Health and social inequities in Spain

.sOC. SC!. .Meti. Vol. Printed

m Great

31. No.

3. pp. 351-358.

0277-9536

1990

90 53.00 + 0.00

Perpamon

Bnlain

HEALTH

AND SOCIAL INEQUITIES

Press plc

IN SPAIN*

JOSEP A. RODRIGUEZ and LOUIS LEMKOW Department

of Sociology,

University of Barcelona, 08034 Barcelona, Spain

Avda

Diagonal

690,

Abstract-This article examines the relationship between health and social differences in Spain. The dominant explanatory models (medical. health system oriented and economical) have focused on health care as the main source of health. They have disregarded the role of socioeconomic variables in the genesis, development and cure of illness. In relation to the distribution of health, the variables analysed here are those of poverty. social class, sex, age, living conditions, lifestyles and some existential indicators using both official aggregated data and survey data. We conclude that Spain is a country with major economic, social and regional differences and manifests important variations in the health of its population. The evidence taken from the data presented here seems to indicate that poverty, living conditions and income play a relevant explanatory role.

INTRODUCTION

conditions, and exposure to noxious agents both in the workplace and at home. Marxist theorists have argued that capitalist social organization. in its pursuit for profits, systematically violates the minimum subsistence level necessary to maintain the body of the labour force in a fit and healthy condition. The worker experiences economic deprivation on an increasing scale and is finally left with insufficient resources to maintain bodily health. There can be little doubt that higher morbidity and mortality rates in the lower social classes are at least in part due to the inadequate medical care services as well as the impact of toxic and hazardous physical environments and to the poor conditions of life and work. But these factors do not seem to explain entirely a large number of illnesses which have been shown to be associated with socioeconomic status. There are elements about the living conditions of the working class that increases the vulnerability to illness in general. Susceptibility to illness may be influenced by the forms of life, by life stress and by the different ways in which people cope with such stress. How people cope with stressful events in their daily life as well as how they organize their lives in response to the social and economic environment define some aspects of their lifestyles. While extensive research has been undertaken in a number of European countries on inequities in health, this has not been the case in Spain. Investigating this question has posed major problems because of the inadequacy and unreliability of data [I]. The fact is that the current bibliography and statistics are scarce. In Spain, the lack of data pertaining to social stratification, standard of education etc., means that we are frequently obliged to use other indirect indicators [2]. Nevertheless as we stated in an earlier paper [3]:

Behind the high standards of life reached by the advanced societies hide some striking differences between social groups and classes. In the case of health, the dominant explanatory models (medical, health system oriented, economical) have focused on health care as the main source of health. They have disregarded the role of socioeconomic variables in the genesis, development and cure of diseases and illnesses (and here lies one of the reasons for their explanatory failure). These interpretations depoliticize the social differences in health by rationalizing them as mere assistancial or resource allocation differences. The problem is broken up: it becomes the object of a specific kind of policy (health policy) and moves away from the rest of the political activity. The medicalization of health problems prevents the social class differences from becoming a source of social conflict, while maintaining. if not increasing, those social

differences.

Disease is not distributed evenly through the population. Certain social groups get sick more often and some populations die at higher rates than others. Social class gradients of mortality and life expectancy has been observed for centuries, and it has been shown that the lower classes have higher mortality, morbidity and disability rates. The most frequent explanations relating social class with health have been based on both the Marxist definition of class; class defined with respect to the position to the means and process of production, and the Weberian distinction of social class; class defined by the economic position (position in the economic market), and status defined by some measures of lifestyles. Associated with the concept of class there is poor housing, crowded living conditions, low income, poor education, poor nutrition, inadequate medical care, high unemployment, occupational *An

earlier

version

of this paper

Meeting of Principal

organized

was

presented

Spain is a strategic country for measuring and analysing the relationship between social structure, inequality and health. largely owing to the enormous socio-economic differences existing between classes, the great degree of repional differentiation, and the radical social separation between men and women.

at the

Incesrigarors on Inequities in Health

by the WHO

(Lisbon,

September

1987). 351

352

JOSEP A. RODRiGUEZ and

Given some of the special research on inequities in health that the following areas require specific area of research could following way.

