How Stratification Shapes Health in the Face of Rapid Economic, Demographic, and Epidemiological Change: Insights from India

Abstract

This dissertation examines how social stratification shape health and demographic outcomes in a context of rapid economic, demographic, and environmental change. Focusing on India, it asks how long-standing hierarchies of caste, class, gender, and place are reproduced, transformed, or reconfigured as the country undergoes sustained economic growth, widespread poverty transitions, population aging, and increasing exposure to climate-related stress. India offers a critical setting for this analysis. It is experiencing one of the world’s largest and fastest demographic transitions, yet these changes are unfolding within deeply institutionalized systems of inequality that continue to shape access to resources, risks, and protection. Across three empirical chapters, the dissertation shows that aggregate development does not eliminate health inequality. Rather, social advantage and disadvantage are reorganized across new domains, from women’s nutritional change to older adults’ functional health and survival. The first chapter examines the effect of India’s long-term economic growth on women’s nutritional status, as measured by body mass index (BMI). While economic expansion can improve nutrition by increasing access to food, healthcare, and education, rising inequality may offset these gains by concentrating resources among the affluent. Using four waves of the National Family Health Survey (1998–2019), this study examines whether BMI has converged or diverged across socio-economic status and states for women aged 25–49. The results suggest that undernutrition declined across all economic groups, with the largest absolute declines among the poorest, narrowing the gap with the affluent. At the same time, overweight and obesity spread beyond the richest groups. ii The second chapter examines how income mobility, particularly transition out of poverty, shapes survival in later life. Using three waves of the India Human Development Survey (2004– 2024), the chapter analyzes how poverty transitions affect mortality risks among adults aged 50 to 79. The results show that persistent poverty and downward mobility are strongly associated with higher mortality risk. The third chapter examines the health consequences of climate shocks in later life, focusing on repeated drought exposure among older adults in rural India. As climate change intensifies envi- ronmental uncertainty, its health impacts are likely to be unevenly distributed, amplifying existing social and economic inequalities. Using longitudinal data from two waves of the India Human Development Survey, the findings show that repeated drought exposure significantly increases the risk of functional deterioration, with the strongest effects concentrated among economically disadvantaged households. The chapter further shows that social capital acts as a crisis-activated resource to buffer against these shocks. Taken together, the three chapters argue that in a society undergoing rapid demographic, epidemiological, economic, and climatic transitions, social stratification remains consequential for health and demographic outcomes. It becomes consequential in new ways. The specific risks change, and the mechanisms linking caste, class, religion, gender, and place to health and demographic outcomes evolve. Yet the underlying structure of advantage and disadvantage persists, reorganizing through the opportunities and vulnerabilities created by each new context. This dissertation makes three central contributions. First, it shows that economic growth does not dissolve traditional hierarchies, but alters how they operate across the life course. Second, it provides rare longitudinal, population-scale evidence from a low- and middle-income country on how economic mobility, aging, and environmental shocks shape health and survival. Third, it integrates demography, social stratification, environmental inequality, and life-course perspectives to show how cumulative disadvantage is dynamically produced during periods of rapid structural change. In doing so, the dissertation extends fundamental cause theory beyond its original high-income Western context, treats caste and religion as fundamental causes of health inequality in their own right, and applies life-course approaches to an aging population in the Global South.