in Canada, New Zealand, and Australia are overrepresented for chronic health conditions such as rheumatic fever, respiratory diseases, renal disease, diabetes, and skin diseases, with barriers to healthcare contingent upon finances, transportation, health literacy, and the provision of culturally appropriate healthcare [47]. First Nations children are constrained by poverty, education, unemployment, and limited access to healthcare, conditions reflective of an “environmental press”.

4. Adolescent/Teen Health Disparities

Adolescence is the developmental phase that marks the shift from childhood to adulthood and is characterized by significant social, emotional, and physical changes, each providing opportunities to experience stress and other adverse health concerns. Poverty is one of the predominant determinants of health disparities among adolescents. Common pediatric-onset chronic conditions include asthma, diabetes, cerebral palsy, sickle cell anemia, cystic fibrosis, epilepsy, spina bifida, chronic pain, inflammatory bowel disease, congenital heart disease, and rheumatic diseases [48]. According to a joint report published by the World Bank and UNICEF in 2022, approximately 14.8% of adolescents aged 10–14 and 11.9% of adolescents aged 15–17 worldwide lived in extreme poverty, as calculated at the USD 2.15-per-day international poverty line [49]. A systematic review of adolescents aged 12 to 18 from economically disadvantaged families revealed they were at a greater risk of experiencing severe chronic health conditions and deteriorating mental health as a result of income instability [50]. Roughly 15–20% of adolescents (ages 12–17) in North America live with a chronic health condition, 90% of whom will require ongoing care into adulthood [51].

Case Example: Hawai’i: Prenatal Exposure to Chronic Stress and a History of Oppression

Prior to European contact, violence, and land appropriation, Hawai’ian people were healthy. As a consequence of the violent overthrow of the Hawai’ian Kingdom, long-lasting social, emotional, economic, and health inequities persist [52]. Native Hawai’ians (NH) experience discrimination and racism that has been associated with depressive symptoms, cortisol dysregulation, higher systolic blood pressure, and an exaggerated cardiovascular response [53]. Chronic health concerns such as obesity, diabetes, hypertension, chronic kidney disease, asthma, stroke, cancer, cardiovascular disease, and Methicillin-resistant Staphylococcus aureus are common for Hawai’ian youth [54]. Additional challenges to the well-being of native Hawai’ians include food insecurity, income insecurity, housing insecurity, low educational attainment, unemployment, and a host of mental health concerns, all representative of an “environmental press”.

In their quest to identify the social determinants of the health burden for Hawai’ian children and adolescents, Liu and Alameda [52] analyzed health records that led to evidence highlighting prenatal exposure to allostatic load as an influence in later-life health disparities. This consideration was influenced by their observation that the rates of chronic health conditions began to increase around age 9, suggesting the possibility of a cumulative health burden. Another study conducted by researchers at the University of Hawai’i, Manoa reported that many Hawai’ian youth receiving emergency hospital care suffered from illnesses traditionally experienced by middle-aged and older adults, a phenomenon suggestive of “weathering” [54]. Collectively, these study findings lend support to the proposition that prenatal exposure to AL could lead to health concerns in later life [5,55].

5. Young Adult Health Disparities

Young adulthood, typically defined as the period between 18 and 30 years, is a critical stage in human development marked by major transitions in education, employment, and personal relationships. Globally, nearly 85 million young adults live in extreme poverty [56]. In the U.S., 17% of young adults aged 18–24 live below the federal poverty line, with poverty rates disproportionately higher among Blacks (29%) and Hispanics (25%) [57]. The stress young adults experience as a result of life transitions, coupled with poverty, provides opportunities to experience allostasis and an “environmental press”. Young adults from low-SES backgrounds are more likely to develop diabetes, cardiovascular diseases, and obesity, largely due to inadequate access to preventive care and nutritious food [58]. According to a United Nations report [59], 17% of US young adults aged 18–24 were obese, and 9% suffered from diabetes. Black and Hispanic young adults had higher obesity rates at 24.5% and 21.2%, respectively, compared to their White counterparts at 15.6% [60]. Despite their healthcare needs, approximately 14.4% of US young adults aged 19–25 were uninsured, with Hispanic and Black persons disproportionately affected at rates of 27.7% and 14.4%, respectively [61].

