Concepts of Health and Illness: Section 7. The Social Patterns of Health and Illness
Significant differences in mortality and morbidity rates continue to exist between income groups and social classes in most developed countries. This salient fact serves to remind us of the continuing importance of social and economic determinants of health. Certainly, there is little doubt that the low standard of living and persistence of absolute poverty in the developing world are the key determinants of health in these countries; as they were in the early stages of development of modern industrialised societies.
The knowledge that our life processes are socially and economically structured as least as much as they maybe genetically determined, turns the exploration of the determinants of population health into a social science:
' Medical science can address the biological pathways involved in disease, the pathology and the opportunities for treatment, but in so far as health is a social product and some forms of social organisation are healthier than others, advances in our understanding of health will depend on social research ' (Wilkinson:1996:13).
The Epidemiological transition and the rise in life expectancy in developed societies:
In the 20th century, life expectancy in developed societies has increased at the rate of two to three years added to life with each decade that has passed. These increases in population life expectancy have primarily come not as a result of people living longer (although there have been significant increases), but from the reduction in infant mortality followed by reductions in childhood mortality - a much higher proportion of the population now lives to old age.
The notion of the `epidemiological transition' is used to denote the historical change in developed countries from predominantly infectious diseases as the primary cause of death to degenerative diseases. This change is reflected in the levelling-out in the curve of life expectancy compared to increases in per capita income in developed countries in the mid to late twentieth century. When levels of economic growth in a society are such that a general rising in the standard of living and income occurs, in tandem with a process of qualitative technical change and development, then we find that general levels of health and life expectancy begin to rise. This transition is also marked by a change in the social pattern/distribution of diseases. What were seen as `diseases of affluence' in the early twentieth century, such as coronary heart disease, stomach ulceration, stroke and obesity now became more common among the poorer sections of these affluent societies reversing their previous social distribution (Wilkinson:1996;43-47).
Social determinants of health in contemporary society
Examining health from a societal perspective rather than that of the individual produces a very different view of the determinants of health. This is not necessarily because the individual determinants of health identified in clinical studies do not add up to become the societal determinants; rather
' (w)hat really moves the health of whole societies, adding to or subtracting from the sum of total health, may be factors which account for only a very small part of the individual variation in health and so escape detection ' (Wilkinson:1996,16.
Material conditions in particular (which includes but is not solely defined by income) are key social determinants of health. When examining the relation of income to health, it is not only the income of individuals that has to be taken into account, but also the wealth of the community. If a country is poor, a small increase in per capita income can make a big difference to health. For example, several sub-Saharan African countries have a GDP less than $1000 per capita, and a life expectancy of 45 years or less - mainly due to high levels of child mortality. Poor material conditions (sanitation & malnutrition) being the primary contributor. However, once a country is rich enough to be able to provide the basic material conditions for good health, a larger national income is unlikely to provide better health for the population as a whole. When comparing such countries there is no significant gradient in the relation between income and health. This relationship between income and health as measured by life expectancy is diagrammatically represented in Figure 5 below. Developed societies are represented in historical epochs, but it is possible to think about present day underdeveloped countries as similar in several ways to developed countries at the beginning of the last century, where small increases in income bring about significant life-expectancy gains.
Figure 5: Life expectancy and income per capita for selected (developed) countries & periods (Wilkinson:1996)
Wilkinson (1996) has argued that a society which has poor health is a society that tolerates or encourages high income inequality. Wide income gaps between social groups in a developed society has consequences for health, not so much because of material deprivation but because of its psychosocial effects. That is, a society with wide gaps between rich and poor produces low levels of social cohesion. The psycho-social processes associated with this lack of social cohesion ultimately affect the health of all, rich and poor alike. This is because the poor become socially marginalised and are therefore less likely to adhere to the norms of that society, resulting in greater levels of crime and personal violence. A society which has poor health is a society that tolerates or encourages high income inequality. These are societies where high proportions of the population are in some way excluded from full social participation, and that does not value all its people equally highly (Marmot:2004). By way of contrast, in more egalitarian societies, even with relatively low per capita incomes, have better health than 'rich' countries. These outcomes are reflected in the Figure 6 below.
In the relationship between health and income, it is the relative income differences that appear to be more important than absolute living standards. Health is therefore related to differences in living standards within developed societies, but not to differences between them. In the developed world it is not the richest countries that have the best levels of health, but the most egalitarian ones.
