In this essay I will discuss the relationship between underlying social structures and health outcomes: the debates about the casual pathways between socio-economic status and health inequalities and what has been done in order to combat the inequalities in health.
The term health inequalities refer to the difference in health opportunities and outcomes between individuals or group of people within society. This is “the term that indicates the universal phenomenon of variation of health by socio-economic status, i.e. poorer people have poorer health” (Health forum 2003)
From many studies and from literature review there is information which suggests that there are inequalities in health, and that the inequality between rich and poor, termed the ‘health gap’, is continuing to grow (Smith et al., cited in Davidson, Hunt & Kitzinger 2003). The wider gap between the rich and the poor is totally and morally wrong.
The National Health Service began after World War II and was built on the ideological principles that health care should be freely and available to all citizens. The National Health Service (NHS) was established as a result of the 1944 White Paper, The National Health Service was based on recommendations in the 1942 Beveridge Report which called for a state welfare system. According to William Beveridge, a national welfare state is the only way for Britain to beat five giants Want, Ignorance, Disease, squalor and Idleness.
The National Health Service was set up in 1948 to provide healthcare for all citizens, based on need, rather than ability to pay; providing a compressive service funded only by taxation.
Initially, and mistakenly, it was predicted that demand and the cost of service would decline as illnesses were cured. In fact, the opposite happened: expensive new technology and an ageing population created some new financial pressure
Despite NHS improvement and the expansion of biomedicine, facts and statistic showed that that health of nation had improved generally but the improvement had not been equal across all social classes . Still exist a link between social class (as measured by the old Registrar General’s scale) and infant mortality rates, life expectancy and inequalities in the use of medical services (Davidson and Townsend, 1992).
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The black report of 1980 was without a doubt one of the best known study of health inequalities and social class, in Britain, based on the Registrar General’s categorization according to occupation. In 1971 the death rate for adult men in social class V was nearly twice that of adult men in social class I. The purpose of The Black Report (1980) was to gather information about the problem of health inequalities among the social classes in the UK and the causes that possibly contribute to these inequalities .(Whitehead, 1988).The report analysed the lifestyles and health records of people from all social classes.The findings were produced as Inequalities in Health: Report of a Research working Group (DHSS, 1980). It suggested that the causes of health inequalities were so deep rooted that only major public expenditure would be capable of altering the pattern (Jenkin 1980). This report showed that the gap in equalities of health between higher social classes and lower not only exist but was widening. The problem had to be investigated outside NHS. (Townsend, 1988). The key causes of inequalities in health were linked with economic and social factors such as , unemployment, low poor environment, poor education and sub standard housing.
“The Black Report shows there persistence of social class and geographical inequalities in health provision and people’s health as measured by rates of accidents, morbidity (illness) and mortality”(Adams 2002 p153).The Black Report noted a number of consideration in order to analyse and explain why health inequalities exists?
The artefact explanation which suggests health inequalities do not really exist in reality, but only appear to because of the way class is constructed. The Black report found evidence to support the view that a person in higher social class is more likely to have good health than a person that is lower class.
The report used cause of death ,life expectancy ,infant mortality rates and mental illness of people in different social classes.
But critics such as Illsley (1986) argue that the statistical connection between social class and illness exaggerates the situation.
Social selection explanations suggest that it is health that determines social class rather than class determining health, as those who are healthy will ‘experience upwards social mobility’ (p36) which raises the death rates and levels of illnesses and disability within the lower classes as the unhealthy are pushed down the social scale (Naidoo and Wills, 1994). On the basis of data from a National of Health and Development, ‘Wadsworth (1986) examined and supported social selection view by using the information from a national sample of males and found a close relationship between illness in childhood and adult social status. For example, 36% of these from non manual backgrounds who experience ill-health in childhood, suffered downward social mobility, compared to 23% to those who had good health.’ (Haralambos and Holborn, 2000, p.313) Wadswroth (1986) found that seriously ill boys were more likely to suffer a fall in social class than others Social selection did not explain the disadvantages that occur at all stages of individual’s lifecycle, also it did not account for the social class differences in health found in childhood, when there is not much social mobility but differences in mortality. (Marsh and Keating, 2006) Shaw et al (1999) argues that those from poorer backgrounds are faced with different economic, social and employment factor which can cause ill health. This shows that class position shapes health, not vice versa. (Giddens, 2006)
The behavioural / cultural approach, explains inequality in health by showing the different ways in which people choose to live their life.it suggests that poorer health in classes IV and V is a consequence of less healthy behaviour associated with the lower classes, for example smoking and excessive drinking. The cultural / behavioural explanations stresses that differences in health are best understood as being the result of cultural choices made by individuals or groups in the population. Macintyre (1986) report explain that health damaging behaviour are essentially individual choices. We live in a free world and everyone can choose voluntary ,what is good and bad for himself. In other words , inequalities are product of the individual choices and behaviour. individuals suffering from poor health have different attitudes, values and beliefs which mean that they do not look after themselves. inequalities in health exist because lower social groups have adopted more dangerous and health damaging behaviour than higher social groups, and may have less interest in protecting their health in the future (Whitehead 1987 in Akers & Abbott 1996).