Gender plays a crucial role in determining health outcomes for young adults. Gender-based discrimination and violence often limit young women’s and transgender individuals’ access to healthcare, education, and economic opportunities, exacerbating health disparities. Transgender individuals are more likely to live in lower-income neighborhoods and experience higher rates of asthma, chronic obstructive pulmonary disease (COPD), and HIV/AIDS compared to cisgender persons [62]. While hormone therapy can be used to assist transgender individuals in transitioning to their identified gender, this treatment could increase risks for cancer and hypertension. Transgender persons have a 40% higher risk of cardiovascular disease (CVD) compared to cisgender people with the same birth sex [63]. A study regarding healthcare bias revealed that 58% of transgender POC reported facing harassment and mistreatment in healthcare settings compared to 33% of their White counterparts [64]. Due to the stigma and attitudes of healthcare providers, transgender persons experience chronic stress (allostasis), and many also suffer from depression and suicidality due to the lack of gender-affirming care. A 2016 study reported transgender suicide attempt rates, ranging from 32% to 50% across countries [65]. A more recent study with transgender persons in the US revealed 81.3% had experienced suicidal ideation, and 42% had attempted suicide over their lifetime [66].

5.1. Case Example: South Africa: The Legacy of Disadvantage

In South Africa, the legacy of apartheid continues to profoundly influence economic, social, and negative health outcomes for Black South African young adults. According to Statistics South Africa [67], the unemployment rate for Black youth aged 18–24 stands at a staggering 63% compared to just 20% for their White counterparts. This economic disparity is a direct consequence of apartheid policies that restricted access to quality education, employment, and economic mobility for Black individuals. Under such economic and social restrictions, Black South African youth are unfairly positioned to experience chronic stress and allostasis. The high unemployment rates among Black young adults not only limit their ability to afford basic healthcare services but also contribute to their vulnerability to chronic health conditions such as malnutrition, mental health disorders, and substance abuse. The increased vulnerability of Black South African young adults may be better explained by a culturally informed ACE model that recognizes the emotional and mental toll South African youth acquire via the epigenetic transmission of racial trauma [68].

Economic disadvantage is further compounded by the geographical and infrastructural inequalities that persist in South Africa. Many Black young adults live in under-resourced townships, which are the result of decades of apartheid. These areas often lack basic healthcare facilities, sanitation, and reliable transportation, making access to healthcare difficult. The HIV prevalence rate among Black youth is 25% compared to just 5% for White youth [69]. A 2021 study by the South African Medical Research Council found that nearly 40% of Black youth in under-resourced areas reported symptoms of depression, but less than 10% had access to mental health care due to cost and distance barriers [70]. The combination of racism, high unemployment, poor living conditions, and inadequate healthcare access perpetuates cycles of poverty for Black South African youth, resulting in an “environmental press”.

5.2. Case Example: India—The Elimination of Extreme Poverty: Caste Exceptions

Worldwide, India has the third-highest number of cancer causes for women, and cardiovascular disease is the leading cause of death for Indian women. Anemia is a common condition of cancer: 51% of Dalit women have anemia compared to 35% of higher-caste women [71]. Despite India’s pronouncement that it has eliminated extreme poverty, this benefit is not applicable to every citizen. Young women from lower castes, particularly Dalit women, face severe health disparities due to the intersection of gender, caste, and poverty. Per the 2021 United Nations report on multidimensional poverty, one-third of India’s Dalit women remain poor and experience limited access to health care [72]. Approximately 23% of Indian women aged 18–30 are underweight due to malnutrition, with even higher rates in rural areas [71]. Maternal mortality rates among Dalit women are nearly twice as high as those for higher-caste women, largely due to inadequate access to maternal healthcare services, poor-quality health facilities, and a lack of essential prenatal care [73,74]. Dalit women are four times more likely to report experiencing sexual violence compared to higher-caste women [75]. These factors highlight the urgent need for targeted interventions to address the unique health challenges faced by Dalit women. Efforts must focus on improving access to healthcare services, particularly maternal and reproductive health, as well as poverty, caste discrimination, and gender-based violence. Dalit women experience an “environmental press” as a result of poverty, gender, and social status.

6. Adult Health Disparities

According to the World Bank [2], approximately 65% of the world’s population falls within the age range of 18–60 years. However, the exact percentage living in poverty is unknown. Poverty in racial and ethnic communities is multidimensional, intersecting with a range of human variations, affecting adult populations differently and disproportionately, and constructing a health and social crisis [76]. Adults who live in impoverished communities experience dysregulated stress responses (allostasis) that may lead to the development of chronic health concerns [77]. Chronic health concerns represent a global health issue that disproportionately affects adults in low- and middle-income countries in the form of diabetes, cardiovascular disease, lung cancer, chronic respiratory disease, tuberculosis, AIDS/HIV, and malaria [78]. It is estimated that 87 million adults aged 19 to 64 are underinsured [64].