difficulties posed by in Spain we suggest in-depth study. This be divided up in the

LOUIS LEMKOW

Table 1. Self-assessmentof health status bv existential indicators I%) Health status Very good

Fair

Poor

24 29 35 31

35 43 40 31

20 13 9 8

I 2

Loneliness

1. In-depth study of inequalities in health related to some of the special peculiarities of Spanish social structure and sexual division of labour, including the following:

Frequent

13

Sometimes Rarely Never

13 15 22

happy

Quite happy Not very/not happy Belief

I

33

36

24

6

I

13 IO

35 23

41 40

9 22

I 5

29 28 35 36

30 42 40 33

I9 I3 9 8

4 2 I

I8 26 29 36 38 32%

43 39 41 37 32

23 I9 I4 8 5 II%

6 4 2 I 2 2%

that life has no meaning

Frequent Sometimes Rarely Never Sarisfaction

24 hr

7

Happiness Very

(a) The subterranean economy and unemployment. (b) Migratory processes and regional differentiation. First

Very poor

Good

I6 I5 I5 20

I

with one’s Ii/e

unsatisfied Quite unsatisfied Satisfied Quite satisfied Very satisfied N (2306) Very

7 II 13 I8 24 16%

38%

Source: Ref. [7]. Sample of 2306 people older than I8 years old. Part of the European Values .%I&.

(c) Sexual division of labour (the marked social separation of women and men in Spanish society).

Early

neanatal

(6 first

days)

2. The study of some of the ‘insults and injuries’ suffered by different socioeconomic groups throughout the life cycle, e.g. environmental, occupational and living conditions. 3. Further studies of access to and the quality of the health care system (both past and present) and critical analysis of proposed legislation. 4. Reassessment and re-working of existing morbidity, mortality, census data and survey research [4]. In this paper we shall be particularly concerned to develop point 4, given that we have commented upon the other items elsewhere [S]. All the data presented here adds to and updates our previous work [3]. THE SOCIAL

Fig. 1. Provincial distribution of infant mortality, 1980 (rates by 10.000 live births). Source: lnstituto National de Estadistica. Mocimiento Natural de la Poblaci& Espafiola: 1980. Vol. I (INE. Madrid, 1986). pp. 59 and 103.

DISTRIBUTION

OF HEALTH

Spain has conquered, during the eighties, some of the best levels of health of Europe, only surpassed by France and Sweden [6]. A great deal of this success has to be attributed to the socioeconomic development initiated in the sixties which led to improvements in the conditions and styles of life of the population. The construction and extension of a national health system has, at the same time, made health care available to the majority of the population. These factors explain a large part of the reductions in the infant mortality rates and the extension of life expectancy. The best expression of such improvements is the 118% increase in life expectancy at birth between 1900 and 1980 (from 34.7 to 75.6 years) and in life expectancy beyond the age of 65. * Using data from a recent survey of the social and cultural values of the Spanish population we can analyse the perception of state of health (subjective level of health) [7]. It is important to note that just under half the population (48%) perceive their health

. L:* :,.* .*p*

Health and social inequities in Spain

to be good or very good [8]. Comparing this data with that of the ‘Encuesta de Salud de Barcelona’ [9] we can contrast the relationship between the subjective perception of health and the biomedical occurrence of disease. According to the latter survey, 23.8% of the population has had their daily activity relatively limited through health problems. Table 1 relates subjective perceptions of health status to existential variables such as loneliness, happiness and life satisfaction; while Table 2 looks at self-assessment of health status by social indicators. As expected, there is a high positive correlation between the subjective level of health and positive indicators such as happiness and satisfaction with life; while the correlation is negative with negative indicators such as loneliness and the belief that life has no meaning. Both income and socio-professional status (two key indicators of class differentiation) correlate very highly with the subjective level of health. Despite the fact that the upper classes are always more critical and aware of their health problems, they define their health in better terms than the lower classes, which suggests they enjoy a substantially better level of health. Despite the good indices for the health of the Spanish population (do the subjective self-assessments contradict the demographic data?) as a whole [IO], there are clearly marked social economic, regional and cultural differences that might be expected to impinge upon health [ 1I]. Elsewhere we have studied the existence of systematic regional differentiation with regard to the health of the population [3, 1I. 121. Figure 1 presents infant mortality rates for 1980. In the first two cases there is a close relationship between the rates and the distribution of health care resources. For the third indicator of infant mortality (first year mortality) the relation with the distribution of health care resources is not so clear and other variables such as income, level of development and urbanization come into play. status