The structural/material approach is that the material situation of the lower class is the most important factor in determining their poorer health. It claims that poor health is the result of ‘hazards to which some people have no choice but to be exposed given the present distribution of income and opportunity’ (Shaw et al, 1999). Poverty is the key factor that links a range of health risks. It is a known fact that poorer people have worse diets and worse housing condition and are more likely to be unemployed and generally have a more stressed life which may lead to increase smoking and drinking habits, potentially dangerous for long term health. This approach put emphasis in the circumstances which people make their choices are strongly affected by the extent of inequality existing in our society. Poverty limit choices, satisfying immediate gratification; it is about being denied the expectation of decent health, education, shelter, a social life and a sense of self esteem Marsh (2000). Poverty and health are definitely linked and not only are the ‘poor more likely to suffer from ill health and premature death, but poor health and disability are themselves recognised as causes of poverty’ (Blackburn 1991, p7. For example, statistics shows that between 1999 to 2003, the North West and East has the highest deprivation and death rates in England. (National statistics, 2003)
Marmot and Wilkinson try to explain that social hierarchy and income/wealth inequalities causes stress and ill health, operating trough mind/emotional pathways affecting people’s wellbeing (lecture notes ) .Health improvements have been made synonymous with income equality, as Wilkinson argues is ‘to improve social cohesion and reduce the social divisions’ Richard Wilkinson (1997) argues that mortality, which is influenced by health, is affected more by the relative living standards of that country. He argues that ‘mortality is related more closely to relative income within countries than in differences in absolute income between them. Statistics show that mortality rates have a trend of being lower in countries, which have less income inequality. He thinks that long-term economic growth rates seem to have no relation to any long-term rise in life expectancy
Acheson Report (1998) was another important study into health inequality which was commissioned by the New Labour government in 1997. The main purpose of Acheson report was to update the findings of the Black Report and particularly to advice on priorities for policy development (Ham, 2004). It was a comprehensive survey of the disadvantaged. The report stated that priority should be given to the health of families with children, improvements in the standards of poor households and that there should be steps taken to reduce income inequalities. (Www.archive.officialdocuments.co.uk, 2004) The findings supported those of the Black Report that the root cause of inequalities was poverty. It was clear that during time death rates have fallen in uk among women and men across all social classes but another serious preoccupation was that the death rates between social class was still evident. and these difference between top and bottom of social class was expanded . Acheson report revealed that inequalities in some areas have risen rather than declined. It shows one more time that exit a strong link between social class and poor health. Poorer people have poor health because they live in poor houses which are health damaging (Alcock 2003).
Health inequality are evident from the start of life through life-course. There is a large evidence that support the idea ,that risk for many chronic illness and conditions is set during foetal life or immediately after birth. Smoking ,drinking have direct effects on foetal growth and development. Smoking is associated with low birth weight, intrauterine growth restriction, placental abruption, premature rupture of the membranes and pre-term delivery. The development of ovaries and testes also appear to be affected by smoking: a woman whose mother smoked has a greater chance of starting her periods early and of having a miscarriage, while boys are more likely to have undescended testes. Thus, smoking has an impact on more than one generation (Selwyn, 2000, p 27).
Household income was used to measure children’s socioeconomic status. During childhood, socio economic gradients have effects in growth and height in language and cognition as well as in social and emotional adjustment.(Kuh et al 2003)
Blane et al (1998) support Townsend explanation of material deprivation :They link health inequality direct to poverty and class. It stresses that poverty, deprivation, the external environment and living conditions are the main causes of illness and mortality. These factors are out of the control of the individuals who live within them.
‘Among child pedestrians the risk of death from being hit by a motor vehicle is multiplied by five to seven times in passing from class I to class IV; for accidental death caused by fires, falls and drowning , the gap between the classes is even greater’ (Townsend/Davisdson 1988).