Social Distribution of Disease
Factors that appear to be important explanations for individual health differences, in practice, cannot fully explain the differences in health between social groups within society, or between one society and another. So for example, it is well-established that a steep gradient in the incidence of coronary heart disease exists between social classes in Britain, and this has been shown to persist after controlling for individual risks of heart disease such as fat consumption and cholesterol levels (Marmot et al:1991).
In terms of disease patterns, we know that there exists a social distribution of exposure to causative risk factors. Geoffrey Rose (1992) has used this understanding to develop an argument for assessing and tackling these behavioural determinants of the health of individuals at the societal level. He demonstrated that rather than identifying those individuals who are living with a particular disease (with an associated causative health behaviour/risk exposure) as being in a different category than the rest of the `normal' population, we should see them as just one end of a population continuum. One of the examples Rose cites to demonstrate this point is high blood pressure. People with hypertension are not a distinct group separate from a normal distribution of blood pressure in society. Rather than having a specific disease/defect not present in the bulk of a population, they actually come within the range of variability described by a bell curve of a normal statistical distribution. After examining the distribution of risk factors for hypertension in a number of different countries at various levels of economic development, Rose concluded that the proportion of people at high risk in any population is simply a function of the average blood pressure, cholesterol levels etc, in that particular society.
These conclusions concerning the social distribution and determinants of disease cut across the notion of disease as an `autonomous individual affliction'. It emphasises that modern diseases and the exposure to the range of causative risk factors are a product of the norms of any particular society.
The persistence of Social Inequalities in Health
Policy-makers in pre-war Britain, accepted by as the norm the existence of large differences in mortality and morbidity levels between the rich and the poor. These differences were seen just as an unfortunate consequence of a market economy. The post-war political enthusiasm for social justice and change that led to the establishment of the British Welfare State, brought about an expectation that social class differences in health would be narrowed following the provision of free comprehensive medical care for the whole population.
Although the general standard of health improved in the post-war years, social class mortality differences failed to narrow. The official view in the mid-1960s was that the cause of these continuing differences in health outcome was behavioural, and that more resources through social policy could not be the solution. But this position ignored research that was available at the time which challenged the notion that the development of welfare state services had succeeded in eliminating disadvantage in access to health and education services, and that low income continued to be a key factor in social disadvantage; the so-called `rediscovery of poverty' in Britain.
State health policy from the mid-1970s formally incorporated the strategy of health education, with the aim of convincing the population that it was their own health behaviour, or to use the modern term `lifestyle', that required changing. However, this strategy was almost immediately challenged by research being conducted both in the USA and in Britain. The first `Whitehall Study' (Marmot et al:1978) found that differences in health behaviours such as smoking, B/P, exercise, and fat intake, were found to account for only a minority of the difference in mortality from CHD between occupational grades. The then Labour government responded by setting-up a commission to summarise the evidence for social inequalities in health.
The Black Report (1980) was the first modern official report into health inequity in Britain. It examined the association between social class and health emergent within official statistics, and demonstrated that mortality & morbidity were not randomly distributed throughout the population. The report identified a number of types of possible explanation for this finding:
Social / natural selection - Those with poor health are downwardly mobile.
Cultural / Behavioural - focus on class differences in health beliefs and behaviour.
Material circumstances - social differences in income, diet, housing and working environment as key determinants of inequalities in health. This was the explanation accepted by the Black Report.
The contemporary picture of health inequalities
Since the publication of the Black Report, there have been a large number of epidemiological studies which have concluded that social class is inextricably linked with social differences in health outcomes. The factors which link social class to health were recognized as reflecting material differences between social groups. These factors included income differences, but are not confined to that. Diet, housing, education, and stressful working conditions, together with what has been termed Social capital (availability of supportive social networks) are all important factors.
The income gap between rich and poor has continued to widen in Britain since the 1980's. Some of the reasons for this trend include a reduction in the real value of state benefits, and a taxation system which favours the well-off (disproportionate number of indirect taxes such as VAT, Fuel etc compared to the more progressive income tax). Britain has some of the lowest wage levels in the E.U, and only relatively recently has the government begun to address the lack of a state childcare system which prevents many women taking-up paid employment.
The evidence for the persistence social class health inequalities are cited within the Acheson Report (1998).
© I Crinson 2007