Public Health (1991), 105, 23 27
© Thc Society of Public Health, 1991
Inequalities in Health Sir Douglas Black Emeritus Professor of Medicine, University of Manchester
I welcome the invitation to contribute to this Festschrift for my friend and colleague Alwyn Smith. I also welcomed the subject which it was suggested I might discuss. N o t only was it first brought to my notice by David Ennals, in the far-off days of 1977, when a Secretary of State had both the will and the licence to do good, it then became a preoccupation for m a n y years, intensively for three years, but intermittently in the following decade. Most germane to the present purpose, it gives me the opportunity, with no more than the minimum of artifice, to draw together three people who persuaded me that the social aspects of medicine could be made not just comprehensible, but even lucid and interesting. The first of these was Alwyn Smith himself, whose advent on the Manchester scene ended a tedious and barren search by Colin Campbell and myself for a Professor of Social Medicine. The other two were my colleagues on the Working G r o u p on Inequalities in Health, Jerry Morris and Peter Townsend. These two were the driving force in the group; the fourth member, Dr Cyril Smith (then Secretary o f the then Social Science Research Council) and I were eager graduate students who provided the ballast needed to keep the vessel upright. I believe that collectively we did a good job, and any lack of appreciation of this has not been of the quality to make us paranoid. Immediate political reactions have admittedly been somewhat polarised, perhaps an unavoidable consequence of our adversarial system; but for the longer term I see the importance of the Report not in the discovery of a problem (for the adverse effects of social and economic deprivation are obvious, on health and in other ways), but in addressing it in such a way as both to quantify its seriousness, and to stimulate further research on a number of aspects. In the terms of reference for the group we were asked to 'assemble available information about the differences in health status a m o n g the social classes'; to identify possible causal relationships; and to suggest further research. We accepted this triple challenge of compilation, speculation and research promotion, with results which are now fairly well known. They Were summarised in e x t e n s o by Townsend and Davidson; ~and their 'Pelican' has since been re-issued together with Margaret Whitehead's The H e a l t h Divide. 2 In this essay, I do not propose to outline the Report, or even to detail what I see as its strengths. That it has strengths might perhaps be inferred from the a m o u n t of study and comment which it has stimulated; and perhaps more obliquely from the a m o u n t of effort expended by the present administration in trying to discount it. Instead, I will examine two key elements in what we were asked to do where we felt the available information was insufficient; and what has been done since to improve the base of information. And, in the concluding section, I will look again at the controversy on what causes a phenomenon whose existence at least seems now to be accepted even by those who do not warm to our attempts to explain it.
Correspondence: Sir Douglas Black, The Old Forge, Duchess Close, Whitchurch-on-Thames, Reading RG8 7EN.
24
Sir Douglas Black
The core of our task, using the terminology of our terms of reference, was to compare health status and social class. To do so in a quantitative way presupposes valid measures of these two properties of populations. We soon came to recognise imperfections in the available indices of both. I now describe these for each of them, and happily some ways in which the indices have improved, so that we c a n take whatever of cheer is afforded by recognising that if we were starting the enquiry now, we would be able to do it better. Indices o f 'health status' We accept the criticism that much of our evidence was based on the long-standing and comprehensive information on death certification available from the Office of Population and Census Surveys (OPCS); and I acknowledge that this belated correlate of health status may well be an imperfect indicator of health as defined by the World Health O r g a n i s a t i o n , - - ' a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. We did indeed consider other measures, such as prevalence of morbidity and rates of sickness-absence or disability. The General Household Survey gave indications of the prevalence of morbidity, but with no real information on the cause of morbidity. Reports of patients seen by family doctors gave diagnostic information, but the sample was much smaller, and m a n y instances of morbidity do not reach any doctor. Moreover, neither of these indices of morbidity was linked to standard measures of social class. As we said in the Report, 'Partly because of the problems of measurement, but also because of the need for time-series statistics, we have given precedence to mortality rates.' But we went on to say, 'But we wish to call attention to the need for measures of health which combine several factors and which allow the real experiences a m o n g the population to be captured.' There have been, during the past decade, various approaches to developing such indices, reviewed in The ttealth DivMe. 