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Social class and health status
POLICY WATCH
segments of the population. This article gives insight into the complexity of the access-for-accesssake propositions. IJsing the most recent health data (1987) from the Department of Commerce and the Census Bureau, Shi compares several health indicators to the availability of primary care and specialty physicians on a state-by-state basis. Shi uses measurement indicators of “life chances,” which include such health status indicators as overall mortality, cause-specific mortality, life expectancy, and infant mortality. Shi also takes into account such independent variables as availability of primary care physicians, socioeconomic status, and rurality. The number of primary care physicians per 10,000 population was the variable with the most expected signs and highest correlations among the life chance indicators, especially with life expectancy (0.54), infant mortality (-0.41), neonatal mortality t-0.29), and low birthweight (-0.38). The number of specialty physicians was less strongly correlated with life expectancy (0.26) and was positively correlated with cancer mortality (0.34). Comparison of the relative significance of these two provider groups reveals that primary care is strongly associated with longer life expectancy, lower overall mortality, and fewer deaths due to cancer and heart disease. Specialty physicians, on the other hand, are associated with higher overall mortality and more deaths due to cancer and heart disease. The author also points out that access to health services resources as measured by whether or not a patient has access to primary or specialty physician care is not the strongest variable associated with increased life chances. Actually, the socioeconomic indicators such as education are the most powerful pre-
dictors of life expectancy and mortality. For example, in states with a high percentage of persons 25 years of age or younger with less than a high school education, mortality rates were significantly higher than in states with a better-educated population. The relationship between income and mortality was mixed and generally inconclusive. Shi’s work adds to the growing body of’ evidence that even the formation of a large cadre of primary care providers is not all it will take to improve overall health status, most particularly in inner-city urban and rural communities-but it’s a good start. While health care reform remains paramount on the national agenda, the central role of primary care should be emphasized. However, providing financial access to the generalist physician may offer little other than to further escalate the cost of medical care; whereas improving education in the general population may provide the most significant and cost-effective mechanism for improving an individual’s life chances.- -MM
Social Class and Health Status [Nelson MD. Socioeconomic status und childhood mortality in North Carolina. Am J Public Health 1992; x2: 1:31 3 1 [Wilkinsorl RG. National mortality rates: the impact of inequality? Am ,I Public Health 1992; 82: 1082-4.1 [Smith CL), Egger M. Socioeconc~mic differences in mortalitv in Britain and the United .?tates. Am J Public Health 1992; 82. 1079--81.1
T
here are very few examples of morbidity varying directly with social class. Myopia and acne are two. In almost every place you can look, however, soJune 1993
cial class and mortality or morbidity are inversely related. It is even reported that when the Titanic sank in 1912, the mortality rate was 3% in first class, 16% in second, and 45% in third. The recognition of such distinctions has been hesitantly accepted in the United States for two reasons: (1) It is inherent in American culture that class distinctions do not exist (“All people are created equal”) and (2) it is widely believed that the poor are heir to the consequences of their own follies. The recent report by Nelson that welfare recipients have significantly higher mortality rates than do nonwelfare recipients (and the accompanying commentary by Wilkinson and the editorial by Smith and Egger) offer further insight into the simple equation that indicates that it is deprivation itself that leads to poor health and a shortened life expectancy. Social class distinctions in both mortality and morbidity have been widely recognized in other countries for years, where the realities of such differences are acknowledged if not supported. England has used an occupational classification as a surrogate for social class for decades. Although class distinctions were eschewed in the U.S. Constitution, race was considered the defining variable. It was used in the apportionment of representatives. Race has been one of the more uniformly reported variables in vital statistics systems ever since, and most analyses dutifully report black and white differences. The practice is so common that most people accept it as if it were a dichotomous variable. When asked to consider social class, people who tend to such reporting systems assert that it is too difficult to define reliably. Yet anyone who has taken an introductory course in biology knows that “race” is virtually useless as a biologic marker: most
The American
Journal
of Medicine
Volume
94
III
POLICY WATCH
-_^_-..__
.__._.__
of us are the beneficiaries of a widely mixed gene pool. Racism is an important phenomenon with serious biologic consequences, but race as a demographic variable is simply a convenient yet meaningless way to sort persons into groups for often perverse reasons. Nelson’s report on childhood mortality is telling: AFDC (Aid to Families with Dependent Children) recipients aged 28 days through 17 years had mortality rates 2.7 times greater than their non-AFDC peers. The odds ratios were highest for diseases and injuries with an environmental component or for which impeded access to needed services would be expected to have a deleterious, if not fatal, outcome. The ratio for fire-related deaths was 7 to 1. The odds ratios were lowest for diseases such as childhood cancer, which often has a significant genetic or congenital vis-A-vis environmental (social or physical) component. Wilkinson, in his commentary,
