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There has always been an association between health and social class and, despite the welfare state and the improvement in health in all sections of societies over the years, this discrepancy remains. It applies to all aspects of health, including expectation of life, infant and maternal mortality and general level of health. Whilst the failure to close the social gap is a disgrace to some, others would claim that so long as these parameters are improving in all levels of society there is no cause for concern. Despite 62 years of The National Health Service, there remain marked differences in all parameters of health across the social classes. Women continue to live longer than men but the gap is closing. Based on 2007-2009 mortality rates, a man aged 65 could expect to live another 17.6 years and a woman aged 65 another 20.2 years.
Social class is a complex issue that may involve status, wealth, culture, background and employment. The relationship between class and ill health is not simple. There are a number of different influences on health, some of which include social class. This is demonstrated by multilevel analysis (a method of assessing health inequalities using several different factors) which shows health inequalities even between households living in the same street. In 1943, Sigerist, following the line of Virchow, wrote, "The task of medicine is to promote health, to prevent disease, to treat the sick when prevention is broken down and to rehabilitate the people after they have been cured. These are highly social functions and we must look at medicine as basically a social science."
The greatest influences on the improvement in health with longer expectancy of life, lower infant mortality, etc. have been not so much medical discoveries as improved social conditions. One study in America found that, despite improvements in cancer detection and treatment, disparities in cancer mortality rates are chiefly related to race and social class.
In 1572 an Elizabethan Act made provision for the punishment of sturdy beggars and the relief of the impotent poor. A similar law followed in Scotland in 1574. In England, an Act of 1601 made provision for "setting the poor on work". This did not generally include accommodation but, in 1631, a workhouse was established in Abingdon and, in 1697, the Bristol Workhouse was established by private Act of Parliament. Scotland had "houses of correction" established in the burghs, by an Act of 1672. Some people regarded all this as too liberal and, in 1834, Malthus argued that the population was increasing beyond the ability of the country to feed it. The Poor Law was seen as an encouragement to illegitimacy and this would lead in turn to mass starvation.
Edwin Chadwick published his "General Report on the Sanitary Conditions of the Labouring Population of Great Britain" in 1842. This showed that the average age at death in Liverpool at that time was 35 for gentry and professionals but only 15 for labourers, mechanics and servants. In 1901, Seebohm Rowntree was able not only to trace in detail the sanitary defects of areas of York but he was able to compare the general mortality rates, infant mortality rates and heights and weights of children of different ages in three areas of York, distinguished according to the proportions living below his poverty line and compared with the servant keeping classes. The Rowntree family founded the famous chocolate company. They were, and still are, a Quaker family with a great social conscience as shown through the Joseph Rowntree Foundation and Trust.
The National Health Service
A Government document in 1944 stated "One of the fundamental principles of the National Health Service is to divorce the care of health from questions of personal means or other factors irrelevant to it".
Aneurin Bevan convinced The Treasury to fund the incredibly expensive package of the NHS in 1948, at a time of post-war austerity and massive nationalisation by the Labour government, with the argument that a national health service, free at the point of access, would so improve the health of the nation that the percentage of GDP spent on health would diminish. He was succeeded by Enoch Powell as Minister of Health after a general election. He found that there is no limit to the amount of money that could be spent on a national health service. It is a bottomless pit.
Causes of health inequalities
The relationship between social class and what are now called health inequalities is clear from simple observation. They affect not just adults but children too. The reason why they occur merits discussion.
- The question of post hoc ergo propter hoc (chicken or the egg) asks if it is the low social class that has led to the poor health or if poor health has led to a deterioration of social status. Studies of the Black Caribbean population in the UK patients found higher rates of psychopathology which were related to socioeconomic disadvantage. However, most chronic diseases tend to present rather later in life, well into adulthood and after careers have been decided and the association with social class is not found. Hence, even looking at the question from the opposite direction and suggesting that the healthy will tend to rise through the social classes does not seem feasible.
