Health and Social Class

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 nearly 60 years of The National Health Service, there remains marked differences in all parameters of health across the social classes, there is significant geographical variation and women, on average, live 5 years longer than men.

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. 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 expectanacy of life, lower infant mortality, etc, has been not so much medical discoveries as improved social conditions.

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.

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.

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.¹ 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 patients with schizophrenia showed that they tend to belong to the lower social classes but this is much less marked for their fathers and this suggests that it is the disease that has caused the low social class rather than the low social class that predisposes to the disease. 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 cardio-respiratory 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 that 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.²
• Social capital is a term used for how connected people are to their communities through work, family, membership of clubs, faith groups, political and social organisations. This has also been shown to have an impact on health. During the 1950s and 60s a study of the Italian-American community of Roseto, Pennsylvania, where heart attacks were 50% less frequent than surrounding communities, explained these differences by the greater social cohesion of this group. This concept has been confirmed by other workers.³ 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 failure of the NHS to provide a uniform level of care was summed up an a seminal paper by Julian Tudor Hart⁴ 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. Professor Carr-Hill's work has not lived up to expectations. The banding has been widely criticised and it is being re-worked.

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 detail, including many tables and charts are availble via the Socialist Health Association website listed at the end.
The Black Report,⁵ 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 to 64 years in rates per 1000 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.

In November 1998 a further report was produced, this time by Sir Donald Acheson, a former Chief Medical Officer. It found little cause for congradulation and also called for the issue of poverty to be addressed.^8,9

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. Malnutrition has 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.

Poverty

• Poverty is still a cause of poor health but poverty must not be equated with social class. Even in our comparatively affluent society poverty exists although what is seen as poverty in Berkshire is very different from poverty in Bangladesh. Official figures depend upon the definition used for poverty and so give little indication of the size of the problem. Only those on the very lowest incomes can be regarded as living in poverty but even the destitute seem able to afford to smoke.
• Hogarth's cartoon of Gin Lane¹⁰ depicts escape from the misery of poverty whilst at the same time compounding the problems. This is hardly analagous with the binge drinking of those who go clubbing several times a week. Prestigious cars are generally safer than cheaper models but it is not poverty that leads a young man to drive a customised car with blacked out windows, a formula one fin on the tail and an ineffective exhaust pipe the size of a drainpipe, and to drive it like a bat out of hell. It is not poverty that leads people to ingest substantially more calories than they expend.
• Those most likely to be affected by poverty are the elderly whilst young children take second place. Hence those most likely to be affected are the most vulnerable.
• Poverty is a real problem. The Black Report and the Acheson Report both suggested trying to reduce the inequalities of income in societies but these have grown instead. In the 1970s there was the Resource Allocation Working Party (RAWP) that took health service funding from affluent areas of the country to give to more deprived areas. This was always unpopular as no one likes to be made worse off. The idea that as society becomes richer that this wealth will trickle down through all levels of society is attractive but has little evidence to support it.
• Poverty may be a result of substance abuse, drugs or alcohol or other factors leading to social exclusion including mental health.
• Dealing with poverty is not attractive to politicians. It is a complex issue that does not perform well at the sound bite level. It means taking money from the better off and this tends to be poorly received by the electorate. It is much easier to ignore the disenfranchised. There are some powerful forces for social good that are not afraid to be off message and the Church of England's report "Faith in the City" in 1986 and "Faithful Cities" in 2006 have berated governments for inaction on social issues. It also takes a charity such as the Prince's Trust to try to do something about disenfranchised youth, especially those with a criminal record. It takes a person from a very privelidged background to do something about some of the failings of society.

Accidents

• Accidents remain a major cause of death and disability in young people, affecting males about twice as often as females. Accidents and their prevention is discussed elsewhere. There is a social gradient with regard to accidents and this is not simply related to the danger of certain occupations as it affects children too. Safety in the home and at work need to be addressed along with risk taking behaviour.

