Why poor means poorly and wealth buys health

March 27, 1998

The west of Scotland is the unhealthiest part of Britain yet within it are small areas whose inhabitants are in the rudest of health. Two studies aim to pinpoint how social class affects our well-being. Ayala Ochert reports

As we approach the end of the 20th century, the idea of social class ought to be obsolete. In fact social class is a matter of life and death - men at the bottom of the social scale live, on average, seven years less than men from the highest social class.

Social inequalities in health were apparent 150 years ago, when health statistics were first collected. But, back in 1980, the government-commissioned Black report shocked the nation by demonstrating the true extent of those inequalities. Four years later, the Medical Research Council's medical sociology unit moved from its home in Aberdeen to be reborn in Glasgow with the aim of investigating how health differences between social groups are produced.

Its new location in the west of Scotland means that the unit has a "natural laboratory" on its doorstep, as director Sally Macintyre explains: "The west of Scotland has the worst health record in Britain, and some of the worst health in the industrialised world. But if you look at small areas, some have low death rates and not much illness. The health in places like that is as good as it is in Sweden or Japan - it's among the best in the world."

So, in 1987, within a short time of settling into its new offices, the unit launched the West of Scotland Twenty-07 study into health in the community. A longitudinal study, the aim was to follow three groups of people - one aged 15 at the start of the study, the next aged 35, and the last aged 55, and to follow them for 20 years until 2007. "We'll be able to describe 60 years of the life cycle," says Macintyre.

Several years later, in 1994, they set up an additional study of teenage health in the west of Scotland, the 11-16 study. "The reason we initiated the second study - which we sometimes call 'son' or 'daughter of Twenty-07' - was because we realised that by starting with the (Twenty-07) study at age 15 we'd missed a crucial period in the lives of young people," recalls Patrick West, who runs the 11-16 study together with Helen Sweeting.

Health inequalities are not just down to social class - gender, ethnic group, area of residence, age and marital status are all linked to differences in health and life expectancy. These disadvantages add up: "If you brought the health of the poorest up to the health of the richest, it would be like eradicating heart disease," says Macintyre. "The effect of the social gradient on the health of the population is about as big as smoking." Given the potential impact of this research, the medical sociology unit costs the MRC a modest Pounds 1 million out of an annual budget of almost Pounds 300 million.

NEIGHBOURHOOD WATCH

The answer to the problem of how to enable people in the lowest social classes to become as healthy as those at the top of society's pile might seem simple - guarantee everyone a basic standard of living so that everyone can afford to eat healthily and go to sports centres.

But, surprising though it might be, implementing the "threshold" model will not make health inequalities disappear. "We found that health (gradually) gets better all the way up the income scale. And if we look at social class, there's not just a difference between those at the bottom and those in the middle, but there's a difference between social class I and social class II, so that suggests that we're not just talking about absolute material poverty," says Macintyre. "But that's not an argument for saying that you should do nothing."

Instead, the healthiest groups should be a benchmark for the sort of good health that we could all achieve. "If in certain areas of the west of Scotland people can achieve good health, that shows what's possible. It shows that we're not up against some essentially Scottish factor that means that nobody in Scotland can have good health."

But, while living in Scotland does not itself make you ill, it seems that living in parts of it can. The "localities" segment of the Twenty-07 study focused on two neighbourhoods in Glasgow - one in the south-west of Glasgow that was poorer than average and one in the north-west that was better off on average. Over and above the differences in health you would expect between rich and poor, the area itself has an additional effect on the health of the individuals living there. "In medicine there is something called the 'inverse care' law, which says that in poor areas you get a lower level of (medical) care," says Macintyre. "We're increasingly finding that there are features of areas that either directly damage health or which help or hinder people from taking up health promotion messages."

So, while a "healthy" basket of food in the poor south-west costs Pounds 10.48, it is only Pounds 9.94 in the richer north-west. Not only is healthy food more expensive, it is also harder to get hold of, in part because supermarket chains avoid poorer areas. Local people rely on expensive corner shops with small supplies of fruit and vegetables. When it comes to sports facilities, the south-west is again poorly served, making it harder for local people to take exercise. "Imagine you're a young mother in a tower block. You're terrified to leave the flat, because the lift is vandalised, there are discarded needles and condoms out on the street. You may be trapped, and you may not feel like going running or walking," explains Macintyre.

Unfortunately, while something could be done to improve these areas, health authorities are usually powerless, since they have no role in the siting of supermarkets or roads. The unit is exploring the idea of "health impact assessments". "At the moment, we probably know more about the effects of road-building on badgers than we do on the health of children, because when we're building a motorway, we might do an environmental impact assessment that talks about lives lost in terms of motorway accidents, but not necessarily about other effects on health," says Macintyre.

If your class, income or area don't get you, then perhaps your ethnic origin or gender will. As part of Twenty-07, the unit has been looking at 30 to 40 year-olds of south Asian (mostly Punjabi) descent, comparing them with people the same age from the main study. They find that they are shorter and tend to put more weight on around their middle. Height tends to be related to health, and generation after generation in Britain has been getting taller, because of better childhood nutrition. And carrying weight around your middle increases your risk of heart disease and diabetes. Although these differences could be in part genetic, one has to be wary of making crass assumptions about the different heights of ethnic groups. The Japanese, for example, are traditionally thought of as short, but those Japanese who grow up in San Francisco are now as tall as the rest of the population.

