Class Inequalities in Health

The Black Report (Black et al, 1980) was commissioned in 1977 by the Labour Secretary of State. Though there had always been a public concern about social class difference and mortality, it was the first ever review of the Health of Britain’s working age population. The initial purpose of the report was to measure the impact of ill health within the workforce (Macintyre, 1997). However, the report shocked the government by revealing a clear correlation between ill heath and lower social class.

Conversely “these inequalities have been widening rather than diminishing since the establishment of the National Health Service (NHS)” (Gray, 1982). This essay is going to focus on the main factors behind class inequalities that the Black Report identified and how relevant this report is today.

The Black Report identified a relationship between social class and ill health, life expectancy and infant mortality rates. The persistence of these inequalities has become the subject of continuing debate. The Black report identified four different possible explanations; artefact, social selection, cultural and material. The artefact explanation considers the existence of health inequalities as simply an artefact of the measurement system used. According to this theory any variance in health within social classes will depend on how both health and class are measured (McIntyre, 1997). However, these inequalities are often still present even when different techniques are employed when measuring social class. It is thought, if anything, that the statistics may in fact under report the extent of class and health inequalities (Kirby et al. 1997).

The second explanation for these health inequalities is social selection. This theory speculates that people with ill health will generally decrease in social status while a fit and healthy person would be more likely to advance social class (Maguire, 2010). This combined effect contributes to the evident health inequalities. Within this idea a distinction between ‘direct’ and ‘indirect’ health selection has been made. ‘Direct’ is where health alone is attributed to social mobility whereas ‘indirect’ is where another quality is involved with the mobility process (Wilkinson, 1987, Platt, 2006) Few supporters of this extreme view can be found. Though ill health may have an effect on social mobility, it is often too small to account for any significant health difference (Wilkinson, 1996). Townsend and Davison (1990) also found that relatively few sick professionals experience downward occupational changes. However, as regards the social selections importance as an explanation of health inequalities it appears to play a small but yet still significant role (Platt, 2006).

The two remaining (cultural and material) explanations of health inequalities have received considerable attention. The cultural explanation proposes that members of lower social classes often choose less healthy lifestyles (smoking, eating larger quantities of fatty foods and participating in less exercise) compared to members of middle or upper class groups, thus resulting in comparatively ill health. However, similar patterns in ill health can also be found within people who follow a relatively healthy lifestyle. Though it can’t be disputed that there is a correlation between a less healthy lifestyle choice and ill health, it cannot be considered the full explanation for the presence of health inequalities (Townsend and Davison, 1990, Pratt 2006)

The final factor behind inequalities in health identified by the Black Report is material. This explanation highlights the role of economic factors in the distribution of ill health. Within this it is thought that members of lower social groups face material constraints and poor living conditions which prevent them from living a healthy lifestyle. These material constraints include poverty, bad housing, low income and a lack of health and educational resources. This theory coincides with Wilkinson’s (1997) argument that “Poverty is the most important determinant of health”. The material explanation does account for a significant amount of the inequality between social classes, possibly more so than the other explanations, but once again it cannot account for all.

The Black Report clearly identified many shortcomings within healthcare. It is also apparent that each of the four factors previously identified play a role in explaining the presence of these health inequalities, though some play a more significant role than others. Due to the change to a Conservative government at the time the report was published it was released quietly (only 450 copies available) with the hope it would go unnoticed (Abercrombie and Ward, 2000). This meant that it was many years until any action was taken. In 1987 the Health Education Council (HEC) commissioned the Health Divide. This report was concerned with measuring the current health inequalities and to determine what progress had been made since the Black Report was published 7 years previously. Like the Black Report the findings emphasized the link between ill health and social class and identified that the gap between social classes had widened.

More recently in 1997 Labour commissioned the Acheson report (Acheson, 1998) which was an independent inquiry into health inequalities (Abercrombie and Ward, 2000). Similar to the Health Divide, the Acheson Report’s findings mirrored those of the Black report. These included rates of long term illness (e.g heart disease and strokes) in 45-64 year olds being 17% in members of upper class groups compared to 48% in lower socioeconomic groups. These results once again indicate a considerable social class health inequality that is still widening (Davey et al, 1990). Also these results agreed with the fourth explanation within the Black report (material) as poverty was identified as the main cause of social inequality.

It is clear that over the last thirty years social inequalities within health has been a major issue. Since these reports were issued reversing this trend of health inequalities has been a high priority on the government agenda (Abercrombie & Ward, 2000). Who are committed to lower these inequalities (Department of Health, 2004). Unfortunately, even with all the actions that have been taken the gap between social groups is thought to have worsened (Sim and Mackie, 2006, Davey, 1990).