Recent research into inequality and ill health tend to support the general findings of the Black Report and point in particular to a widening of the health gap between the rich and the poor. Inequalities in health are found at virtually every stage of the life cycle. Morbidity and mortality rates have been shown to be consistently higher among more disadvantaged economic groups and in socially deprived areas (Marmot & McDowall 1986). Whitehead’s (1987) review of inequalities in health came up with new and international findings and further corroborated evidence of class variations in health. Her findings suggested a serious widening of inequalities in health throughout the 1980s. Phillimore et al (1994) further illustrate this. During the period 1981–1991 a widening of mortality differentials was observed for all age categories under 75 years, between the most affluent and the most deprived areas. Other evidence has pointed to socioeconomic status as a major factor influencing morbidity as well as mortality. Yuen et al (1990) inspected acute and chronic self reported illness using data from the General Household Survey (1981–84) and found an inverse relationship between reported levels of illness and socioeconomic status.

Cross-cultural research shows that health inequalities are an international problem. Pappas et al (1993) compared mortality between socioeconomic groups between 1960 and 1986 in the USA. They confirmed that the poor die earlier and have more health problems. They also showed that the disparity was increasing. Health inequalities in the USA are even starker than in the UK. Navarro (2004) suggested that a member of the poorest class in the USA can now expect to die 14 years earlier than a member of the most affluent class.

In 2000, an important study showed that inequalities continued to widen at the start
of the new millennium. Some key facts and figures from this study are illustrated below.

The Shaw et al (2000) study was one of a number of recent studies that linked social class inequalities to geographical inequalities. There has been a steady North to South shift in terms of the focus of economic activity in the UK since the end of the 1970s. Smith (1989) demonstrated how different regions of the UK are increasingly acting like magnets either for wealth or social deprivation. As there are geographical distributions of poverty and wealth, so too are there similar patterns for health. There is now a geography of health and wealth in which social deprivation and high morbidity and mortality rates go hand-in-hand.

Extreme morbidity and mortality variations between the Northern and Southern regions of the UK are difficult to ignore. The research illustrates a geographical mapping of poverty and of health and illness (Carstairs 1989 and Phillimore 1989). These patterns may be local as well as regional. For example, life expectancy decreases by 1 year for each of six stops on the London Underground that one travels from Tower Hill into the East End (Shaw 2005). These trends have become more obvious in recent years. We are concerned here with inequalities within the UK but international inequalities have also worsened as our discussion of globalization in Chapter 5 indicated. For example, life expectancy is an astonishing 48 years more in Japan than in Sierra Leone (Marmot 2005).

The lifestyle of the lower socioeconomic classes has been viewed as an important cause of health inequality (DoH 1991). The government’s philosophical approach is sympathetic to the view that people are ultimately responsible for their own health. This allows the government to see their role as facilitators and educators, rather than providers of benefits and services. While cultural differences between social classes may explain some of the variation in health, as a single explanation culture/lifestyle is highly problematic and should be treated with caution. It would be misleading to separate lifestyle and behaviour from their social context since these relate to such things as availability of choice (Wilkinson & Marmot 2003). The ‘Health and Lifestyles’ (Blaxter 1990) survey showed that most people were aware of healthy messages such as those regarding diet, smoking and exercise. However, making healthy choices was a complex matter. Few people had wholly healthy or unhealthy lifestyles; most engaged in a mixture of more or less healthy behaviours, and their choices were subject to a variety of influences including beliefs and material and social circumstances. This survey also showed that people in disadvantaged circumstances were less likely to experience health improvement as a result of lifestyle change owing to the health damaging effects of their material circumstances (see Chapter 11). Graham’s (1993) research has also showed the ways in which hardship influences health choices. For some people, life is so difficult now that it seems impossible to worry about the future. She showed, for example, how women in difficult circumstances used smoking to cope with the stresses and strains of everyday life, even though they were aware of its damaging effects.