2 One of tile more comprehensive is the Nottingham Health Profile, divided into two parts, of which Part I assesses 'health', from reported experience of pain, energy, mobility, sleep, social isolation and emotional reaction; while the second (Part lI) brings in health-related activities, such as employment and social and sexual relationships. In addition to the use of indices based on subjective and thus basically qualitative assessments of well-being, quantifiable correlates of health are being explored, such as birth-weight. Indices o f 'social class' Samuel Johnson is said to have taken not-too-quiet satisfaction in his ability to repeat from memory an entire chapter from a book on Ireland. Entitled ' O f Snakes in Ireland', the rest of the chapter reads, 'There are no snakes in Ireland'. A very similar chapter could be written on indices of social class; but its content would be less definite, for we can have a Table I OPCS occupational groups 1
II IIIN III M IV V
Professional (e.g. doctor, lawyer) Intermediate (e.g. nurse, teacher) Skilled non-manual (e.g. secretary, shop assistant) Skilled manual (e.g. carpenter, bus driver) Partly skilled (e.g. postman, bus conductor) Unskilled (e.g. cleaner, labourer)
25
Inequalities in Health
picture of snakes, but scarcely an operational definition of 'social class'. Thus even more than in the case of health, we are driven to look at correlates rather than at the thing itself. Pragmatically, we used a measure which was well-established, ready to hand, nation-wide, and capable of analysis at different periods of time. It was, of course, the OPCS categorisation in terms, not of social class, but of occupational class, which is outlined in Table I. It is important first of all to recognise the limitations of this approach, and then to say something of alternatives which have been very actively explored since the report came out. To begin with, the system has major flaws which perhaps reflect its origin when few women worked and there was little unemployment; an instrument of social analysis which allocates married women to their husband's occupation, and the unemployed to their most recent previous occupation must have been progressively weakened by the changing status of women, and the incidence of mass unemployment. There has also from time to time been re-allocation of specific occupations from one group to another. More important, in recent years there has been a general tendency for 'upward' movement in the distribution of people in terms of occupation. Table II shows the distribution in occupational class of men aged 15-64 in 1971 and those aged 1(~64 in 1981. These limitations require recognition and acknowledgment, and have rightly stimulated a search for alternative measures of socio-economic status. But it is also important to recognise the limitations of the limitations, which do not seriously affect our analysis of the male employed population, n o r - - e v e n more i m p o r t a n t - - o f their infants and children, which shows a massive disadvantage to health of social deprivation. Our use of a national index of s o c i o e c o n o m i c status allowed comparison with national death certification to have a strong numerical basis, but it also carried the disadvantage that any search for discrete causative factors was likely to be submerged by confounding variables within so large and diverse a population. The subsequent search for other indices of deprivation has included a focus on measures appropriate and practically applicable to areas as small as the 'wards' of local government, or those identifiable by postcode. Table 16 in The Health Divide 2 outlines five area-based studies using local indicators of deprivation. Examples of such indicators include the level of unemployment, car-ownership, rented or owned housing, number of persons per room, single-parent households, and disconnection of electricity. These area studies in different regions of the country have shown a consistent relationship between socio-economic deprivation and various measures of 'ill-health'. Further corroboration that the relationship exposed in the national study was 'real' comes from the demonstration of a gradient of mortality a m o n g civil servants related to their grade within the service? Other studies have confirmed the importance of deprivation Table II Per cent of population in classes in 1971 and 1981 Class I
II IIIN III M IV V
1971 %
1981 %
5
6
18 12 38 18 9
23 12 36 17 6
26
Sir Douglas Black
during infancy and childhood as a cause of illness and death, not only in early life, but also later o n - - i n Donald Court's graphic phrase, 'childhood illness casts long shadows ahead'. It would, I think, be fair to say that the various studies of the past decade have led to a general acceptance that there is a problem of considerable magnitude; but, there are still major disagreements on how it is to be explained, which must have a bearing on how it should be dealt with.
