Lectures 8-9: Lectures 8-9 Social inequalities in health


Social inequalities in Irish health: Social inequalities in Irish health ‘Irish people die younger because they tolerate an inequality between them that breeds ill-health, and they accept a health care system and a view of health care which implicitly places lesser value on the lives of those with lesser means.’ Wren (2003) An Unhealthy State


Social Inequalities in Health 1: Social Class: Social Inequalities in Health 1: Social Class Long history in sociology Engels (1845) The condition of the working class in England Mayhew (1851) London labour and the London poor Rowntree (1901) Poverty; a study of town life


Engels (1845): Engels (1845) Identifies poverty, food, housing, over-crowding, economic insecurity and inadequate health care as causes of excess mortality Argues that the ruling class is committing ‘social murder’ of the industrial working class by allowing such conditions to exist


The ‘problem’ of class: The ‘problem’ of class Do we have social class in Ireland? How do we define it?


Classical Definitions: Classical Definitions Marx Weber Economic Position Status Party Class as relationship v class as attribute


Definitions of Class in Ireland: Definitions of Class in Ireland 1 Professional workers 2 Managerial and technical 3 Non-manual 4 Skilled manual 5 Semi-skilled 6 Unskilled 7 All others gainfully occupied and unknown CSO Census 2002


The ‘Problem of Class’: The ‘Problem of Class’ Difficult to specify clearly Occupational scales confuse class and status Women’s social class The ‘demise’ of class Changes in the organisation of work Social reform and citizenship Social mobility and social drift Fragmentation and the underclass Poor record keeping


Class: Class Working Class Middle Class Underclass Ruling Class Socio-economic group (SEG) vs Class


Absolute Poverty: Absolute Poverty Absolute poverty is defined as the inability to meet basic human needs, such as food, shelter and, avoidance of disease. It is typically operationalised in terms of a monetary threshold—a poverty line


Relative Poverty: Relative Poverty Relative poverty, defines poverty in terms of its relation to the standards that exist elsewhere in society. Townsend refers to poverty as a form of relative deprivation, or “the absence or inadequacy of those diets, amenities, standards, services and activities which are common or customary in society”. The poverty line in this case is defined as some proportion of a society’s average per capita income or expenditure, for example, less than one half the country’s average per capita income


Death Ratios by SEG Ireland: Death Ratios by SEG Ireland


Absolute and relative deprivation: Absolute and relative deprivation Limit on health returns of more material wealth at a societal level. We don’t get healthier as a society the richer we get Not the absolute standard of living which matters but the relationship between individuals Wilkinson (1996) ‘the ethos of the market compromises health’


Link between socio-economic status (SES) and health : Link between socio-economic status (SES) and health Overall decline in mortality rates in UK but decline for the more affluent significantly greater (e.g. McLoone & Boddy, 1994) In recent years gap has widened and the most deprived groups had worse mortality between 1980 and 1990


Britain vs Japan (Wilkinson, 1996): Britain vs Japan (Wilkinson, 1996) 1970s – similar in terms of income distribution and life expectancy Japan income distribution narrows, life expectancy increases Britain income distribution widens, life expectancy falls


Male Mortality & SEG/Social Class Ireland All Causes: Male Mortality & SEG/Social Class Ireland All Causes


Male Mortality & SEG/Social Class Ireland: Cancer: Male Mortality & SEG/Social Class Ireland: Cancer


Male Mortality & SEG/Social Class Ireland: Ischaemic Heart Disease: Male Mortality & SEG/Social Class Ireland: Ischaemic Heart Disease


Male Mortality & SEG/Social Class Ireland: Suicide & intentional self-harm: Male Mortality & SEG/Social Class Ireland: Suicide & intentional self-harm


Socio-economic differences in health: Explanations: Socio-economic differences in health: Explanations Differences are Artefacts Diagnostic practices and identification of the cause of death vary over time and space Variations in diagnosis, certification, classification and coding processes have been contributing to observed class and health relationships Bloor et al,1987 ischaemic heart disease less likely to be recorded for working class men in 1930s than 1960s ‘Shrinkage’ of certain occupational categories (RG V) Promotion/demotion of the deceased (numerator/denominator bias