- The material explanation blames poverty, poor housing conditions, lack of resources in health and educational provision as well as higher risk occupations for the poor health of the lower social classes. Poverty is demonstrably bad for health. Life expectancy is low in poorer, less developed countries but the diseases that afflict the developed world tend to be related to obesity and tobacco and injudicious consumption of alcohol. Within the wealthy nations we find that they are most prevalent in their poorest regions and the lower social classes.
- The cultural explanation suggests that the lower social classes prefer less healthy lifestyles, eat more fatty foods, smoke more and exercise less than the middle and upper classes. They have less money to spend on a healthy diet, although this is probably rather less important than a lack of knowledge of what is a healthy diet. People who have been on their feet all day in shops or factories are less likely than office workers to seek activity in the evening, although their daily work has not been adequate to exercise the cardiorespiratory system. Despite the phrase as drunk as a lord, the association between binge drinking and social class has been readily noted and Frederich Engels wrote that "Drink is the bane of the working classes". Oscar Wilde inverted this to "Work is the bane of the drinking classes". Before the first report on Smoking and Health by the Royal College of Physicians, there was little difference in the incidence of smoking between social classes. Now there is a distinct gradation across social classes. It may seem reasonable to suggest that, when money is short, the first place for economies should be in the consumption of alcohol and tobacco but surveys have shown that in times of economic recession, there is no decline in demand. There is evidence that risk behaviours are unevenly distributed between the social classes and that this contributes to the health gradient. Health is also better in those of higher intelligence as measured by IQ but this does not account for all of the disparity. The West of Scotland Twenty-07 cohort study found that IQ was the second highest risk factor for poor health in socially deprived communities.
- Social capital is a term used for how connected people are to their communities through work, family, membership of clubs, faith groups, and political and social organisations. This has also been shown to have an impact on health. During the 1950s and 1960s a study of the Italian-American community of Roseto, Pennsylvania, where heart attacks were 50% less frequent than in surrounding communities, explained these differences by the greater social cohesion of this group. This concept has been confirmed by other workers. The idea that social isolation is bad for health is also supported by self-report studies that show housewives, the unemployed and the retired as reporting significantly poorer health than those who are employed.
The inverse care law
The failure of the NHS to provide a uniform level of care was summed up in a seminal paper by Julian Tudor Hart, called The Inverse Care Law. "In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and replacement staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served."
The GP contract of 2004 included the Carr-Hill factor that was supposed to reward those who work in deprived areas. Far from reducing equality this created a two-tier system in which some practices found themselves with considerably fewer resources than they had under the old system. The Department of Health's answer was to introduce a correction factor called the Minimum Practice Income Guarantee (MPIG). Intended to be a temporary expediency, it became a permanent feature of GMS funding. Calls to scrap the MPIG and proposals by the Conservative-Liberal Coalition Government to remove practice boundaries have introduced an unprecedented element of uncertainty into the arena of general practice funding, with the potential to make the health inequalities between high and low socioeconomic groups even wider.
The Black Report
The report on Inequalities in Health Care was commissioned by Health Minister, David Ennals in 1977 to address why the NHS had failed to reduce social inequalities in health. Despite the welfare state, there was evidence that social class difference with regard to health had widened. The expert group was chaired by Sir Douglas Black, former president of the Royal College of Physicians. The government changed and the release of the paper on August Bank Holiday Monday 1980 gave it almost iconic status as a government cover-up. The press release that accompanied it drew attention away from some of the more devastating findings. Scholars frequently refer back to it but, not only did the government of the day studiously ignore it, but it has been considered "off message" by the subsequent party of government. Patrick Jenkin, Minister at the time, was advised by civil servants to publish with the minimum of publicity because of the report's potentially huge implications for expenditure.
More details, including many tables and charts, are available via the Socialist Health Association website listed under 'Document references' below.
The Black Report showed that there had continued to be an improvement in health across all the classes during the first 35 years of the National Health Service but there was still a correlation between social class and infant mortality rates, life expectancy and inequalities in the use of medical services.