Possible explanations We may be reasonably confident that there will be no simple single explanation for the association between low income and p o o r health. On the most general issue, which of these variables is the independent or leading one, and which the dependent, we should begin by recognising that in differing circumstances each is capable of playing the leading role. The onset of illness in the bread-winner is very likely to cause descent in the social scale, only partly masked by the anomaly that if the illness is severe enough to cause unemployment, the patient will remain allocated to his previous occupation. On the other hand, poverty and other forms of social deprivation bring with them a constellation of disadvantages, some of which are recognised as risks to health, e.g. p o o r housing, over-crowding, greater liability to accidents in cramped homes and in the street, food which even if adequate in quantity may be deficient in quality, lacking expensive 'protective' foods such as fruit and vegetables. The q u a n t u m of added ill-health in manual workers and the unemployed cannot be adequately accounted for by downward drift determined by spontaneous physical or mental illness, and we had little doubt that the general social factors just outlined were preponderantly the independent variable, and thus the major, though not the only, explanation o f what we were set to study. Other things which we saw as subsidiary 'causes' were difficulties in access to health care, inadequate take-up of preventive measures, the specific risks of certain occupations some of which were also ill-paid, and the greater prevalence a m o n g manual workers of practices prejudicial to health, of which smoking is by far the most harmful. In this quite complex system, others have placed greater emphasis than we have done on behavioural or life-style factors; but in the civil service studies it was possible to allow for life-style variables, whose combined influence accounted for less than a quarter of the risk of heart disease associated with grade o f employment. 3 A more radical approach 4 maintains that neither socio--economic deprivation nor ill-health are truly independent variables, but that both depend on individual inadequacy or failure to cope. There is no easy way to disprove such a hypothesis, which seems to me the apotheosis o f what has been called blaming the victim, but it may perhaps be challenged on the pragmatic ground that failure to cope is innocent alike of diagnosis and of treatment, and so can lead to no practical action. Two hundred and twenty years ago Oliver Goldsmith published a p o e m with the couplet, 'Ill fares the land, to hast'ning ills a prey, Where wealth accumulates, and men decay.' Until a few months ago, I think I would have accepted that as a fair description of Britain in the eighties. N o w I am less c e r t a i n - - s o much of the wealth dredged from the N o r t h Sea seems to have made its way to the vaults of Zurich with no more than a passing flash of fool's gold for the great majority of our people. Concurrently, monetarism and free market economics have encouraged selfishness under the guise of enterprise, and we manipulate things instead of producing them. Fiscal policy has exposed the wealthy to the temptations
Inequalities in Health
27
of greater affluence, while social provision for those disadvantaged by low pay and even unemployment has fallen in real terms, most critically for the future by the failure of child benefit to keep pace with inflation. There can therefore be little surprise that the most recent comprehensive examination of the problem in this country 2 shows not only that 'serious social inequalities in health have persisted into the 1980s, but that the (very welcome) general improvement in sickness and death rates has had a smaller impact on manual than on non-manual workers, so that the gap between manual and non-manual workers in their experience of health has actually widened. I remain of the belief that the measures which we recommended ten years ago are at the very least a sensible indication of what will be needed if we are in any way concerned about the great and increasing gap in health between rich and poor. The emphasis on improving the circumstances of children trapped in poverty goes to the heart of the problem for the future. By no means all of the recommendations were even expensive, though o f course the scale of the problem meant and means that some of them were and are. But at the very least, our social engineering--piecemeal though it may have to be--should be in the direction of making health care an element of social justice rather than a component of the reward system of a plutocracy. References
1. Townsend, P. & Davidson, N. (1982). Inequalities in Itealth, Harmondsworth: Penguin Books. 2. Whitehead, M. (1988). The Health Divide, London: Penguin Books. 3. Marmot, M. G., Shipley, M. J. & Rose, G. (1984). Inequalities in death--specific explanations of a general pattern. Lancet, i, 1003-1006. 4. Crombie, D. L. (1984). Social class and health status. Inequality or difference. Journal of the Royal College of General Practitioners, Occasional Paper 25.