Table 2. Self-assessmentof health status by social indicators (%) Health status

Age 0.r) la-24 25-34 35-44 45-54 554 65-74 75 and more SPX Men Women Led

Very good

Good

Fair

Poor

28 23 I5 IO IO 8 I3

35 39 36 35 24 21 26

32 34 42 42 44 38 23

3 3 6 II 20 26 32

I 0 2 2 5 6

I8 I5

36 29

36 39

8 I4

2 2

I9 17 I4

36 33 30

37 39 39

7 9 I4

I I 3

I9

34

37

9

I

I8 I4 I5

30 36 28

42 35 37

IO II 15

I 2 3

Very poor

12

r

353

y= 0.079

x + 7.476

R-squared:

.

’ ./

10

.. .

6

l

.

0

0.

.

0.’ I

.

. I

6p”’ 0

10

Without y=-0.764 12

0.364

I

I

I

20

30

40

hygienic I+

services

9.31 R-squared:

0.26

.

c

61 0

.

.,

I

With

.

I . 3

2

1

three or more services

Fig. 2. Regression between overall mortality and household hygienic services, Spain 1981 (data by provinces). Source: see footnote for Table 3.

Table 3 presents correlation and regression coefficients between various mortality indicators (total, infantile, foetal) and some economic and welfare indicators (income, sanitary senices, etc.) at the provincial level. In the case of mortality through all causes and for all ages it is important to note the relationship to life conditions; the lack of sanitary services seems to explain up to 40% of the interprovincial variations (Fig. 2). Income and standard of life indices seem to be of less relevance (20% of mortality variation between provinces). Infant mortality doesn’t correlate well with indicators of income, they are in fact not statistically significant. Nevertheless life conditions again are of relevance. When it comes to late foetal mortality (Fig. 3) we find that income indicators have the greater explanatory

I 12

L

y--0,069x+6.292 R-squared :0.196 I.

of inmnw

High Medium Low Socio-prq/kkmd

.wam

Professionals/managers Clerical and services workers Skilled workers Manual workers

Source: Ref. [7]. Sample of 2306 people older than I8 years old. Part of the European Values Sm&.

Standard

of life

index

Fig. 3. Regression between late foetal mortality (per 1000 live births) and the standard of life index, Spain 1981 (data by provinces). Source: see footnote for Table 3.

JOSEPA. RODRIGUEZand LOUIS LEMKOW

354

Table 3. Correlation and regression coefficients between provincial mortality rates and socioeconomic indicators. 1981 Overall mortality

Infant mortality

per 100 inhabitants

National income per cap&a Standard of life index Average income per capita Households without bathroom Households with three or more bathrooms Central heating

Late foetal mortality per 100 births

per 100 births

RJ

C.C.

R’

0.174 0.218 0.1 0.384 0.26 0.064

-0.417 -0.463 -0.316 0.62 -0.51 -0.253

0.058 0.058 0.167 0.187

cc.

R’

cc.

0.095 0.196 0. IS? 0.082 -

- 0.024 - 0.24 I 0.408 -0.432

-0.308 - 0.433 - 0.426 0.286 -

Source: INE. .Morimitwo Nuturul de la Pohlacidn. Atio 1981 ([NE. Madrid, 1987); Encuesra de Presupur.ww Fumiliarrs 1980-81 (INE. Madrid. 1983); Di.sparidadesecondmico-socialesde Ias procincias espotiolas(INE. Madrid, 1986); Banco de Bilbao. Renro National de Espon‘o 1983 .r su dirrribucibn prorinriul (Banco de B&do. Bilbdo. 1986).

weight: almost 20% of the inter-provincial (Fig. 4).

variation y=3269~+32.652

HEALTH

AND

R-squared:0.415

POVERTY .

important effect of income and status variables on the level of health has been established in a recent study of the city of Barcelona (Table 4) [9, 131. These results pose some methodological and statistical problems in terms of extrapolation. Despite the fact that the unit of analysis (the municipal district) The

4

.

y=-0.ooO4781 .