If we take food as an example of lifestyle, we can see a social gradient in diet quality. The major dietary difference between the social classes is that the poor substitute cheaper, processed foods for fresh foodstuffs. Processed foods are still heavily promoted by the food industry which has an enormously powerful influence on food standards (Wilkinson & Marmot 2003). Nutritional status thus continues to reflect socioeconomic status. Blaxter (1990) found that, among the more disadvantaged, meeting energy demands was an important consideration. While middle class women were preoccupied with providing a ‘well balanced’ meal, among the less well-off, there was more concern with providing a meal that was sustaining and ‘filling’.

Research in Britain has also shown that poverty has a direct effect on physical development. Long-term nutritional status influences physical development and thus nutritional disadvantage is established early in life. Height and physical stature can be regarded as a general indicator of this. Children of unemployed parents are shorter than children from households where the father is working (Rona et al 1978). A report published by the University of Ulster (Barker et al 1988) also showed evidence of a height gradient related to socioeconomic status. This report suggested that the children of manual workers were, on average, shorter. This was true for both sexes. The Glasgow Healthy City study (George 1993) highlighted the difficulties of achieving good nutritional status if you are poor. It found that poorer areas have fewer reasonably priced outlets for fresh food. To get good value and healthy food you need a car or good transport. Thus, healthy diets cost more.

The Black Report (Townsend et al 1992) identified material deprivation as the most important cause of heath inequalities as we noted earlier. Since then, a large number of studies have highlighted material and social deprivation as key determinants of ill-health (Wilkinson & Marmot 2003). Power (1994) illustrated the link between health and income distribution and suggested that the health gradient is not an anomaly but that in most European countries health has been shown to be linked to social circumstances. More recently, Gwatkin (2000) has demonstrated that this is a global problem.

The social context sets the parameters for behaviour, choice, access and use of resources. Health inequalities are linked to multiple factors, many of which locate the source of the problem in a lack of finance and an impoverished environment. Those from lower socioeconomic positions live in poverty with low wages, often enduring hazardous working conditions, poor housing and run-down neighbourhoods.

Living and working environments influence health. McCarthy et al (1985) discussed the health consequences of damp housing, mould and respiratory disease. This was supported by research which noted that mould growth produced by damp caused respiratory problems (Blackman et al 1989). The authors also observed significant health differences between inner and outer city children in Belfast and fixed the blame for this on bad heating and housing design. For example experience of the Divis Flats in Belfast is a case in point, which illustrates how reduced building costs (poor design and insulation, the use of toxic materials such as asbestos and calcium chloride in the cement to speed the drying process) are ultimately translated into subsequent medication and hospital costs (see Lowry 1990). Kogevinas (1990) in a longitudinal study also found a close link between housing tenure and the ability to cope with health threats. This study showed that housing tenure and cancer survival rates are related.

The type of local neighbourhood also influences health. Blaxter (1990) noted the importance of neighbourhoods suggesting that poor areas are health damaging. Macintyre et al (1993) argue for a more pragmatic approach to research suggesting that even if public servants cannot influence the economic status of the population, it might be possible for local authorities to upgrade the environment of poorer areas in ways which could promote health. They argue that there is a need to inspect poorer localities and evaluate the influence of environmental factors on health. For example, childhood accident rates are strongly influenced by environment.

The Macintyre et al (1993) study concluded that improving the local environment promoted better health. The authors discuss the findings from two areas of Glasgow. They look at the physical characteristics of each area such as safe and healthy environments, public and private services, sociocultural features and the reputation of the area. They showed that living in the better area meant better access to healthier and more affordable foodstuffs. Public services were better and there were more recreational facilities.

