Only a handful of studies

Only a handful of studies examined the RD-health association outside the U.S. and Europe; all revealed strong evidence that, above and beyond absolute income, RD is an important predictor. In research using a large probability sample of Japanese men and women, RD measured by the Yitzhaki Index was found to associate with poor SRH independently of absolute income (Kondo et al., 2008). Further, a study based on a nationally representative cohort of Costa Rican individuals aged 30 and over found a positive association between RD, measured by area-level Gini Coefficients, and mortality. Modrek, Dow, and Rosero-Bixby (2012) In South Africa, research linking income and mortality data between 1993 and 1998 has shown that multiple measures of RD significantly predicted mortality after adjustment for absolute income (Salti, 2010). Finally, research linking RD to adult nutritional status in rural Zambia found that a lower subjective perception of SES is associated with a significantly lower body mass index (Cole, 2012). The results of these studies combined suggest that RD is an important predictor of health, sometimes independent of absolute income, outside the context of the U.S. and Europe. In this paper, we investigated RD as a pathway between income inequality and health in the low-income setting of Palestinian refugee camps in Lebanon. We examined self-rated health (SRH) as the main health measure but also checked the sensitivity of our results using self-reported chronic conditions. With the exception of a few studies investigating the pathways between social inequalities and health among Palestinians in Israel (Daoud, Soklone, & Manor, 2009a, 2009b), very few have specifically examined social inequalities within Palestinian refugee communities. Though the World Bank classifies Lebanon as an upper middle-income country, Palestinian refugee camps on Lebanese territory constitute pockets of poverty (Ramadan, 2013). Palestinians arrived to Lebanon as refugees in 1948 after the creation of the State of Israel; they order Exendin-3 (9-39) amide currently number 450,000 according to the records of the United Nations Relief and Works Agency, UNRWA (UNRWA, 2013). For more than six decades, they have faced exclusionary policies that restrict their employment, property ownership, and other civil rights (Abdulrahim & Khawaja, 2011; Chaaban et al., 2010). More than 50 percent of Palestinians in Lebanon reside in twelve recognized refugee camps under conditions of poverty and overcrowding; the rest reside in “unofficial gatherings”, some of which have worse infrastructure than official camps. UNRWA’s mandate is the provision of education, health care services, and relief to Palestinian refugees, but not legal protections, which are usually provided by the United Nations High Commissioner for Refugees (Knudsen, 2009). Palestinian refugees in Lebanon exhibit a low rate of secondary school completion and are banned from participating in syndicated professions such as engineering, law, and nursing. As such, most Palestinians are economically and spatially segregated from the rest of Lebanese society; those who work do so in the informal labor sector and half earn less than the Lebanese minimum wage (Garrity, Somes, & Marx, 1978). Palestinian women experience more disadvantage than Palestinian men due to the intersection of gender and ethnic exclusion; women who work are primarily segregated in jobs inside the camp and earn lower wages compared to men (Abdulrahim & Khawaja, 2011). In this context of segregation, RD deserves examination as a potential explanation for health inequalities within the Palestinian refugee community in Lebanon. Moreover, as Palestinian refugees have universal access to primary health care through UNRWA’s clinics, they present a unique case for testing the RD theory, which proposes that the social inequality-health relationship cannot be explained by differential access to health care. Utilizing data gathered in 2010, we examined the relationship between the health of Palestinian women residing in refugee camps and two alternative measures of RD, each calculated using a different proxy measure of absolute SES (household non-health expenditures per capita, and household non-food expenditures per capita), with camp of residence as the reference group. To investigate the contribution of RD as a determinant of health, we added a measure of RD to standard determinants of health, which include age, chronic conditions (Garrity et al., 1978), household size (Wu & Li, 2012), education (Lleras-Muney & Cutler, 2008), and absolute SES (Lleras-Muney, Cutler, & Vogl, 2011). Whereas our main measure of health is SRH, we also examined the robustness of our findings on the relationship between RD and health by examining self-reported chronic conditions as another health outcome.