When it comes to gender differences, it is just as easy to fall into the trap of making inaccurate assumptions. We now take it for granted that women live longer than men, and tend to assume that the reason is largely biological. But women's greater longevity has only been evident since the middle of the 18th century and is still not the case in some countries, such as India and Pakistan. "Very few people look at why there are the differences (in life expectancy). We've been trying to make that less of a given and more of a question," says Macintyre.

In Britain, the most "socioeconomically patterned" diseases are coronary heart disease and respiratory disease, but being poor is more insidious than that: "It's as if you age faster - you get the same things but younger. There's not one specific disease that's going to get you if you're poor, everything is going to get you."

YOUNG AND PITIFUL

Youth is usually synonymous with health, so it was a surprise to Patrick West and Helen Sweeting when they discovered quite high levels of ill health among the young people in their studies. Around one in five 15 year-olds reported a long-standing illness, most commonly asthma or pain in their back or limbs.

Social background was less important for the health of young people than it was for their parents, but inequalities do eventually catch up, and differences not apparent at 15 were starting to appear by the time they turned 18.

While young bodies are failing at a surprisingly fast pace, what is happening to young minds is even more worrying. One-third of young men and two-fifths of young women were showing signs of "psychological morbidity" by the age of 18. Nor is this just a case of teenage angst - if any of the young people in this category turned up at a GP's surgery, says West, you would expect the GP to do something about it.

All the indications suggest that the mental health of young people is getting worse. A recent pilot study found that rates of poor mental health had doubled since the Twenty-07 study began in 1987. Part of the anxiety may come from the fear of unemployment - actually being unemployed doubled the chances of psychological distress in young people. Children were starting to worry about unemployment very early on - one in five 11 year-olds predicted that they would be unemployed when they grow up. By the time they were 21, as many as one in three expected to be unemployed over the next five years.

Another source of tension is family life. Young people who spent most time with their families seemed to be in better shape than the rest - less likely to smoke and more likely to do well in school. But those who argued frequently with their parents were more likely to smoke, drink and take drugs, did worse in school and had low self-esteem.

The association of low self-esteem and unhealthy lifestyles is a bone of contention at the unit. "There is a widespread assumption in health education that boosting kids' self-esteem will increase their ability to say no to peer pressure and means they won't get involved in risky lifestyles. Crudely speaking, if you respect yourself, you don't take risks," says West. "We think that's debatable, and possibly completely wrong." The assumption by health educationalists has been that children are coerced into smoking or drug-taking, but the unit is exploring the idea that young people choose these activities for themselves and that sometimes they may actually enhance their self-esteem. "If we think that boosting kids' self-esteem is going to have much impact on reducing their likelihood of smoking or drinking, I think we're whistling in the wind," says West.

STUDY LEADERS

The year started well for Sally Macintyre, director of the MRC medical sociology unit. She found her name on the New Year's Honours list, having been awarded an OBE for services to medical sociology. It was not just her work for the MRC that got Macintyre noticed - she is also involved in various outside committees, including the Committee on Genetic Testing.

"There's a lot of talk about genetic predispositions and how useful they'll be in population health. People say, 'if only we could screen everybody for a predisposition to cancer and coronary heart disease'. But actually the effects of doing that depend on which way people will jump. People could say, 'I'm at low risk of getting high cholesterol or high blood pressure so I'm going to eat like a pig and not go running', and in population terms that might make everyone less healthy," she says.

Her interest in medical sociology is based on theoretical as well as practical considerations: "The fact that there's a height gradient by social class is an embodied physical reflection of our social structure - somehow our social system and its stratification is getting into people's bodies and affecting how tall they grow. So looking at inequalities in health can help you understand your society," says Macintyre, who baulks at postmodernist claims that class and gender are dead and that we can all "invent" ourselves.

Fortunately, her research indicates that her own propects for good health are excellent - she is middle class, has a nice job, a supportive husband, as well as a healthy lifestyle. "I've always been fairly health conscious, because I trained as a dancer when I was younger. I go running and last year, as part of an all-woman expedition I did first ascents of two peaks, around 6,000 metres high, in the Karakorum mountains in Pakistan," says Macintyre, although she does admit to maybe drinking a little too much.

She finds that many people she meets refuse to believe that there are social class inequalities in health - the basis of the work at the unit: "A lot of people say anybody can be healthy."

Patrick West is senior researcher for the youth section of the Twenty-07 study and the more recent 11-16 study. His interest in youth issues stretches back a long way, but right now his work is particularly apposite as he has two teenage children of his own - a son of 15 and a daughter of 12. "There are occasions when I check out questionnaires and ideas with them," he says. On the whole, his work is a source of amusement for the family, and his children often tease him with questions like: "Do you think that kids with one leg are more likely to smoke than kids with two legs, Dad?"

Sometimes work impinges on his personal life in a less amusing way, particularly research relating to family life, which, he says, reflects less favourably on himself and his wife. Like many other busy professional couples, they often feel guilty about not being home more of the time. "When you find responses about mum and dad that are not absolutely glowing in questionnaires, you do catch yourself," he adds.

At other times, the research itself can be distressing: "On many occasions, when kids have completed our self-esteem questionnaire, we're sitting next to them and the question says, 'I like myself' and they write 'strongly disagree'." Unless children report sexual abuse, West must decide whether to report to the school what children say.

On one occasion, a young girl wrote: "I'm being threatened every day by someone, but every time I try and tell anyone about it, I get frightened and run off. " When West looked up from the questionnaire, she had already gone. He reported this incident to the school, but the numbers of children with problems is too great for him to mention every case. "Even if there were a nurse or counsellor in the school, I wouldn't know if that problem was known to the school. As a researcher, what should you be doing?" he asks.

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