Social class and inequalities in health...

Social class and inequalities in health

With the introduction of the British nhs, with its ideal of each according to need and equal access we assumed that differences in the health of different social classes would go. The reverse has happened!

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^{The Black Report: Inequalities in Health}

National Service Frameworks (eg nsfs for heart disease, diabetes, mental health, and older people) aim to redress inequalities, but increase inequalities (rich people make more use of new resources). This is compounded by the fact that the South-East is becoming ever richer while in some of our great Northern cities over 50% of households are ‘breadline poor’.

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^{Joseph Rowntree Foundation 2007}

p53 genes and the locus and post-codes of poverty

How does poverty cause ill-health? In breast cancer, relapse is more likely in deprived postcodes, where smoking, drinking and an unhealthy diet make p53 mutations more likely,

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so its cancer-protecting protein is less abundant (see p649). The big way to remove health inequality is to ↓smoking in poorer people. And if some wealthy people quit too, so what? So health inequalities don’t matter as long as overall health is improving? Not quite. Justice matters too. It is the lack of justice which led to the nhs—which would have been the best invention of the 20^th century, if only it had removed inequalities.

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uk Registrar General’s scale of 5 social or occupational classes
Class I	Professional	eg lawyer, doctor, accountant
Class II	Intermediate	eg teacher, nurse, manager
Class III^N	Skilled non-manual	eg typist, shop assistant
Class III^M	Skilled manual	eg miner, bus-driver, cook
Class IV	Partly skilled (manual)	eg farmworker, bus-conductor
Class V	Unskilled manual	eg cleaner, labourer

uk Registrar General’s scale of 5 social or occupational classes
Class I	Professional	eg lawyer, doctor, accountant
Class II	Intermediate	eg teacher, nurse, manager
Class III^N	Skilled non-manual	eg typist, shop assistant
Class III^M	Skilled manual	eg miner, bus-driver, cook
Class IV	Partly skilled (manual)	eg farmworker, bus-conductor
Class V	Unskilled manual	eg cleaner, labourer

Poor people living in North London (eg Tottenham Green) live ∼17yrs less than rich people (in Chelsea); their life expectancy (71yrs) is 〈 that in Ecuador, China and Belize (none has a national health service!).

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Mortality rates are higher in social class V vs class I: In stillbirths, perinatal deaths, infant deaths, deaths in men aged 15-64 and women aged 20-59 this factor is 1.8, 2, 2.1, 2, and 1.95. Ditto for lung cancer (smr¹=1.98), heart disease (1.3) and stroke (1.9). Melanoma and Hodgkin’s disease are exceptions.

Effects of social class and geography are hard to tease apart: in the uk, city dwellers’ mortality rates are ∼22% (95% confidence interval: 19%-25%) higher than those in the most rural areas (especially for lung cancer and respiratory disease—and pollution is a likely cause of this).

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Within occupations the effect of social class is seen in a ‘purer’ way than when groups of many occupations are compared: in a study of 〉17,000 Whitehall civil servants there was a 〉3-fold difference in mortality from all causes of death (except genitourinary disease) comparing those in high grades with those in low grades. Similarly in the army, there is a 5-fold difference in mortality from heart disease between highest and lowest ranks.

We know that illness makes us descend the social scale, but this effect is probably not big enough to account for the observed differences between classes. It is more likely that the differences are due to smoking behaviour, education, diet,² poverty, stress, and overcrowding. Cognitive ability can partly explain socio-economic inequalities in health (‘intelligent people look after themselves’—has some truth). Note that smoking is 3-fold more common in nurses than in doctors

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and cognitive factors must play some part in this. This need not imply pessimism about attempts to break the chain that links socio-economic status and cognitive ability with health. During some life stages, environmental factors may be able to influence cognitive skills. Interventions can be targeted in order to optimize these effects.

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By removing smoking you may have removed someone’s only pleasure: their life will certainly seem longer!

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