From the Archive | Part one: Class, health and medicine

Mike Haynes is a professor of economics at the University of Wolverhampton in the United Kingdom. His article, Capitalism, class, health and medicine, was published in 2009 by International Socialism and is republished with permission.

Over the past 30 years – during all the time we have been told that class is dead – something strange has been happening in the study of health. A generation of epidemiologists who study patterns of death (mortality) and illnesses (morbidity) have been obsessing about social inequality. Journals such as the Lancet and the British Medical Journal have published pieces presenting the latest research that talks about the most basic inequalities and social structures. The concern has been to map the link between health and inequality in a descriptive sense: to show that those with a higher social situation suffer less ill health than those with a lower one.

Stand outside any doctor’s surgery and you will see people carried there by inequalities. Their illnesses, major and minor, physical and mental, are markers of where they stand in society. When it comes to ill health, less is always more – the less your situation, the more likely you are to have a health problem. It is a short step from here to pointing to the use of class as an explanatory category: your class position causes you to be more or less sick, to live more or less long. And from here it is only another short step, though one more establishment researchers are understandably loath to take, to argue that, since capitalism is at the root of class society, it is capitalism that makes you more or less ill. If health problems are the product of social organisation, and if we want to really address them, we have to focus on the social conditions and social organisation that give rise to them. As Sir Michael Marmot, the leading epidemiologist in the UK puts it, “Inequalities in health between and within countries are avoidable.”

Premature death arises from three sources: infectious or communicable diseases such as typhus, typhoid, smallpox, cholera, Aids, etc; non-communicable diseases such as heart disease, cancer, nutritional diseases; and violence. In the past infectious diseases played a much larger part than they do today. It is not that non-communicable diseases did not exist but that infectious diseases carried people off first. The shift towards a predominance of death from non-communicable diseases (and violence) is called the “epidemiological transition”. Infectious diseases have not gone away. In poorer parts of the world such diseases continue to play a crucial role – Aids is one example, alongside diseases of poverty that flow from dirty water, inadequate sanitation and the like. But only in Africa is infectious disease still the major cause of premature death: “Of the 45 million deaths among adults aged 15 years and older in 2002, 32 million were due to non-communicable disease and a further 4.5 million to violent causes.”

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Not every disease and cause of death shows a clear socio-economic pattern but the most common diseases and causes of death do. Death does not strike randomly. There has always been a general understanding of this. What is different now is the focus on the systematic process of causation and the need to connect up different elements of an explanation of health and ill health, to seek out what has been called “the cause of the cause”. It is this that takes us to the problem of social class and health, and to a view of capitalism as a toxic form of human society.

The way that health is closely moulded by inequality and unequal power and control was set out in 1980 in the UK in The Black Report. Originally sponsored by the 1970s Labour government it was politically sidelined by the first Thatcher government. The opponents of the social approach to health then tried to explain away the evidence of the link between health and inequality. They attacked the reliability of the data, focusing on what is called the “health selection effect”. Causation might run not from society to health but from health to society. For example, as unemployment rises we know that the unemployed will register more illness than the employed. So does unemployment make you sick or does being sick mean that you are more likely to be unemployed? The attempts to focus on health selection, however, have failed. In most instances the causation does flow from society to health: “There is no evidence to support health selection as an explanation of broader social inequalities in health,” wrote Marmot in 1994 and the evidence against the health selection hypothesis has grown.

In 2003 the World Health Organization published the second edition of a document edited by Marmot and Richard Wilkinson called, The Solid Facts. This attempted to quash such arguments and finally establish that there is a strong “social gradient” of health and ill health. Social conditions mould people’s early lives, their work and leisure, their patterns of consumption, friendship groups, etc, and this can then explain, at the group level, patterns of disease and death to quite an astonishing degree. Wilkinson and Kate Pickett reiterate this same argument in a recent book, The Spirit Level. In rich societies, as the level of inequality rises, so average life expectancy falls and the rates of physical and mental illness rise. Inequality can also help predict levels of obesity, teenage pregnancy, illiteracy, crime, murder, people in prison, happiness – the connections seem almost endless. Greater inequality produces a situation where the same health risks produce different outcomes depending on who you are. Take a group of senior civil servants who smoke and compare them with a lower grade group who also smoke. Which will have the higher death rate? This is the type of question asked in the “Whitehall Studies”, led by Marmot, which tracked ill health among civil servants in the UK for many years and whose results have inspired countless other studies. Here is the answer in Marmot’s words:

“An administrator who smokes 20 cigarettes a day has a lower risk of dying from lung cancer than does a lower grade civil servant who smokes the same amount even after pack years (packs per years times the number of years the person has smoked), tar content and the gradient in mortality from coronary heart diseases among non-smokers are taken into account.”