POLICY
makes the more surprising observation that it is not just absolute wealth that determines health status, but income distribution between social classes in a single society. In countries with comparable ratios of gross national product per capita, those with a narrower range of income distribution have higher life expectancies than those in which the gaps are wide. It is not just the lower income strata in such a society that would benefit from the relief of poverty, but, according to Wilkinson, the upper income strata are dragged down by the inequitable income distribution patterns. (He offers no explanation for this finding, but the data are intriguing.) Wilkinson thinks that the picture he outlines places the study of health inequalities at the top of the public health agenda and “demands” that health be treated as a “genuinely social phenomenon.” There are several similar studies by different authors, using quite different methods, all of
SPEAK----
“Ultimately, state actions [such as those in Hawaii, Florida, Massachusetts, Oregon, Vermont, Colorado, Kentucky, Maine, Montana, Minnesota, Washington, California, Ohio, New Jersey, and New York] could pave the way for a national plan that builds on these state initiatives and brings in the laggard states. This is not topdown or bottom-up. It is a middle way-a coming together of policy and politics in the health field,” urge James R. Tallon, Jr. (Majority Leader of the New York State Assembly) and Richard P. Nathan (Provost of the
IV
June 1993
which point to the significance of poverty as a determinant of health status (rather than the other way around, as is sometimes postulated to be the case). The Black report (named for its author, not the subject) was so compelling that it appears to have been suppressed by the Thatcher government in England and has been very difficult to obtain in the U.S. The significance of this work is hard to understate. For many years, black-white differences in mortality rates in the U.S. have defied comprehension. They are comprehensible, however, when viewed as a manifestation of class differences, compounded by racism. In the present climate, in which the U.S. is finally moving slowly towards a national policy that might equalize access to medical care services, it is important to contemplate the need to afford unequal access if the access issue is to be seen as part of an effort to improve the public health, not just its politics.-GP
The American
Journal
of Medicine
Volume
94
Nelson A. Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York) in “A Federal/State Partnership for Health System Reform” (Health Aff [Millwood] 1992; 4: 11-2). Setting in motion a meaningful dialogue and partnership between states and federal policymakers is one of the most challenging factors of true reform, ranking right up there with mandatory universal coverage and cost-containment. But motion must first overcome inertia, and there’s plenty of that as well. Stay tuned.-WFB
segments of the population. This article gives insight into the complexity of the access-for-accesssake propositions. IJsing the most recent health data (1987) from the Department of Commerce and the Census Bureau, Shi compares several health indicators to the availability of primary care and specialty physicians on a state-by-state basis. Shi uses measurement indicators of “life chances,” which include such health status indicators as overall mortality, cause-specific mortality, life expectancy, and infant mortality. Shi also takes into account such independent variables as availability of primary care physicians, socioeconomic status, and rurality. The number of primary care physicians per 10,000 population was the variable with the most expected signs and highest correlations among the life chance indicators, especially with life expectancy (0.54), infant mortality (-0.41), neonatal mortality t-0.29), and low birthweight (-0.38). The number of specialty physicians was less strongly correlated with life expectancy (0.26) and was positively correlated with cancer mortality (0.34). Comparison of the relative significance of these two provider groups reveals that primary care is strongly associated with longer life expectancy, lower overall mortality, and fewer deaths due to cancer and heart disease. Specialty physicians, on the other hand, are associated with higher overall mortality and more deaths due to cancer and heart disease. The author also points out that access to health services resources as measured by whether or not a patient has access to primary or specialty physician care is not the strongest variable associated with increased life chances. Actually, the socioeconomic indicators such as education are the most powerful pre-
dictors of life expectancy and mortality. For example, in states with a high percentage of persons 25 years of age or younger with less than a high school education, mortality rates were significantly higher than in states with a better-educated population. The relationship between income and mortality was mixed and generally inconclusive. Shi’s work adds to the growing body of’ evidence that even the formation of a large cadre of primary care providers is not all it will take to improve overall health status, most particularly in inner-city urban and rural communities-but it’s a good start. While health care reform remains paramount on the national agenda, the central role of primary care should be emphasized. However, providing financial access to the generalist physician may offer little other than to further escalate the cost of medical care; whereas improving education in the general population may provide the most significant and cost-effective mechanism for improving an individual’s life chances.- -MM
Social Class and Health Status [Nelson MD. Socioeconomic status und childhood mortality in North Carolina. Am J Public Health 1992; x2: 1:31 3 1 [Wilkinsorl RG. National mortality rates: the impact of inequality? Am ,I Public Health 1992; 82: 1082-4.1 [Smith CL), Egger M. Socioeconc~mic differences in mortalitv in Britain and the United .?tates. Am J Public Health 1992; 82. 1079--81.1