0.24

t 0.33

E

0.16

IL -I

_.-_

. ,

a04

120

Avemge

.

160

: 0.206

I + 0.797 R-squared

.

.

.m ,

200

income per capita

.

.

.

240

(thousands

of pesetas)

Fig. 4. Regression between late foetal mortality (per 1000 inhabitants) and the average income per capita, Spain 1981 (data by provinces). Source: see footnote for Table 3.

Levels of

In/ant nrorralit~ rates R‘ 0.1 I9 CC. 0.344 Liwr cirrhosis ntorralir~ (mm) RZ 0.566 C.C. 0.752 Lung morralir~ RZ 0.415 C.C. 0.644 Life rxpecronc~ R‘ 0.538 C.C. -0.734 Losr rco*.s o/ life Rz’ 0.294 C.C. 0.542

24

is of smaller size and greater homogeneity than the province, the limited universe (only 10 districts) detracts somewhat from the statistical significance of the analysis. The relationship between infantile mortality and socioeconomic indicators of the districts is not very signifqcant, but the relationship between other health indicators and socioeconomic status seems to be stronger. Poverty becomes the main explanation of differences in health between districts. Poverty seems to account for 56% and 42% of the variation between districts for liver cirrhosis mortality (Fig. 5) and lung

Table 4. Correlation and regression coefficients between health indicators and socioeconomic indicators in the city of Barcelona, 1986 (data by districts)

Poverty

20

of poverty

Fig. 5. Regression between liver cirrhosis mortality (LCM) rate in men and level of poverty, Barcelona 1986 (data by districts). Source: see footnote for Table 4.

e-0 .

I

16

12

Level

i .

8

Upper

Working

Wealth

CkiSS

CIXS

0.295 -0.544

0.082 -0.286

0.211

0.085 -0.291

0.286 -0.534

0.221 -0.470

0.237 0.486

0.192 -0.439

0.163 -0.403

0.107 -0.327

0.15 0.387

0.078 -0.28

0.44 0.633

0.348 0.59

0.45 - 0.67 I

0.31 I 0.558

0.2 0.448

0.072 -0.269

0. I5 -0.388

0. I -0.316

0.044

Higher education

Source: Ayuntamiento de Barcelona. La Salur a Barcelona 1986 (Ayuntamiento de Barcelona, Bxcelona. 1986); lnstitut d’estudis Metropolitans de Barcelona. Enquesra hfcfropolirona 1985-1986 (CMB, Barcelona. 1986).

Health Table

Districts

5. Distribution

of health

and social inequities

355

and wealth among the districts of the city of Barcelona. 1986

% Wealth

% Poverty

Liver cirrhosis mortality (men)

I.1 9.9 3.6 12.2 27.9 1.3 7.0 2.0 3.3 5.7

22.2 16.2 21.8 7.8 4.8 I I.4 8.2 21.4 15.0 15.0

79.4 49.1 50.7 26.4 21.1 42.7 25.6 39.6 25.5 51.4

DI D? D3 D6 D5 D6 Dl D8 D9 DIO

in Spain

Lung mortality

(men)

Lost years of life

Life expectancy

160.8 90.0 98.0 57.6 59.2 76.2 57.3 64.3 57.6 78.5

84.91 41.55 42.26 38.69 36.84 38.6 35.61 40.53 36.83 45.10

13.27 77.81 76.86 77.89 70.09 77.73 11.98 16.87 77.60 76.79

Source: Ayuntamiento de Barcelona. Lu Saluta Burwlono 1986(Ayuntamiento de Barcelona, Barcelona. 1986); lnstitut d’estudis Metropolitans de Barcelona. Enyuesro Metropolitana 1985-1986 (CMB. Barcelona, 1986).