© Thc Society of Public Health, 1991
Inequalities in Health Sir Douglas Black Emeritus Professor of Medicine, University of Manchester
I welcome the invitation to contribute to this Festschrift for my friend and colleague Alwyn Smith. I also welcomed the subject which it was suggested I might discuss. N o t only was it first brought to my notice by David Ennals, in the far-off days of 1977, when a Secretary of State had both the will and the licence to do good, it then became a preoccupation for m a n y years, intensively for three years, but intermittently in the following decade. Most germane to the present purpose, it gives me the opportunity, with no more than the minimum of artifice, to draw together three people who persuaded me that the social aspects of medicine could be made not just comprehensible, but even lucid and interesting. The first of these was Alwyn Smith himself, whose advent on the Manchester scene ended a tedious and barren search by Colin Campbell and myself for a Professor of Social Medicine. The other two were my colleagues on the Working G r o u p on Inequalities in Health, Jerry Morris and Peter Townsend. These two were the driving force in the group; the fourth member, Dr Cyril Smith (then Secretary o f the then Social Science Research Council) and I were eager graduate students who provided the ballast needed to keep the vessel upright. I believe that collectively we did a good job, and any lack of appreciation of this has not been of the quality to make us paranoid. Immediate political reactions have admittedly been somewhat polarised, perhaps an unavoidable consequence of our adversarial system; but for the longer term I see the importance of the Report not in the discovery of a problem (for the adverse effects of social and economic deprivation are obvious, on health and in other ways), but in addressing it in such a way as both to quantify its seriousness, and to stimulate further research on a number of aspects. In the terms of reference for the group we were asked to 'assemble available information about the differences in health status a m o n g the social classes'; to identify possible causal relationships; and to suggest further research. We accepted this triple challenge of compilation, speculation and research promotion, with results which are now fairly well known. They Were summarised in e x t e n s o by Townsend and Davidson; ~and their 'Pelican' has since been re-issued together with Margaret Whitehead's The H e a l t h Divide. 2 In this essay, I do not propose to outline the Report, or even to detail what I see as its strengths. That it has strengths might perhaps be inferred from the a m o u n t of study and comment which it has stimulated; and perhaps more obliquely from the a m o u n t of effort expended by the present administration in trying to discount it. Instead, I will examine two key elements in what we were asked to do where we felt the available information was insufficient; and what has been done since to improve the base of information. And, in the concluding section, I will look again at the controversy on what causes a phenomenon whose existence at least seems now to be accepted even by those who do not warm to our attempts to explain it.
Correspondence: Sir Douglas Black, The Old Forge, Duchess Close, Whitchurch-on-Thames, Reading RG8 7EN.
24
Sir Douglas Black
The core of our task, using the terminology of our terms of reference, was to compare health status and social class. To do so in a quantitative way presupposes valid measures of these two properties of populations. We soon came to recognise imperfections in the available indices of both. I now describe these for each of them, and happily some ways in which the indices have improved, so that we c a n take whatever of cheer is afforded by recognising that if we were starting the enquiry now, we would be able to do it better. Indices o f 'health status' We accept the criticism that much of our evidence was based on the long-standing and comprehensive information on death certification available from the Office of Population and Census Surveys (OPCS); and I acknowledge that this belated correlate of health status may well be an imperfect indicator of health as defined by the World Health O r g a n i s a t i o n , - - ' a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. We did indeed consider other measures, such as prevalence of morbidity and rates of sickness-absence or disability. The General Household Survey gave indications of the prevalence of morbidity, but with no real information on the cause of morbidity. Reports of patients seen by family doctors gave diagnostic information, but the sample was much smaller, and m a n y instances of morbidity do not reach any doctor. Moreover, neither of these indices of morbidity was linked to standard measures of social class. As we said in the Report, 'Partly because of the problems of measurement, but also because of the need for time-series statistics, we have given precedence to mortality rates.' But we went on to say, 'But we wish to call attention to the need for measures of health which combine several factors and which allow the real experiences a m o n g the population to be captured.' There have been, during the past decade, various approaches to developing such indices, reviewed in The ttealth DivMe. 