Davies (2001) explains that:
‘The Labour government came into power in 1997 with a commitment to tackle health inequalities, and offered a ‘third way’ with regard to policies on health’ (p183)
The major health strategy published after the Acheson Report was the White Paper ‘Saving Lives: Our healthier Nation’ (DoH 1999a) in July 1999. It endorsed the Acheson Report by emphasising the need to reduce inequalities in health. At the same time as the White Paper, ‘Reducing Health Inequalities: an action report’ was published. It referred to policies for a fairer society, building healthy communities, education, employment, housing, transport, crime and healthcare (DoH 1999b).
Later that year “Opportunity for all- Tackling poverty and social exclusion” launched by Tony Blair was published with the aim to eradicate child poverty in twenty years’ time. These report was not only focus on welfare ,which is mainly the cause of inequalities but on other factor that have influence affect .
“Saving Lives: Our healthier Nation” is another public health strategy for the U.K, which aimed to improve health and to reduce the health gap. The strategy established a “three way deal for health”, meaning that individuals, communities and government all have a key part to play, It shows how we can all make a difference. Working together, individuals, communities and the Government can save lives by preventing needless and untimely deaths. By tackling poor health, we can all live longer and live healthier. (www.dh.gov.uk)
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In November 1999, the ‘Sure Start’ programme began ‘to promote the physical, intellectual, social and emotional development of young children and their families’ (Sure Start 1999). more than 500 Sure Start programmes were in action, by may 2003, reaching about one third of all children aged under four who were living in poverty. Not only do these programmes promote health and family support services but early education also. Another government initiative aimed at improving the education of disadvantaged children is the ‘Education Action Zones’. And to encourage children from low-income families to remain on at school an ‘Education Maintenance Allowance’ was introduced (Graham 2001: 108).
The government’s main target for poverty was ‘to reduce the number of children in low income households by at least a quarter by 2004, as a contribution towards the broader target of halving child poverty by 2010 and eradicating it by 2020’; but by 2001/2002, midway through the period set by the target, the government were only two fifths of the way to meeting this (Palmer et al 2003). Tax and benefit reforms were also introduced by the government, targeted at low income families with children.
As paid employment is seen as the best way to avoid poverty, the government developed and reformed many policies to overcome barriers to employment. The government’s biggest investment was £5.2 billion in New Deal initiatives, aimed at promoting employment for different groups but especially young people who have been unemployed for six months and people over twenty five who have been unemployed for two years or more (Graham 2001). The aim of the initiative was to increase long-term employability by offering short-term employment opportunities. In April of 1999, the government introduced the first ever ‘National minimal wage’ to the UK, this policy was aimed at reducing ‘in-work poverty’ and decreasing the number of individuals dependent on social security.
Conclusion
Numerous government reports such as The Black Report, (1980) The Health Divide (1987) and The Acheson Report (1998) as well as official statistics have all related socio economic factor and ill health. They have revealed massive class inequalities in health, by stating that nearly every kind of illness and disease is linked to class.
Both the Black Report and Acheson Report identified policies to improve the circumstances of children as an essential condition for the reduction of health inequalities. Children are considered to be our investment for our future and need to be well cared and to be free from health inequalities.
Individuals in the lower socio-economic class may find themselves tight in a lifestyle cycle where problems that contribute to health inequalities remain unchanged. People lifestyles and condition in which they work and live affect their health .putting in other words :Poor social economic status affects health throughout life. Evidence suggests that people down social ladder run usually twice the risk of being ill as those near the top. Unemployment ,low payment, poor social housing, lack of qualification, are the important key that need tackling by government .It is not appropriate to educate people on healthier lifestyle choices ,when most of the time these choices are not available to them .
Taylor and Field conclude:
There is now a general acceptance in research and policy circles that health inequalities are socially caused, and the major detriment is socio-economic inequality within society (2003:61).
Health inequalities are evident from the start of life through life course. In this this essay I have try to outline the inequalities in health and what is being done at present and what are the ideas and plans for the future.
With government involvement, local authorities support, there is a hope that inequalities can be reduced. Till that time comes ,we all are destinated to live in a society where dramatic health inequalities remain a dominant part of our lives.
As human being except material condition, which are important in our life, we need to feel loved and valued, we need to be part of our society ,we need to have free choices .Without these we become unhappy and be more slave of depression, anxiety which all rebound physical health.
I want to finish my essay with Wilkinson and Marmot quote:
“We hope that by tacking some of the material and social injustices, policy will not only improve health and well being,but may also reduce a range of other social problems that flourish alongside ill health and are rooted in some of the same socioeconomic processes.” (Wilkinson and Marmot 2003.pg 9)
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