(Fig. 6) respectively. Poverty also appears to be responsible for 54% of the variation of life expectancy. In Barcelona, a city with a generally high level of per capita income and welfare, we find notable differences in health level according to district. These variations seem to be explained by the distribution of poverty. In the large and wealthy cities, the continuing and even developing pockets of poverty (cities still remain very substantially segregated at a socioeconomic level) questions the notions of urban welfare and underlines the great differences between very high levels of well-being (upper class residential districts) and the very low levels in the marginal areas of the city (Burgess’s transition zones perhaps?). The differences in health according to the district where the upper class live compared to the areas where there is a great deal of poverty is considerable (Table 5). In modern mortality

y=2.135x+

10.452

R-squared:

0.566

80

.

t 60!-

4

,

6

12

Level

16

20

24

of poverty

Fig. 6. Regression between lung tumour mortality (LTM) rate in men and level of poverty, Barcelona 1986 (data by districts). Source: see footnote for Table 4.

60

I-

y--0.161x+79.766

R-squored:0.536

76 r

74 c

I

I

I

I

,

4

8

12

16

20

Level

Fig. 7. Regression poverty, Barcelona

of

., 24

poverty

between life expectancy 1986 (data by districts). footnote for Table 4.

and level of Source: see

societies poverty becomes the main source of health inequalities (Fig. 7). The 1983 Barcelona’s Health Survey [8] contributed with original data on the distribution of ill-health among social groups. Interpreting the results of Table 6 is complex given that behaviour in the face of illness can be affected by cultural, social and economic circumstances. Very significant, however is the relationship between social class and dental health (measured as the percentage of the population lacking half or more of their teeth). As we go down the socio-professional scale dental health declines very noticeably. More than a quarter of semi-skilled workers and manual workers have bad dental health compared to a mere 6% of top level managers. Visits to the dentist by those of high socioeconomic status is basically oriented towards prevention, while at the bottom end of the scale, visits are very often made for extractions (the latter is the only kind of dental treatment which

Tltble 6. Distribution of health by social class. city of Barcelona, 1983 (% of occurrence of events during the 2 weeks prior to the interview) Due to health problems

Top level managers and technicians of large orgzanizations Managers of small organizations Middle managers,administrdtive Skilled workers Semi-skilled workers Manual workers *DenPal

stayed in bed

stayed at home

Visited the doctor

Dental health*

8.7 10.5 11.0 a.4 8.9 7.9

21 21.5 22.3 21.7 24.1 23.7

13.7 19.7 23.6 22.2 23.0 23.2

k51 10.9 17.8 21.8 25.7 26.2

health = % of population lacking half or more of their teeth. Source: Ant6 J. M. D~que.w c/e So/u! a Barwho (Ayuntdmiento de Barcelona, 1985). pp. 107 and 118.

Visited dentist

IW 16.5 15.6 10.4 13.5 11.5

JOSEP A.

RODRiGUEZ

is paid for by the social security system). The dental services is an effective system barrier lower classes, preventing them from attaining level of dental health. Working with the socioeconomic categories

Table 7. Age distribution of deaths by social class. Spain 1981 Age groups

Class I

Class II

Class 111

Class IV

I s-29 30-39 40-49 50-59 60-69 70 and more Tolal

1.8 4.0 8.8 19.9 23.6 41.9 100%

4.2 4.8 11.0 25.4 28.9 25.6

3.1 4.3 10.5 22.5 23.8 35.9

I00%

100%

1.6 I.9 5.4 IS.1 19.9 56.0 100%

Class I = professionals, top level technicians and managers. Class 11 = clerical and sevices workers. Class 111= industrial workers. Class IV = farmers. Source: INE. Mocimhnro Narurnl tie la Poblacidn. Atio 1981, Vol. I (INE. Madrid. 1987). p. 113. Table 8. Late foetal mortality by socio-professional groups (rates by 100 live births)