Adults living in impoverished communities suffer from poor nutrition, toxic exposures (e.g., lead), higher risk of obesity due to the inadequate quality of available foods, increased intake of calories from foods high in trans-fatty acids, and environments that do not foster physical activity [79,80]. The absence of grocery stores in low-income neighborhoods limits opportunities to consume fresh fruits and vegetables, foods helpful in reducing risks for cancers of the mouth, pharynx, larynx, esophagus, stomach, and lung [81]. Poverty also affects the built environment (i.e., the human-made physical parts of the places where people live, work, and play, including buildings, open spaces, and infrastructure), services, culture, and communities’ reputations, all of which have independent effects on health outcomes. At the community level, residents of lower-income neighborhoods are less likely to have access to higher-quality health care [82,83]. Adults living in poverty have increased health vulnerabilities, early mortality and high rates of disability, depression, anxiety, and loneliness [84]. Eighty percent (80%) of excess mortality due to cardiovascular disease, stroke, cancer, chemical dependency, diabetes, homicide, and unintentional injuries appears concentrated in Black persons and other racial and ethnic minoritized populations [85]. However, the prevalence of poor health is highest among those in the lowest-income and less-educated categories regardless of age or race/ethnicity [86].

Case Example: “Cancer Doesn’t Discriminate”—Black and Latina/Hispanic Women

Disparities in cancer diagnoses exist despite the widely held notion that “cancer doesn’t discriminate” [87]. The Mayo Clinic [88] suggests that avoiding tobacco, eating healthy, getting vaccinated, and seeking regular medical care can help lower your risk of cancer, but factors such as poverty can increase a person’s risk. Persistent poverty counties are defined as those with 20% or more of the population living below the federal poverty level since 1980. Lower socioeconomic groups face multiple obstacles when navigating suggested cancer prevention measures such as eating a healthy diet. For example, having a low intake of garden-fresh fruits and vegetables is associated with a higher risk of gastrointestinal cancers [89]. Lowering cancer risk by healthy eating has been proven difficult due to food insecurity in areas of persistent poverty. Haskins et al. [90] reported that one in ten Americans live in a food priority area (FPA). Food priority areas consist of low-quantity and low-quality grocery stores, in addition to inadequate transportation to arrive there. Haskins et al.’s research identified a direct relationship between food priority areas and various health outcomes, including cancer.

The risk for negative cancer outcomes increases when poverty intersects with race/ethnicity and gender. A study by the Canadian Breast Cancer Network [91] from 1999–2014 revealed that Black American women had higher cancer-related deaths compared to White American women. The CBC study revealed that Black women were more likely to get triple-negative breast cancer—a very aggressive type of breast cancer—than White American women. The risk for breast cancer is increased for Black women because of their susceptibility to its risk factors, many of which are preventable lifestyle diseases such as diabetes, heart disease, and obesity [92]. However, for Black women living in persistent poverty countries, the need for inexpensive, fast meals may outweigh their concerns about unhealthy foods and the increased risk of cancer. Data from The Breast Cancer Research Foundation [92] indicate that Black women are less likely than White women to have adequate health insurance or access to healthcare facilities, which can affect screening and follow-up care. The average Black family spends almost 10% more of their income on healthcare premiums than the average White family, though they make significantly less [93]. Women from low-income areas experience disproportionately lower breast cancer screenings with the fear of abnormal results functioning as a major barrier [94].

Cervical cancer is one of the most preventable types of cancer through the human papillomavirus (HPV) vaccine and regular screenings for early detection. Cancer is the leading cause of death for Hispanic and Latino people, with Hispanic women having the second-highest rate of dying from cervical cancer after non-Hispanic Black women [95]. Hispanic and Latina women also have the lowest rates of screenings compared to Black and White women regardless of their insurance status [96]. This might indicate a disconnect between health literacy, cultural factors, and health practices. Research continues to suggest that structural barriers prevent low-income Hispanic women from receiving adequate health care [97]. To illustrate, new Hispanic immigrants and undocumented immigrants residing in Arizona for less than 5 years are ineligible to receive health insurance [97]. Since the average age of Hispanic immigrants is 27, this 5-year ineligibility adds an additional barrier to cervical cancer prevention, which is most effective when the HPV vaccine is administered at age 11 and vaginal screenings at age 21 [98]. To remedy the treatment disparities for marginalized populations, the American Association for Cancer Research [99] suggests that an increase in the diversity of women, disabled individuals, and minority groups in the cancer care workforce, and cancer research could enhance cultural competence, humility, and a better understanding of the needs of all patients. Limited access to cancer screenings and higher morbidity and mortality rates for Black and Latina/Hispanic women compared to their White counterparts represent an “environmental press”.