T
here are very few examples of morbidity varying directly with social class. Myopia and acne are two. In almost every place you can look, however, soJune 1993
cial class and mortality or morbidity are inversely related. It is even reported that when the Titanic sank in 1912, the mortality rate was 3% in first class, 16% in second, and 45% in third. The recognition of such distinctions has been hesitantly accepted in the United States for two reasons: (1) It is inherent in American culture that class distinctions do not exist (“All people are created equal”) and (2) it is widely believed that the poor are heir to the consequences of their own follies. The recent report by Nelson that welfare recipients have significantly higher mortality rates than do nonwelfare recipients (and the accompanying commentary by Wilkinson and the editorial by Smith and Egger) offer further insight into the simple equation that indicates that it is deprivation itself that leads to poor health and a shortened life expectancy. Social class distinctions in both mortality and morbidity have been widely recognized in other countries for years, where the realities of such differences are acknowledged if not supported. England has used an occupational classification as a surrogate for social class for decades. Although class distinctions were eschewed in the U.S. Constitution, race was considered the defining variable. It was used in the apportionment of representatives. Race has been one of the more uniformly reported variables in vital statistics systems ever since, and most analyses dutifully report black and white differences. The practice is so common that most people accept it as if it were a dichotomous variable. When asked to consider social class, people who tend to such reporting systems assert that it is too difficult to define reliably. Yet anyone who has taken an introductory course in biology knows that “race” is virtually useless as a biologic marker: most
The American
Journal
of Medicine
Volume
94
III
POLICY WATCH
-_^_-..__
.__._.__
of us are the beneficiaries of a widely mixed gene pool. Racism is an important phenomenon with serious biologic consequences, but race as a demographic variable is simply a convenient yet meaningless way to sort persons into groups for often perverse reasons. Nelson’s report on childhood mortality is telling: AFDC (Aid to Families with Dependent Children) recipients aged 28 days through 17 years had mortality rates 2.7 times greater than their non-AFDC peers. The odds ratios were highest for diseases and injuries with an environmental component or for which impeded access to needed services would be expected to have a deleterious, if not fatal, outcome. The ratio for fire-related deaths was 7 to 1. The odds ratios were lowest for diseases such as childhood cancer, which often has a significant genetic or congenital vis-A-vis environmental (social or physical) component. Wilkinson, in his commentary,
POLICY
makes the more surprising observation that it is not just absolute wealth that determines health status, but income distribution between social classes in a single society. In countries with comparable ratios of gross national product per capita, those with a narrower range of income distribution have higher life expectancies than those in which the gaps are wide. It is not just the lower income strata in such a society that would benefit from the relief of poverty, but, according to Wilkinson, the upper income strata are dragged down by the inequitable income distribution patterns. (He offers no explanation for this finding, but the data are intriguing.) Wilkinson thinks that the picture he outlines places the study of health inequalities at the top of the public health agenda and “demands” that health be treated as a “genuinely social phenomenon.” There are several similar studies by different authors, using quite different methods, all of
SPEAK----
“Ultimately, state actions [such as those in Hawaii, Florida, Massachusetts, Oregon, Vermont, Colorado, Kentucky, Maine, Montana, Minnesota, Washington, California, Ohio, New Jersey, and New York] could pave the way for a national plan that builds on these state initiatives and brings in the laggard states. This is not topdown or bottom-up. It is a middle way-a coming together of policy and politics in the health field,” urge James R. Tallon, Jr. (Majority Leader of the New York State Assembly) and Richard P. Nathan (Provost of the
IV
June 1993
which point to the significance of poverty as a determinant of health status (rather than the other way around, as is sometimes postulated to be the case). The Black report (named for its author, not the subject) was so compelling that it appears to have been suppressed by the Thatcher government in England and has been very difficult to obtain in the U.S. The significance of this work is hard to understate. For many years, black-white differences in mortality rates in the U.S. have defied comprehension. They are comprehensible, however, when viewed as a manifestation of class differences, compounded by racism. In the present climate, in which the U.S. is finally moving slowly towards a national policy that might equalize access to medical care services, it is important to contemplate the need to afford unequal access if the access issue is to be seen as part of an effort to improve the public health, not just its politics.-GP
The American
Journal
of Medicine
Volume
94
Nelson A. Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York) in “A Federal/State Partnership for Health System Reform” (Health Aff [Millwood] 1992; 4: 11-2). Setting in motion a meaningful dialogue and partnership between states and federal policymakers is one of the most challenging factors of true reform, ranking right up there with mandatory universal coverage and cost-containment. But motion must first overcome inertia, and there’s plenty of that as well. Stay tuned.-WFB