I II III IV

1975

I976

I977

1978

1980

1981

0.66 I.0

0.66 0.97 I .02 I.48 I.0

0.67 0.96 0.95 I .49 I .o

0.54 0.84 0.87 I .36 0.90

0.63 0.64 0.75 0.97 0.74

0.55 0.66 0.72 0.90 0.7 I

I .08 I .60 I.1

LOUIS

cost of for the a high

of the Mokniento Natural de la Poblacion (1987) we can study the health/class relationship by age groups. Each socio-professional group maintains mortality rates according to different age groupings (Table 7 and Fig. 8). If we exclude from our analysis the agricultural population (older and with lower birth rates), the highest socio-professional group (I) has a lower mortality rate up to the age group 70 plus. The upper class dies old. Curiously, group II (administrative) maintains rates higher than those of group 111 (workers) with the clear exception of the 70 plus age group. Class I appears to live longer than other sections of Spanish society: 41% live beyond 70, while only 30% of workers and 26% of administratives do. The analysis of late foetal mortality by socioprofessional groups over the most recent years allows us to measure the differences between health and classes and its progressive reduction. From 1975 to 1981 late foetal mortality has been lowered by an average of 35%. It has been reduced in all the socioeconomic groups and especially amongst the agricultural population (44%), administrative groups (34%) and workers (33%). Given the only small reduction of LFM of the upper class and the significant reductions in other groups we can see that differences have been narrowed (Table 8 and Fig. 9). The progressive ageing of the Spanish population and the growth of the numbers over 65 years of age will introduce a new dimension to social inequalities in health. The gained years, a result of the process of the ageing of the population, should be evaluated in terms of the quality of those years gained. In the case of old people in Spain there is a progressive and clear

Class Class Class Class Total

and

Class I = professionals. top level technicians and managers. Class II = clerical and sevices workers, Class 111= industrial workers. Class IV = farmers. Source: INE. Mo~imienro Natural C la Poblaridn Espariola (INE, Madrid. several years).

LEMKOW

% E

60 0 5o 40

deathsI”

q q 0

%

cIass

I

96 deaths

I” class

II

%

I” class

III

deaths

% deaths

I” ckass IV

30 x) 10 0 15-29

30-39

40-49 Age

50-59

60-69

70+

groups

Fig. 8. Age distribution of deaths by social class, Spain 1981. Source: see footnote for Table 7.

+ % 0

LFM

in class IV

l

% LFM

in class II

% LFM

In class III

0

96 LFM

in ctou

I

z -I

0.0 1975

I

I

I

1976

1977

1976

I 1960

I 1961

Fig. 9. Evolution of late foetal mortality rates by social class. Source: see footnote for Table 8.

decline in access to economic and social resources (62% of the people over 65 years old are under the poverty line). At the same time there is a developing dependency by the group on the health care system [ 143. Differences between the sexes in terms of mortality are well known, but these differences pose many questions: if the sexual division of labour implies (as it surely does in the Spanish case at least) the social subordination of women, and given the complex reproductive biology of women, then one might expect to find some significant health outcomes to result from this situation. Women seem to suffer more illnesses than men, but live longer. In order to understand this process, research should be carried out on health and the sexual division of labour. A recent area of concern in the study of inequalities in health is the appearance of AIDS. The distribution of AIDS in Spain seems to be indicative of yet further inequalities in health. In 1987, of the 508 controlled AIDS cases since 1985, 282 have died. The distribution by groups is different from many other countries: 51.4% are heroin drug addicts and 21.8% homosexuals. This is particularly relevant in Spain since heroin drug addicts come largely from low economic status backgrounds (those sharing ‘needles’). Long term unemployed, prisoners and delinquents are the most important part of this heroin drug addict population, and consequently the most affected by AIDS.

Health and social inequities in Spain Table 9. Conditions

of dwellings

according

to socio-professional

categories.

Socio-professional

Bathroom

Spain

1981 (%)

categories

RI

R2

R3

UI

u2

u3

u4

1.6 8.1 51.2 27.1

1.8 23.5 74.7

21.5 13.6 58.2 6.1

0.7 0.7 52.3 46.3

2.1 33.0 64.3

0.4 3.0 66.5 30. I

3.0 7.0 80.0 10.1

6.3 12.0 19.6 2.1

3.3 1.8 41.2 53.1

10.9 34.6 53.5 0.9

0.5 3.3 80.2 16.0

2.0 10. I 21.9

0.4 5.3 84.0 10.3

I.7 14.3 80.2 3.8

10.1 23.3 7.0

28.2 15.9 55.9

85.0 14.0 I.1

33.2 44.6 22.2

18.4 40.7 40.9

41.2 41.4 17.4

61.1 33.5 5.4

rercices

None Only lavatory/only toilet One full bathroom Two or more bathrooms Running

357

H’(IIC~

None

Cold only Individual heater Central heating Hearing None

Individual Central

RI = farmers with workers. R2 = farm managers. R3 = small farmers/farm workers. WI = top executives of industrial and services corporations. U2 = top level managers. U3 = middle managers/foremen. U4 = self-employed/workers (industry and services). Source: INE. Eflcuesro de Presupuesros Familiares 1980-1981, Vol. II (INE, Madrid, 1983). pp. 126. 138 and 152.