Socio-economic differences in health: Explanations: Socio-economic differences in health: Explanations Social Causation and Health Selection Highly charged debate since Black Report (1982) Does class cause illness or illness cause class? Drift down – illness as a mechanism of social selection Studies of post-retirement age groups suggest drift down unlikely (e. Fox et al, 1990)


‘Indirect selection’: ‘Indirect selection’ Illsley (1955) Aberdeen women who married above their social class tended to be taller, of better physique and general health than the women from their class of origin who remained within their class Wadsworth (1986) Schoolboys who had had 28 days consecutive hospitalisation tended to ‘experience a fall in their fortunes’ regardless of class of origin


Socio-economic differences in health: Explanations: Socio-economic differences in health: Explanations Cultural and behavioural explanations Lower classes indulge in more unhealthy/risky behaviours such as, smoking drinking, eating more fatty foods and taking less exercise resulting in early death Begs the question why they do this Difficulty directly reading health behaviours off socio-economic classification (e.g. the ‘new middle class’)


Socio-economic differences in health: Explanations: Socio-economic differences in health: Explanations Materialist Explanations Material and ‘social’ capital Focus on the impact of poverty, the distribution of income, unemployment, housing conditions, pollution and working conditions Access to health care Education


Income & Poverty: Income & Poverty Higher incomes can provide better nutrition, housing, schooling, and recreation. Independent of actual income levels, the distribution of income within countries and states has been linked to rates of mortality Underinvestment in public goods and welfare and the experience of inequality are both greater in more stratified societies and that these, in turn, affect health. Highly stratified societies take an additional toll on health beyond that associated with absolute deprivation. Although the association between income and health is stronger at lower incomes, income effects persist above the poverty level. Health effects at the upper part of the distribution may more strongly reflect relative status, while at the lower part they may be more linked to absolute deprivation.


Income effects on mortality: Income effects on mortality


Occupation: Occupation Whitehall study (Hemingway et al , 1997) Men and women in the lower grades were at increased risk of poor physical functioning independent of disease status.


SES and environmental exposure: SES and environmental exposure Those lower on the SES hierarchy are more likely to live and work in worse physical environments. Poorer neighbourhoods are disproportionately located near highways, industrial areas, and toxic waste sites, since land there is cheaper and resistance to polluting industries, less visible. Housing quality is also poorer for low-SES families. Compared with high-income families, both children and adults from poor families show a sixfold increase in rates of high blood lead levels, while middle-income adults and children show twofold increase. Low-SES persons also experience greater residential crowding and noise. Noise exposure has been linked to poorer long-term memory and reading deficits and to higher levels of overnight urinary catecholomines (epinephrine and norepinephrine)among children and to hypertension among adults.


SES and social environment.: SES and social environment. SES-related health effects of social environments may be even more important than those of physical environments. Isolation and lack of engagement in social networks are strong predictors of health. The socially isolated have relative risks of mortality ranging between 1.9 to almost 5 times greater than those with better social connections. Patterns of social interaction also affect disease risk. For sexually transmitted diseases, transmission is more rapid in high-risk networks, which are often clustered in poorer areas, thus putting lower-SES persons at greater risk for exposure. Re-housing and urban renewal dismantled long-standing social structures and organization contributing to numerous health problems.


Slide30: Acheson D, Independent Inquiry into Inequalities in Health Report, London: Stationery Office. 1997 Balanda, K P & Wilde, J Inequalities in Mortality 1989-1998, A Report on All-Ireland Mortality Data, Dublin: The Institute of Public Health, 2001. Black Report – Inequalities in Health, Report of a Research Working Group, HMSO: London 1980. Wilkinson, Richard G, Unhealthy Societies – The Afflictions of Inequality, London, 1996 Wren, Maev-Ann, Unhealthy State – Anatomy of a Sick Society, Dublin: New Island, 2003