2 One of tile more comprehensive is the Nottingham Health Profile, divided into two parts, of which Part I assesses 'health', from reported experience of pain, energy, mobility, sleep, social isolation and emotional reaction; while the second (Part lI) brings in health-related activities, such as employment and social and sexual relationships. In addition to the use of indices based on subjective and thus basically qualitative assessments of well-being, quantifiable correlates of health are being explored, such as birth-weight. Indices o f 'social class' Samuel Johnson is said to have taken not-too-quiet satisfaction in his ability to repeat from memory an entire chapter from a book on Ireland. Entitled ' O f Snakes in Ireland', the rest of the chapter reads, 'There are no snakes in Ireland'. A very similar chapter could be written on indices of social class; but its content would be less definite, for we can have a Table I OPCS occupational groups 1
II IIIN III M IV V
Professional (e.g. doctor, lawyer) Intermediate (e.g. nurse, teacher) Skilled non-manual (e.g. secretary, shop assistant) Skilled manual (e.g. carpenter, bus driver) Partly skilled (e.g. postman, bus conductor) Unskilled (e.g. cleaner, labourer)
25
Inequalities in Health
picture of snakes, but scarcely an operational definition of 'social class'. Thus even more than in the case of health, we are driven to look at correlates rather than at the thing itself. Pragmatically, we used a measure which was well-established, ready to hand, nation-wide, and capable of analysis at different periods of time. It was, of course, the OPCS categorisation in terms, not of social class, but of occupational class, which is outlined in Table I. It is important first of all to recognise the limitations of this approach, and then to say something of alternatives which have been very actively explored since the report came out. To begin with, the system has major flaws which perhaps reflect its origin when few women worked and there was little unemployment; an instrument of social analysis which allocates married women to their husband's occupation, and the unemployed to their most recent previous occupation must have been progressively weakened by the changing status of women, and the incidence of mass unemployment. There has also from time to time been re-allocation of specific occupations from one group to another. More important, in recent years there has been a general tendency for 'upward' movement in the distribution of people in terms of occupation. Table II shows the distribution in occupational class of men aged 15-64 in 1971 and those aged 1(~64 in 1981. These limitations require recognition and acknowledgment, and have rightly stimulated a search for alternative measures of socio-economic status. But it is also important to recognise the limitations of the limitations, which do not seriously affect our analysis of the male employed population, n o r - - e v e n more i m p o r t a n t - - o f their infants and children, which shows a massive disadvantage to health of social deprivation. Our use of a national index of s o c i o e c o n o m i c status allowed comparison with national death certification to have a strong numerical basis, but it also carried the disadvantage that any search for discrete causative factors was likely to be submerged by confounding variables within so large and diverse a population. The subsequent search for other indices of deprivation has included a focus on measures appropriate and practically applicable to areas as small as the 'wards' of local government, or those identifiable by postcode. Table 16 in The Health Divide 2 outlines five area-based studies using local indicators of deprivation. Examples of such indicators include the level of unemployment, car-ownership, rented or owned housing, number of persons per room, single-parent households, and disconnection of electricity. These area studies in different regions of the country have shown a consistent relationship between socio-economic deprivation and various measures of 'ill-health'. Further corroboration that the relationship exposed in the national study was 'real' comes from the demonstration of a gradient of mortality a m o n g civil servants related to their grade within the service? Other studies have confirmed the importance of deprivation Table II Per cent of population in classes in 1971 and 1981 Class I
II IIIN III M IV V
1971 %
1981 %
5
6
18 12 38 18 9
23 12 36 17 6
26
Sir Douglas Black
during infancy and childhood as a cause of illness and death, not only in early life, but also later o n - - i n Donald Court's graphic phrase, 'childhood illness casts long shadows ahead'. It would, I think, be fair to say that the various studies of the past decade have led to a general acceptance that there is a problem of considerable magnitude; but, there are still major disagreements on how it is to be explained, which must have a bearing on how it should be dealt with.