LIVING

CONDITIONS

AND LIFESTYLES

With regards to living conditions it can be seen clearly from Table 9 that important differences occur between those living in the countryside and those living in the city as well as between classes. This is relevant, as we have already mentioned living conditions explain health variations between provinces and population groups. We shall now deal with some of the classical lifestyle indicators related to health. Extensive research has been undertaken on the relationship between tobacco consumption and ill health. In particular the relationship between smoking and social indicators has been examined [15]. Consumption of tobacco, alcohol and hard drugs manifest an element of social difference in health. In the case of tobacco, variation is visible according to sex (more men smoke) and age groups (young people), and income and occupation (the higher socioeconomic groupings consume more) (Table IO). One way to account for the high level of tobacco consumption in Spain is the wide social Table

IO. Social

patterns of tobacco consumption, (% population over I5 years old)

sex Men Women Age grou/xy From I5 to 20 yr From 21 to 25 yr From 26 to 45 yr From 46 to 65 yr More than 65 ,yr Monrh~r income Less than 5O.OOJlpts From 50.000 to 75.ooO pts From 76.000 to 100,000 pts More than 100.000 pts

Spain

1985

Smokers

Heavy smokers

55 21

28 8

54 61 48 31 I7

I3 28 25 I4 7

formal schooling Primary school High school College/university National average

1 I. Social patterns

Table

31 38 46 52

I5 I6 I9 23

22 41 54 58 41%

II I8 21 29 18%

of alcohol

consumption,

Spain

1985

People having consumed alcoholic beverges during the last month (%) Wine/beer Sex Men Women Age From I5 to From 21 to From 26 to From 46 to Over 65 yr Total

20 25 45 65

yr yr yr yr

All alcoholic beverages

Liqueur

78 53

45 23

81 58

74 76 74 59 46 65%

50 56 42 22 I3 340/o

81 81 18 62 48 69%

Distribution of habitual-consumers within the consumer group Percentage of

consumers Month@

Educorion No

toleration of this habit: 53% of the population is apparently not bothered by being in the presence of smokers. Alcohol consumption similarly shows that sex and age differences are important; however, in relation to socio-professional groups we find a different pattern to that of smoking: heavy consumption is higher with those of lower income and education (Table 11). It is interesting to note that according to the survey data used here [IS] regular alcohol consumption is considered to be less dangerous than tobacco.

Less From From More

Wine/ beer

Liqueur

income

than 5O.ooOpts 50,000 to 75,000 pts 76.000 to lOO,OOOpts than IoO,M)o pts

59 68 74 81

60 57 52 42

21 I6 I6 II

53 12 79 82 69%

60 59 43 44 53%

20 23 7 I5 16%

Education

Source: Ref. [l5]. Stratified national sample of 2500 people older than I5 years old; weighted by ages and provinces. Level of confidence of the sample: 95.5%.

formal schooling Primary school High school Colleaeiuniversity Nation2 total _ No

Source: Ref. 1151. Stratified national sample of 2500 people older than I5 years old: weighted by ages and provinces. Level of confidence of the sample: 95.5%.

JOSEP A. RODRIGUEZ and

358

Table 12. Soaal pauerns

of

LOUISLEMKOW

regular-consumption of ‘druas’. Spain 1985

S<.Y Men Women &?e

From I5 to 25 yr From 26 to 45 yr

From 46 to 65 yr Ehcarion No formal schooling/primary school High school College/university Toal Regular consumers in the general population

COCZWle

Cannabis

Tranauillizen

72 28

31 69

50 50

69 31

13 48

64 36

-

39

-

27 51 22 100%

69 I8 13 100%

21 40 33 100%

0.5%

0.3%

4%

Source: Ref. [I5]. Stratified national sample of 2500 people older

than 15 years old; weighted

by ages and provinces. Level of confidence of the sample: 95.5%.