Despite suffering worse health, the working class receive inferior medical care. Tudor Hart 1971 and Tudor Hart 2006 argued that an inverse care law is operated in Britain, whereby the provision of services is inversely related to the need for those services, i.e. those areas in most need are worst served. Tudor Hart related this to the influence of a market economy on healthcare. The more disadvantaged have poorer access to the full range of medical services and they also tend to under-utilize healthcare resources. Survival rates may be poorer. For example, The Thames Cancer Registry (1994) showed social class to be a major factor in cancer survival rates. For most cancers, patients from lower socioeconomic groups have lower survival rates than patients from higher socioeconomic groups. Furthermore, consultation rates and GP attendance appeared also to be linked to social class and a difference in treatment and response from medical professionals has also been noted (Blaxter 1984 and Cartwright 1976).

The social capital theory suggests that an individual’s well-being is linked to social equality, social support and social cohesion (Kawachi 1997 and Wilkinson 1994). We discussed social capital in Chapter 5 and are concerned here specifically with its impact on health. For example, Wilkinson (2005) suggests that socioeconomic differences do not simply cause damage to health through material deprivation. He says that inequality has damaging psychological effects by lowering self-esteem and increasing stress levels. Stress may have direct effects or may translate into unhealthy coping behaviours such as excess drinking or smoking. Using data comparing income differentials between different countries, Wilkinson (1992) suggests that, in developed countries, mortality is more closely related to relative income within countries than the absolute wealth of a country. In other words, how wealth is shared out can be more important than the overall wealth of a country. For example, the USA is four times as wealthy as Costa Rica but life expectancy for Black men in the USA is 9 years lower than in Costa Rica. More egalitarian societies therefore tend to be healthier and to have lower mortality rates (Wilkinson & Pickett 2006).

Support for this thesis also came from the studies of Whitehall civil servants conducted by Michael Marmot. These studies found that even among people who were not poor, there was a social gradient in mortality that ran from the top to the bottom of the civil service. Marmot thus concluded that health differences were not limited to poor health for the poor and good health for everyone else (Marmot 2003). He posited the existence of pyscho-social pathways to ill health which were linked to factors such as respect, autonomy and social support (Marmot 2004). For example, the Whitehall II study showed that low control in the workplace predicted coronary heart disease (Marmot et al 1997). Marmot & Wilkinson (2001) suggest that the pyscho-social effects of relative deprivation also involve ‘insecurity, anxiety, social isolation, socially hazardous environments, bullying and depression’. Marmot argues that reducing the slope of the social gradient will achieve substantial health gains (Marmot 2003).

Robert Putnam (2000) highlights the negative effects of a breakdown of social cohesion and trust (see Chapter 5). Putnam argues that this is part of a wider social disengagement that is at the heart of many social problems. He argues that being a member of small organized groups that meet, face-to-face, on a regular basis, is one of the basic building blocks of social (and civic) cohesion. Further, he argues that social capital has a direct impact on a person’s health. Reduced social capital, social cohesion and social solidarity are translated into increased crime and political conflict as well as higher mortality rates and poorer health. Kawachi and Kennedy (2002) argue that trust has a direct effect on the relation between income inequality and life expectancy. Thus, high levels of income inequality in a society produced low trust, and low trust creates a poor social environment that in turn impacts on health. Putnam’s general thesis is that fostering social capital is good for society and individuals.

Some evidence from the USA supports the social capital thesis. Klinenberg (2002) argues that levels of social capital among vulnerable groups, particularly the elderly and infirm, was a predictor of their likelihood of surviving temperatures that reached over 120° Fahrenheit during the Chicago heat wave of July 1995. Distribution of deaths showed that fatalities came from mostly low income, elderly, African-American and from violent regions of the city. There was also a gender difference. When age was controlled for, it was found that men were more than twice as likely to die as women. It showed how social vulnerability as measured by social isolation accounted for the frequency and distribution of deaths during the heat wave. Men constituted 80% of the unclaimed bodies in the morgues during the heat wave. Thus, it was the low social capital of the poor elderly men that created their acute vulnerability when faced with an intense heat wave.