The following table shows death rates by sex and social (occupational) class in those aged 15-64 years in rates per 1,000 population. It relates to England and Wales (1971) and males refers to all males but females refers to married women only and classifies them by their husband's social class.
|Social (Occupational) Class||Males||Females||Ratio M/F|
|IIIn (Skilled non-manual)||5.80||2.76||1.96|
|IIIm (Skilled manual)||6.08||3.41||1.78|
|IV (Partly skilled)||7.96||4.27||1.87|
It shows that the death rate in that age group is 2.5 times as high in social class V as in class I and that the rate for men is almost twice that for women in all groups.
The following table shows birth weights of babies by father's social class and those with no father acknowledged, from Chamberlain 1975. It shows how going through the social classes down to where no father was acknowledged there was a progressive decline in babies over 3000g and an progressive increase in babies under 2500g.
|Percentage who were||I and II||III||IV and V||No father acknowledged|
|less than 2,500 g||4.5||5.6||8.2||9.5|
|more than 3,000 g||81.0||76.3||72.7||66.7|
The rate of usage of GP services increases with declining social class. This was attributed to more illness whilst they concluded that upper classes will consult over more minor problems. Primary care was seen as very important. Poor standards were identified in the areas of greatest need and primary care was identified as a major component in dealing with the problem.
Much more of both the problems and the perceived solutions are found on the website. They were unafraid to suggest changes in social policy such as a move towards the high taxation, high state dependency of the Scandinavian countries. Some of their suggestions have been addressed by changes to GP contracts but, generally, results are rather mixed. The uptake of vaccination and immunisation has improved greatly, although the uptake for measles, mumps and rubella (MMR) is a cause for concern. The uptake of cervical smears across all sections of society including all ethnic groups is quite astounding. The report also mentioned the benefits of fluoridation of water supplies for dental health. As the article on some dental and periodontal disease explains, the current level of fluoride treatment is about 5% of the country.
It may be tempting to think that the problems addressed by this report of over a quarter of a century ago are history; however, there is much evidence that many aspects are no better and that some are even worse.
The Acheson Report
In November 1998 a further report was produced, this time by Sir Donald Acheson, a former Chief Medical Officer. It found little cause for congratulation and also called for the issue of poverty to be addressed.
Addressing the problem
In the past, the major contributory factors to poor health were poor sanitation and infectious diseases. Today the problems relate to smoking, diet and accidents. Alcohol continues to contribute. Diet problems have changed from calorie deficiency to calorie excess.
Social class is not simply a matter of income. A plumber probably earns rather more than a priest but the latter is likely to have the healthier life. The difference in health between social classes is not simply a matter of disposable income.
At the time of writing, the Coalition Government is dismantling the previous administration's 'command and control' approach to public health and is proposing the establishment of local health and wellbeing boards. These would be inclusive organisations involving all the key players in the local health economy, including local authorities, GP commissioners and providers of both primary and secondary care. They would be given a budget and charged with the responsibility to identify and address local public health needs, including health inequalities.
The Coalition's policy on public health is based largely on the Marmot Review Fair Society, Healthy Lives. The finer details of the Government's policy on public health issues have yet to be determined but the main principles are enshrined in its white paper Healthy Lives, Healthy People, as follows:
- It is important to build people's self-esteem, confidence and resilience right from infancy - with stronger support for early years. Self-esteem is the key to motivating individuals and addressing lifestyle factors that lead to health inequalities. There will be continued commitment to reduce child poverty, an increase in health visitors and a refocusing of the Sure Start scheme.
- Preventative services will be focused on delivering the best outcomes for citizens and the emphasis will be on local empowerment initiatives rather than top-down regulations ('the Big Society').
- Local government and local communities will be at the heart of improving health and wellbeing for their populations and tackling inequalities.. There will be a new integrated public health service - Public Health England.
- The Department of Health will publish documents in 2011 on mental health, tobacco control, obesity, sexual health, pandemic flu preparedness, health protection and emergency preparedness and the wider determinants of health.