Table 12 presents data on the consumption of cannabis, tranquillizers and cocaine. A familiar pattern is again seen with cannabis consumption: more men and younger. But with tranquillizers the opposite is true; we find that more women take them and that this consumption is not concentrated among younger women. The consumption of illegal or semilegal (cannabis) drugs is lower (as one might expect) than for the legalized forms such as alcohol and tobacco. 50% of the population has smoked cannabis and 4% smoke it normally.

CONCLUSION: HEALTH

THE POLITICS INEQUALITY

OF

We can conclude here, by stating that Spain as a country with major economic, social and regional differences manifests important variations in the health of its population. The determinants are complex and various, but the evidence taken from the data presented here would seem to indicate that poverty, living conditions, income and socioprofessional status play a relevant part in explaining these variations. Because disease originated in part from social conditions, health programmes could not fully succeed without changing the illness-generating conditions of society. Incremental reforms within the health care system would remain ineffective unless accompanied by broad structural changes in society (H. Waitzkin, 1983). Health problems cannot be analysed apart from macro-level political and economic issues. Reforms call for profound changes in existing structures of power: wages (redistribution of wealth), nutrition, housing, work conditions, environment, etc. Health policy must transcend the health sector alone in order to counterbalance the system’s tendency to blame the victim to explain the ‘failure’ of the health care system in maintaining health. The reduction of social inequalities in health passes through the use of a broader (more social) definition of health and the definition of a redistributive policy including work, economic, housing, environment and cultural aspects. In spite of the availability of health care for all, the poor still die

sooner. Health, as a socio-political phenomenon needs socio-political analysis to be understood and acted upon. REFERENCES

I. Ramis 0. Desigualtats, Pobresa, Atur i les seves implications en la salut: evidencies i problemes metodol6gics a Catalunya. In AIW i S&r. Institut d’Estudis de la

Salut, Generalitat de Catalunya, Barcelona, 1984. 2. Durin M. A. Desigualdad social y enfermedad. Tecnos, Madrid, 1983. 3. de Miguel J. M., Lemkow L. and Rodriguez J. A. Social inequities related to health in Spain. In The Health Burden of Social Inequities, pp. !71’-185. WHO, Copenhagen, 1986. 4. Lemkow L. Socio-economic status differences in health. Sot. Sci. Med. 11, 1257-1262, 1986. 5. Lemkow L. The subterranean economy as a survival strategy: the Spanish case. In Unemploymenr, Social Vulnerability and Health in Europe (Edited by Schwefe! D., Svensson P-G and Zallner H.), pp. 143-147. Springer, Berlin, 1987. 6. OECD. Measuring Health Care 1960-1983: Expendilures, Costs, and performances. OECD. Paris, 1985. 7. DATA S.A. Estudio de1 Sistema de Valores. Dec. 1983. 8. Orizo F. Esparia enfre la Aparia y el Cambio Social. Mapfre, Madrid, 1983. 9. Ant6 J. M. Enquesra de Salut de Barcelona, 1983. Ayuntament de Barcelona, Barcelona. 1984. 10. dd Miguel J. M. and Guillin M. The Spanish Health Crisis. Universidad de Oviedo. 1987. I!. Rodriguez J. A. Salud y Sociedad. Tecnos, Madrid, 1987. 12. de Miguel J. M. La salud pliblica del firuro. Arie!, Barcelona, 1985. 13. Ayuntament de Barcelona, La Salut a Barcelona 1985. Ayuntament de Barcelona, Barcelona, 1986; La Salur a Barcelona 1986. Ayuntament de Barcelona, Barcelona, 1987. 14. Dominguez A!& C. and Rodriguez J. A. Estudio de Necesidades: Indicadores de nive! de vida y salud. In LLibre Blanc del Enrelliment a Caralunya. Generalitat

de Catalunya, Barcelona, 1987. 15. Centro de Investigaciones Socio!6gicas, Attitudes y Comportamientos de 10s Espaiioles ante e! Tabaco, e! alcohol y las drogas (research No. 1487, Dee. 1985). Report presented in Recta Espati. Incest. Social. 34, 243419,

1986.