Education

• The key to improving much of the health inequality lies in education. Education has to be the basis of the initiation of change. Change is not easy to achieve and its management is discussed in burnout. What is required is a change of attitude. The mere possession of facts is not enough. No one can deny that they know that smoking is dangerous. No one can deny that they are aware that there are substantial risks associated with taking illicit drugs. What is needed is a change of attitude. Hollywood has much to answer for in terms of perpetuating the myth that smoking is "cool" long after the dangers became known. Knowing of risks and noting risks are very different matters
• Attitudes form early and the attitudes of children to drugs, alcohol and sexual irresponsibilty need to be moulded at an appropriate but early stage. This includes their approach to food. The intervention of a celebrity chef has done much to highlight the inadequacy of school meals and the poor habits that are engendered. In the late 1950s school meals cost a shilling (5p) each. The current figure is around 70p but the equivalent figure corrected for inflation is around £1.50p. School lunches in the 1950s were awful and it is unsurprising that those currently repsonsible for the school meals service complain about the difficulty of producing a healthy diet at equivalent to half the cost. Healthy food does not have to be expensive food. Eating less meat and more fresh vegetables is cheaper. Conveniance food is expensive. Taste is acquired. A healthy diet from the outset is likely to reduce the craving for food that is rich in fat, salt and fast sugars whilst dismissing fresh fruit and vegetable as rabbit food. It is important that parents do not undermine the message taught at school but peer pressure and conformity can be a force for good as well as ill.

Government intervention

Self discipline and personal decisions are very import but governments do have responsibilties.

• Whilst it is impossible to ban smoking altogether, much can be done to reduce it, especially in public places. Raising taxation does reduce consumption but some may argue that this adds a burden to the most vulnerable members of society.
• Taxation also affects the consumption of alcohol.
• At last, with public outcry ahead of political will, in the not too distant future it will be possible to have a drink in a pub without leaving smelling of smoke. Scotland and the Republic of Ireland are already ahead of England and Wales.
• Government initiatives can encourage sport and exercise.
• Food can be enriched. Folic acid and iron are added to bread. Subsidy as well as taxation can make healthy foods a more attractive price than less healthy alternatives.

There can be little doubt that governments can affect outcome, including using financial incentives to manipulate "free choice". What will never be debated in public is the desirability of such as policy.

• Political inertia can easily be justified in terms of freedeom of choice. There is never any shortage of newspaper columnists who are ready to denounce the "health fascists" and "nanny state" with all the eloquence of authorative ignorance. Politicians may decide that a courageous, ethical policy will gain them more enemies than friends.
• Both tobacco and alcohol are prolific sources of revenue to the Exchequer. If the Chancellor is too enthusiastic about raising the rate of taxation he may find that consumption drops so much that revenue declines. Some will argue that the associated reduction in demands on health and other expenditure due to alcohol abuse and tobacco consumption will more than offset this shortfall. The problem with this argument is that it fails to see the whole picture. The assumption is that if an individual does not die prematurely or suffer chronic debility as a result of a self-inflicted malady that he will live for ever without being a burden to the state.
• As Benjamin Franklin observed, "There are two certainties in life - death and taxation". We all become ill eventually and will presumably become a burden to the NHS in doing so. It is a matter of when, rather than if. In the meantime older people are more likely to be admitted to hospital, they are more likely to take medication and to be on multiple drugs. In addition there may be degenerative diseases of osteoarthritis requiring joint replacement surgery or neurodegenerative diseases such as Alzheimer's disease or Parkinson's disease. Poor mobility and reduced cognition may produce a demand on social services.
• Old people are an enormous drain on the economies of the developed countries and with an aging population the numbers are multiplying.
• In the 1960s the average man would retire and have 7 years of pension before he died. Today that figure is 17 years. This is a major contributory factor to the pensions crisis that has enormous implications for the whole economy.
• Whilst no politician would admit this, the fact remains that a healthy population is not necessarily a desirable goal. People are not only living longer than before but they are, on average, more healthy age for age. Nevertheless, the demands on healthcare, social care and pensions from people who do not contribute to the economy may be crippling. Certainly these healthier, older people need to continue to work for longer. There is a certain attraction to the concept of "lemmings" with free choice deciding to pay excessive amounts of taxation to lay down their lives and pensions earlier than the rest. Can we really afford to be without them?