To see how this happens we need to go on a journey into the relationship between class, capitalism, health and medicine.

Class society and the health issue

Humans have not always lived in class societies. For tens of thousands of years our ancestors lived in small mobile groups, which survived by gathering and hunting. We know little about how these groups functioned save that their lifestyles were based on a basic equality and a communal reciprocity which leads to them being called “primitive communist”. For some commentators the result was lives that were nasty, brutish and short. Infanticide, for instance, was practised to make sure that supplies were sufficient to feed the number of mouths. Others suggest that life was more comfortable and that social deprivation was limited – there was a greater degree of ease than we can easily imagine, even a kind of primitive “affluence” in the satisfaction of basic wants and the absence of modern style artificially constructed needs.

What is more important from our point of view is that, once settled human societies begin to emerge from 10 000 BCE to 6 000 BCE, class organisation also developed with them. The ruling groups seized control of the social surplus, consuming more of it and also organising society to perpetuate their rule and their control. The paradox of the development of class society is that, although in the long run it develops the material wealth of society, it does so in such a way that the benefits go disproportionately to the few. This led to inequality being marked not only in differing life expectancies but in the degree to which lives are marked by disease.

To make sense of this we need some basic demographic concepts. Infant mortality refers to deaths under the age of one, child mortality to deaths under the age of five and adult mortality to deaths over the age of 15. The fourth crucial concept is life expectancy. This is usually measured from birth. It is an average of the length of time those born live, so if life expectancy is low this does not necessarily mean that there are no old people. Rather life expectancy will be pulled down if large numbers die in the first years of life.

With the development of class society new social forces emerged which moulded the patterns of life and death. Access to material resources now became unequal, along the lines of the class nature of society. This was true of normal times but it was even more true in years of famine. The regularity of famine reflected the interaction between nature and the economic and social systems, and the way that these determined the nature of agricultural production. Malnourishment was extensive. You could often determine a person’s place in society by how they looked physically. As Wilkinson puts it, “The rich were fat and the poor were thin.”

The concentration of population in urban centres, albeit on a scale incomparably smaller than today, created a new vulnerability to infectious disease agents. In the towns not only were social conditions often bad, but also the water supply was polluted, sanitation systems were primitive and the air foul. The result was epidemic diseases such as typhus, typhoid, smallpox and endemic diseases (there all the time) such as tuberculosis. And every so often there was a good chance of pandemic diseases such as plague.

In these settled societies violence now became more organised, whether it was the violence within societies or the violence between societies. War became a regular feature of social development and in its wake came not only death and destruction on the battlefield but social immiseration in the areas through which armies marched and fought.

With low productivity and diseases rife, population grew slowly for thousands of years, as is apparent in table 1.

Table 1: World population and percentage urban share

Source: www.census.gov/ipc/www/worldhis.html early urban estimates Kingsley Davis, UN World Urbanisation Prospects. The 2005 Revision; The 2007 Revision.

The key issue here was the combination of material deprivation, infectious diseases and weakened bodily resistance. The social effects of this were uneven. The rich who ate better could hope to live better. “Countries in which access to nutritious food varies by social class for whatever reasons tend to show class gradients in height and health status,” write two modern researchers. But the rich could not escape from the patterns of infectious disease. In an urban environment epidemic diseases easily jumped from a poor house to a richer one, and both houses might draw on the same water supplies or buy food in the same markets. In 1694 Queen Mary died of smallpox, one of a long line of European monarchs to go this way. Almost 170 years later, in 1861, Prince Albert, the husband of Queen Victoria, was carried off by typhoid. Similarly, lack of knowledge of how to deal with the complications of childbirth could kill rich women as easily as it could poor and in the early weeks all babies were vulnerable.

This helps to explain the fact that, although lifestyles differed considerably between classes, when it comes to measuring mortality rates the class differences were less than might be imagined.

Capitalism

In Western Europe capitalism began to emerge from feudalism in the 16th century, and as it did so it began to change the pattern of disease. But the really dramatic shifts came with the industrial revolution and the development of industrial capitalism at the turn of the 19th century. Technological change and increased production created a larger surplus, which allowed societies to begin the “demographic transition”. They shifted from a pattern of high birth rates and high death rates to low birth rates and low death rates. In this transition, however, the death rate initially fell faster than the birth rate. The result was that rapid population growth occurred before a new balance was reached. Table 1 shows how world population has grown and its projected new equilibrium at around nine to 10 billion (despite the fears of Thomas Malthus who believed that population growth would outrun the food supply).

In the first instance urban and industrial growth intensified health and mortality problems, not least in the big cities. Britain led the way, becoming in 1851 the first urban state with more than half its population in towns. Others followed in the 20th century. Today on a global scale half the world’s population is now urban, as can also be seen from table 1.