Possible explanations We may be reasonably confident that there will be no simple single explanation for the association between low income and p o o r health. On the most general issue, which of these variables is the independent or leading one, and which the dependent, we should begin by recognising that in differing circumstances each is capable of playing the leading role. The onset of illness in the bread-winner is very likely to cause descent in the social scale, only partly masked by the anomaly that if the illness is severe enough to cause unemployment, the patient will remain allocated to his previous occupation. On the other hand, poverty and other forms of social deprivation bring with them a constellation of disadvantages, some of which are recognised as risks to health, e.g. p o o r housing, over-crowding, greater liability to accidents in cramped homes and in the street, food which even if adequate in quantity may be deficient in quality, lacking expensive 'protective' foods such as fruit and vegetables. The q u a n t u m of added ill-health in manual workers and the unemployed cannot be adequately accounted for by downward drift determined by spontaneous physical or mental illness, and we had little doubt that the general social factors just outlined were preponderantly the independent variable, and thus the major, though not the only, explanation o f what we were set to study. Other things which we saw as subsidiary 'causes' were difficulties in access to health care, inadequate take-up of preventive measures, the specific risks of certain occupations some of which were also ill-paid, and the greater prevalence a m o n g manual workers of practices prejudicial to health, of which smoking is by far the most harmful. In this quite complex system, others have placed greater emphasis than we have done on behavioural or life-style factors; but in the civil service studies it was possible to allow for life-style variables, whose combined influence accounted for less than a quarter of the risk of heart disease associated with grade o f employment. 3 A more radical approach 4 maintains that neither socio--economic deprivation nor ill-health are truly independent variables, but that both depend on individual inadequacy or failure to cope. There is no easy way to disprove such a hypothesis, which seems to me the apotheosis o f what has been called blaming the victim, but it may perhaps be challenged on the pragmatic ground that failure to cope is innocent alike of diagnosis and of treatment, and so can lead to no practical action. Two hundred and twenty years ago Oliver Goldsmith published a p o e m with the couplet, 'Ill fares the land, to hast'ning ills a prey, Where wealth accumulates, and men decay.' Until a few months ago, I think I would have accepted that as a fair description of Britain in the eighties. N o w I am less c e r t a i n - - s o much of the wealth dredged from the N o r t h Sea seems to have made its way to the vaults of Zurich with no more than a passing flash of fool's gold for the great majority of our people. Concurrently, monetarism and free market economics have encouraged selfishness under the guise of enterprise, and we manipulate things instead of producing them. Fiscal policy has exposed the wealthy to the temptations
Inequalities in Health
27
of greater affluence, while social provision for those disadvantaged by low pay and even unemployment has fallen in real terms, most critically for the future by the failure of child benefit to keep pace with inflation. There can therefore be little surprise that the most recent comprehensive examination of the problem in this country 2 shows not only that 'serious social inequalities in health have persisted into the 1980s, but that the (very welcome) general improvement in sickness and death rates has had a smaller impact on manual than on non-manual workers, so that the gap between manual and non-manual workers in their experience of health has actually widened. I remain of the belief that the measures which we recommended ten years ago are at the very least a sensible indication of what will be needed if we are in any way concerned about the great and increasing gap in health between rich and poor. The emphasis on improving the circumstances of children trapped in poverty goes to the heart of the problem for the future. By no means all of the recommendations were even expensive, though o f course the scale of the problem meant and means that some of them were and are. But at the very least, our social engineering--piecemeal though it may have to be--should be in the direction of making health care an element of social justice rather than a component of the reward system of a plutocracy. References
1. Townsend, P. & Davidson, N. (1982). Inequalities in Itealth, Harmondsworth: Penguin Books. 2. Whitehead, M. (1988). The Health Divide, London: Penguin Books. 3. Marmot, M. G., Shipley, M. J. & Rose, G. (1984). Inequalities in death--specific explanations of a general pattern. Lancet, i, 1003-1006. 4. Crombie, D. L. (1984). Social class and health status. Inequality or difference. Journal of the Royal College of General Practitioners, Occasional Paper 25.