7. Older Adult Health Disparities

Older adults are individuals 65 years of age and older, most likely to be retired, and already experiencing chronic health conditions. The process of aging generally includes opportunities to experience changes in income, health, employment, living conditions, personal relationships, physical abilities, and mental health. Individually or combined, these experiences heighten opportunities for chronic stress and allostasis. Most of these changes are exacerbated by poverty. As people age, many face the challenges of inadequate retirement savings, rising healthcare expenses, and restricted access to vital services [100]. This financial insecurity not only impacts their ability to fulfill basic needs such as food and housing but also leads to stress that could worsen current health problems [101]. Older adults encounter more significant challenges in accessing and using services compared to other age groups, mainly due to factors such as physical health problems, disabilities, and mental health issues [102]. The 10 most common chronic health conditions for older adults include hypertension, high cholesterol, obesity, arthritis, ischemic/coronary heart disease, diabetes, chronic kidney disease, and heart failure [103]. Many of these common health conditions originated much earlier in life. The National Council on Aging [103] reported that a total of 47 million households with older adults are currently facing financial challenges or are at risk of experiencing economic insecurity as they age. NCOA findings revealed that 80% of households with older adults are either unable to meet their current basic and long-term care needs or are at risk of being unable to do so in the future [103]. Older women of color experience higher poverty rates than any other demographic: nearly 20% of Latina and Black women aged 65 and older live in poverty, which is twice the rate for White women and nearly three times the rate for White men [104].

7.1. Case Example: Health Disparities in the Mississippi Delta

Residents of the Mississippi Delta in the US frequently experience chronic stress due to harsh economic and environmental conditions [105]. The Mississippi Delta is a rural area characterized by high rates of chronic diseases and is recognized for its unfavorable health outcomes and significant health disparities [105]. Mississippi has a poverty rate of 22%, and its healthcare system ranks 37th out of 38 states with similar large Black populations [106]. According to USA Facts [107], 17.4% of residents in the Mississippi Delta were age 65 and older. The top chronic diseases experienced by older adults (65+) in the Mississippi Delta include hypertension, high cholesterol, arthritis, diabetes, kidney disease, and heart disease [108]. Heart disease is the leading cause of death in Mississippi [109]. According to the Health Equity Scorecard, Mississippi ranked near the bottom or last in terms of health outcomes, healthcare access, and healthcare quality for both Black and White populations [106]. The number of deaths in Mississippi from potentially preventable diseases such as diabetes is significantly higher than the national average for both racial groups. In almost all categories where disparities were assessed, the health burden was more significant for Mississippi’s Black population (106-Stribling, 2021). Ageism, race, high poverty rates, and limited access to healthcare reflect an “environmental press” for older Black adults in the Mississippi Delta.

7.2. Case Example: Hungary: Universal Insurance: The Challenges of an Aging Population

Persons 65 and above make up roughly 20.5% of Hungary’s population [110]. The life expectancy in Hungary is 74.5 years, which is 5.4 years less than the European Union (EU) average. One in ten, or 5.9 million, older Hungarian adults had incomes below the official poverty threshold of USD 14,040 in 2022. As of December 2023, 13.10% of Hungarians were reported to be at risk for poverty [111]. Universal healthcare (NEAK) is free for most residents. This health coverage may be provided via in-kind services or as a cash benefit. Hungary’s healthcare for older adults is available through a combination of long-term care and social services. Despite these services, Hungary ranks at the bottom of the Aging Society Index based on an evidence-based model that involves five components: productivity and engagement, well-being, equity, cohesion, and security. Older Hungarian adults reported a generally poor health status whether residing in rural or urban areas, partially as a result of low health participation rates in preventive health such as dental visits, influenza vaccinations, and cancer screenings [111,112]. Notwithstanding universal healthcare, older adults in Hungary appear to experience an increased health burden, suggesting that agism and poverty may be intersecting factors in this “environmental press”.

8. Conclusions

Poverty represents a social justice issue because it is generally influenced by the economic policies of a society. The intersection of social inequality and economic disparity may result in a cycle of poor health outcomes for persons occupying disadvantaged statuses. The health burden for marginalized groups reflects global trends, where poverty and economic marginalization amplify the effects of ACEs and limit access to basic healthcare services. The compounded effects of economic inequity, poverty, and social exclusion lead to disproportionately high morbidity and mortality rates for persons based on group membership, particularly children [1,5,8,10]. The lack of attention placed on the harm associated with a child’s lack of access to food, water, shelter, clothing, safety, education, and healthcare suggests an uninformed vision for the growth and well-being of that society. Collaboration between private and public entities and local governments to address the root causes of health disparities (i.e., racism, discrimination, and social and economic inequality) is necessary to promote policies that ensure equitable healthcare access [5,8,12,25]. The health burden of a group is not limited to a single context but is seen globally, where local social and economic inequalities compound the adverse health effects on marginalized populations [27]. Examining these issues on an international scale reveals how social stratification and economic inequality shape health outcomes for vulnerable populations around the world. Finally, it may be valuable to produce a framework for understanding the dimensions of health from birth forward, as the effects of health disparities are best understood amid cumulative frameworks, where health challenges early on may persist across the lifespan, leading to chronic health problems, shorter life spans, and factors such as “weathering” [5].