- The Marmot Review identified that people living in the poorest areas die on average 7 years earlier than people living in richer areas and spend up to 17 more years living with poor health. They have higher rates of mental illness, of harm from alcohol, drugs and smoking, and of childhood emotional and behavioural problems. Although deaths from infections are becoming increasingly rare, tuberculosis, sexually transmitted diseases and pandemic flu remain continued threats.
- There will be new initiatives to tackle unemployment.
- Communities will be designed for 'active ageing' and sustainable growth, with protection of green spaces and encouragement of local food production.
- There will be working collaboratively with business and the voluntary sector through a 'Public Health Responsibility Deal' with five networks on food, alcohol, physical activity, health at work and behavioural change.
Further reading & references
- Commission on Social Determinants of Health - final report, World Health Organization, 2008
- Sharma A, Lewis S, Szatkowski L; Insights into social disparities in smoking prevalence using Mosaic, a novel BMC Public Health. 2010 Dec 7;10:755.
- Egan M, Kearns A, Mason P, et al; Protocol for a mixed methods study investigating the impact of investment in BMC Med Res Methodol. 2010 May 11;10:41.
- White C, Edgar G; Inequalities in healthy life expectancy by social class and area type: England, Health Stat Q. 2010 Spring;(45):28-56.
- Life expectancy, Office for National Statistics
- Yang M, Eldridge S, Merlo J; Multilevel survival analysis of health inequalities in life expectancy. Int J Equity Health. 2009 Aug 23;8:31.
- The Black Report of 1980; (Chapter 10 gives a summary of findings and recommendations), Socialist Health Association
- Byers T; Two decades of declining cancer mortality: progress with disparity. Annu Rev Public Health. 2010 Apr 21;31:121-32.
- The Joseph Rowntree Foundation, JRF website 2010
- A National Health Service, Socialist Health Association, 2010
- Rivett G; Aneurin Bevan (1897-1960) National Service History, 2011
- Seddon N; Quite Like Heaven? Options for the NHS in a Consumer Age 2007
- Maguire K, The Black Report and Inequalities in Health
- Petrou S, Kupek E, Hockley C, et al; Social class inequalities in childhood mortality and morbidity in an English population.; Paediatr Perinat Epidemiol. 2006 Jan;20(1):14-23.
- Warren JR, Hernandez EM; Did socioeconomic inequalities in morbidity and mortality change in the United States over the course of the twentieth century? J Health Soc Behav. 2007 Dec;48(4):335-51.
- Morgan C, Kirkbride J, Hutchinson G, et al; Cumulative social disadvantage, ethnicity and first-episode psychosis: a Psychol Med. 2008 Dec;38(12):1701-15.
- Batty GD, Der G, Macintyre S, et al; Does IQ explain socioeconomic inequalities in health? Evidence from a population based cohort study in the west of Scotland.; BMJ. 2006 Mar 11;332(7541):580-4. Epub 2006 Feb 1.
- Batty GD, Deary IJ, Benzeval M, et al; Does IQ predict cardiovascular disease mortality as strongly as established risk Eur J Cardiovasc Prev Rehabil. 2010 Feb;17(1):24-7.
- Bruhn JG, Philips BU Jr, Wolf S; Lessons from Roseto 20 years later: a community study of heart disease.; South Med J. 1982 May;75(5):575-80.
- Tudor Hart J; The Inverse Care Law. Lancet 27 Feb 1971. 1(7696):405-12
- Chisholm J; Joint letter on the minimum practice income guarantee (MPIG), British Medical Association, 2006
- Reforming general practice boundaries, BMA General Practitioners Committee, 2010
- Olatunde O, White C, Smith MP; Life expectancy and disability-free life expectancy estimates for Middle Super Health Stat Q. 2010 Autumn;(47):33-65.
- The Acheson report - up close from the BBC
- The Acheson Report
- Liberating the NHS: Local democratic legitimacy in health, Dept of Health, 2010
- Lansley A; Secretary of State for Health's speech to the UK Faculty of Public Health Conference - 'A new approach to public health'
- Marmot, M; Strategic Review of Health Inequalities in England post 2010, Dept of Health
- Lansley A; Healthy Lives, Healthy People, 2010
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Laurence Knott