From our first breath in the hospital to the day we die, we live in a society characterized by unequal opportunities for maintaining health and taking care of ourselves when ill. These disparities reflect persistent racial, socio-economic, and gender-based inequalities and contribute to their persistence over time. Social scientists have established that gaps in access to information, uneven material resources, unequal treatment in medical institutions, and differences in interpersonal networks link social inequalities to disparities in morbidity, mortality, and health behaviors. However, we know less about how these links operate in everyday life. This dissertation uses findings from three years of comparative ethnographic research in four urban neighborhoods and 60 in-depth interviews with seniors from different race, class, and gender groups, to show how inequality shapes seniors' responses to the health and illness demands of growing old. The findings show how spatial disparities, resource differences, and social networks profoundly affect the way seniors respond to the challenges of aging. However, explaining how these inequalities operate in everyday life requires understanding how culture links past inequality, present experiences, and behavior in the unequal contexts of the American city.
Although the poor and marginalized have to deal with the problems of growing old at a younger age, all those who live through "old age" face shared predicaments (chapter 2). In old age, seniors across socioeconomic and racial lines confront new challenges grounded in the degeneration of their bodies. As people grew older, they often face pain, a loss of energy, declining mobility, cognitive slowing, and sensory changes. They must confront increased health problems, the deaths of loved ones, and the erosion of prized characteristics like beauty, stamina and wit. Ultimately, they must deal with their own mortality. The problems of their foundering bodies come to profoundly limit what they can do in the world. In facing these predicaments, many seniors from across the social spectrum come to a shared realization that "old age" becomes a primary force in shaping their everyday lives. As they interact with the physical and social world, the dwindling capacities and physical uncertainties of their aging bodies create persistent problems of social action that require a response--the aging body becomes a "structural dilemma."
While they face a shared set of problems, what different groups of seniors see as the most desirable, reasonable, and plausible responses to this dilemma reflect different "cultures of aging" (Chapter 3). These responses reflect both past inequalities and present circumstances.Different combinations of motivations (i.e. protecting the body or maximizing enjoyment before it breaks) and orientations (i.e. the body is self-regulating or the body needs to be regulated) acquired over the life course lead seniors to pursue different strategies in old age-- some spend all day at the doctor's, others spend the day at the bar or other social settings. Some go to the farmers' market for produce, others get sugary drinks at Starbucks. Some wait until a physical problem lands them in the emergency department, others check in with the doctor every time they develop a cough. These differences often break down along the lines of ethnicity and past socioeconomic status. However, they continue to affect how people act even when they have similar resources, access to health care, and information in the present.
Social networks, which also reflect past and present inequality, matter a great deal in old age. Friends, families, neighbors, and acquaintances affect how seniors respond to the everyday challenges of aging (chapter 4). However, how these "social ties" operate depends on shared cultural norms and understandings that differ between groups. For instance, for some helping neighbors is an obligation whereas for others it is an economic exchange. Being in contact with friends can mean lunch and a ride to the doctor or it can mean skipping an appointment to go to the pool hall. While being together matters, what "being together" means is different for different groups of seniors.
The persistent material, organizational, and spatial inequalities that shape individuals' lives over the working years also profoundly affect how they can respond to aging (chapter 5). Seniors from both middle-class and poor neighborhoods rely extensively on a social "safety net" to secure access to basic resources like food, housing, and medical care. However, middle-class seniors have access to substantially more services and services of a higher quality. Further, seniors confront old age with substantially different individual resources that reflect past inequality. Those who enter old age with homes, pensions, and supplementary insurance have more options for responding to problems both large (e.g. a major illness) and small (e.g. getting food they desire). In contrast, poor seniors must rely on referrals from "street level bureaucrats" like social workers and clinicians who maintain substantial control over their lives. The entrepreneurial structure of grant funding compounds this problem by funneling competitive resources to the most affluent areas. At the same time, ongoing funding cuts and other austerity measures threaten to erode funding on a local, state, and federal level and consequently diminish services that poor seniors most depended on.
These findings show that attempts to explain how inequality, health, and behavior affect one another over the life course cannot ignore the interplay between structural inequality and culture. First, culture provides a fundamental mechanism that links past structural inequality and present behavior. People's understandings, motivations, shared strategies, and repertoires are not just an interesting addendum to material inequality, but a reflection of it. They limit which behaviors are desirable, reasonable, and plausible, and consequently are key to the reproduction of stratified social systems. Second, while social ties matter immensely, discussing "social capital" without reference to the socio-historical and cultural contexts in which these ties exist is misleading. Culture ultimately shapes what "being together" means. Third, which cultural categories most profoundly structure behavior in a given context reflect unequal resources-- and in old age, the aging body becomes a fundamental category and stratifying resource. Explaining how people respond to complex bio-social dilemmas like growing old requires us to move beyond models of disembodied actors towards a deeper understanding of situated bodily cultures that reflect inequalities both past and present.
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