Over time the falling death rate led to an increase in life expectancy. This fall in the death rate is commonly thought to have been bound up with medical advance but this was not the case. Some specific diseases like smallpox were reduced because of medical advance, but until the mid 20th century medical knowledge was so slight (and often mistaken) that it had a limited impact on population growth. Critics like the early 18th century essayist Joseph Addison could comment that “we may lay it down as a maxim, that when a nation abounds of physicians, it grows thin of people”.

There are four genuine causes of the improvement in life expectancy. The first was the increase in the standard of living. Where this occurred better nutrition led to healthier bodies. Height and weight grew, and so did resistance to disease. The second, closely related, was the possibility of better standards of public hygiene. The third was the improvements in public health that came with the development of clean water systems, sewage systems and measures to deal with pollution. It should never be forgotten that one of the greatest killers of infants throughout history is dehydration brought on by diarrhoea. In 19th century England, for example, diarrhoea is reckoned to have killed as many infants every two years as all the 19th century cholera outbreaks put together. Today diarrhoea is still estimated to be the second biggest killer of children worldwide, overwhelmingly in poor countries. The fourth factor worth noting is that some diseases may have mutated into less virulent strains.

These four elements help to explain the ways in which infectious diseases eventually came to be contained by rich countries. The result has been the shift to a pattern of ill health and death from non-communicable diseases to the so-called “diseases of affluence”, except that these now began to fall disproportionately on the lower classes in wealthier societies. Capitalism’s potential to solve humanity’s problems is not and cannot be realised because of the ways in which the system also traps us into putting human need second to profit and competition. To see this we have only to look at the patterns of mortality that exist in the world today.

The first thing to note is the huge gaps in life expectancy that still exist between countries. In 2004 life expectancy in Japan was 82 years; in Sierra Leone it was only 34. This is not because there is a lack of food and other basics. The world today produces more than enough to go round. For decades now global food supplies have risen ahead of population growth. In 1961 there were 2 255 calories available per head of world population. By 2000 the figure was 2 805, a 25% increase despite the huge growth in numbers. The resources exist then to create the basis for a healthy life for everyone – the problem is that they are not used this way. In this situation the most vulnerable continue to be the youngest. Infant mortality in Sierra Leone is 316 per 1 000 live births, whereas in countries like Japan and Finland it is only 4.5 per 1 000.

The second element is the size of the differentials in mortality that exist within countries and the fact that, despite improvements in health, such gaps have been widening in key countries. This is not least the case in the UK and the US. These gaps can be measured in the pattern of infant and child mortality, adult deaths and life expectancy. To illustrate this table 2 shows life expectancy gaps in the UK using the official social classification.

Table 2: Changing male life expectancy at birth in the UK

Source: ONS, news release, “Variations Persist in Life Expectancy by Social Class”, 27 October 2007.

There is good reason to think that per capita income (in today’s values) of around $10 000 is sufficient to solve the material problems underpinning health inequality. At this level there is enough to go around and enough to provide the resources for adequate public health. What separates societies, therefore, is less the per capita income over this level (in the UK/US case we are looking at roughly three times this) than the degree to which it is unequally distributed, and the scale of relative deprivation between different social groups. The greater the degree of inequality, the greater the health gaps. As Wilkinson has put it, “People in a country can be twice as well off on average as those in another country without benefit to their mortality rates” if the distribution of income and wealth is unequal.

This is explained by a third element, which is the way that capitalism not only generates material inequality, but also social mechanisms, that lead to ill health. The problem is both the material pressures on human beings – our basic work security, the environment, pollution, etc – and the uneven social and psychological means we have for dealing with the unequal outcomes that follow.

This leads to a fourth element, which is that when these patterns are revealed the system can also encourage perverse responses. If society makes you ill, the obvious solution is to deal with the diseases of ill health at the societal level. But the temptation is often to push resources into dealing with the consequences. If the procedures to deal with consequences are themselves a source of profit, then the temptation will be to bend further discussion away from causes and social solutions towards a self-perpetuating pattern focused on medical technologies, drugs, therapies and the like.

Fortunately capitalism also creates a fifth element: the knowledge base to understand the real relationship along with groups of people, those at the bottom and “professionals”, who should better understand the situation and can join together to demand change. However, the extent to which this will happen is a political issue. For a century now the medical profession has been divided between what have been called mercenaries, seeking to exploit ill health for gain, and missionaries, who are concerned to remove its social causes. But the mercenaries have now been supplemented by the managers who have benefited from the commercialisation and privatisation of health and who tell us that the way forward is health markets that they can run jointly with the mercenaries.

Mike Haynes

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