health and poverty: past, present and prospects for the future

10
Sot'. &'i. Med. Vol. 36, No. 2, pp. 157-166, 1993 0277-9536,93 $5.00 + 0.00 Printed in Great Britain. All rights reserved Copyright t 1993Pergamon Press Ltd HEALTH AND POVERTY: PAST, PRESENT AND PROSPECTS FOR THE FUTURE JAKE M. NAJMAN Department of Sociology, University of California, Davis, CA 95616, U.S.A. and University of Queensland. Australia 4072 Abstract--Periodically the results of class comparisons in mortality rates have been reported. These reports have permitted comparisons since the earlier part of this century to the present period. The data thus available enables us to make some tentative predictions about the likely magnitude of class inequalities in mortality in the future. We consequently argue that: --the concept of class should be abandoned in favour of a more direct measure of economic inequality which emphasises those living in poverty. ~espite overall declines in mortality for all socioeconomic groups, in the most recent period there has been an increase in the relative mortality disadvantage in some countries. this increase in mortality disadvantage is paralleled by an increase in the proportion of people. particularly children, living in poverty. Five groups constitute the bulk of those living in poverty and, of these, three (single mothers, the aged and the disabled) are likely to increase in numbers in the future, producing a likely' increase in class-related mortality inequalities. Reducing these inequalities will depend upon welfare and education initiatives more than on any changes likely to be produced by the health system. Key wordsmpoverty, social class, mortality trends, demographic trends in poverty, single mother, aged, unemployed, ethnic/racial minorities the disabled Knowledge of an association between social class and health has a long history. Antonovsky [1] has re- viewed much of this literature and a recent paper by Schellekens [2] adds to this by noting class differences in mortality in two Dutch villages in the eighteenth century. The Dutch data shows that the upper-class group living in these villages had more than a 10-year advantage in life expectancy and half the rate of early childhood mortality of the lower class group. As will repeatedly be noted, relative class inequalities in many developed countries are similar to those ob- served 200 years ago in these two Dutch villages. Inequalities in life chances (specifically mortality rates) associated with an individual's location within his:her socioeconomic system have been a consistent concern of those interested in health and illness. This interest is derived from perhaps three reactions to the available evidence. Firstly, there is the issue of social justice and a concern with health inequalities as a measurable manifestation of the magnitude of this injustice. Discussions of the magnitude of health and other inequalities have had (and continue to have) a powerful impact on legislation and social action. Secondly, there has been a theoretical and concep- tual interest in the demonstration of socioeconomic health inequalities. This interest includes a concern with the quality and accuracy of the data and with the specific causes of health inequalities. Despite a pro- lific literature it is still unclear why socioeconomic differences in mortality (and morbidity) are so con- sistently observed. Thirdly, there are the competing orientations of those who advocate policies which are intended to reduce the magnitude of socioeconomically produced health inequalities. At least three strategies are dis- cernible; those that would support an extensive pro- gramme of health education, disease prevention and community intervention; those that would seek to increase the accessibility to and quality of medical services and those who perceive that the most effec- tive way of reducing health inequalities lies in initiat- ives in the welfare and education sectors of society. Socioeconomically determined health inequalities have been of central concern in the past and in the context of future demographic and economic trends, such inequalities will continue to be of importance. These trends point to a continuing and significant deterioration in the relative health circumstances of those at the most disadvantaged level of the socioeco- nomic hierarchy. PATTERNS AND TRENDS IN THE ASSOCIATION BETWEEN SOCIOECONOMIC STATUS ANt) MORTALITY Here we consider trends and patterns in the associ- ation between socioeconomic status and mortality, in order to provide the context for a subsequent discus- sion of the likely health impact of predicted changes in socioeconomic inequality in a number of the developed countries. Three concerns will be devel- oped in this discussion: the selection or choice of 157

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Page 1: Health and poverty: Past, present and prospects for the future

Sot'. &'i. Med. Vol. 36, No. 2, pp. 157-166, 1993 0277-9536,93 $5.00 + 0.00 Printed in Great Britain. All rights reserved Copyright t 1993 Pergamon Press Ltd

HEALTH A N D POVERTY: PAST, PRESENT A N D PROSPECTS FOR THE F U T U R E

JAKE M. NAJMAN

Department of Sociology, University of California, Davis, CA 95616, U.S.A. and University of Queensland. Australia 4072

Abstract--Periodically the results of class comparisons in mortality rates have been reported. These reports have permitted comparisons since the earlier part of this century to the present period. The data thus available enables us to make some tentative predictions about the likely magnitude of class inequalities in mortality in the future. We consequently argue that:

- - the concept of class should be abandoned in favour of a more direct measure of economic inequality which emphasises those living in poverty.

~ e s p i t e overall declines in mortality for all socioeconomic groups, in the most recent period there has been an increase in the relative mortality disadvantage in some countries. this increase in mortality disadvantage is paralleled by an increase in the proportion of people. particularly children, living in poverty.

Five groups constitute the bulk of those living in poverty and, of these, three (single mothers, the aged and the disabled) are likely to increase in numbers in the future, producing a likely' increase in class-related mortality inequalities. Reducing these inequalities will depend upon welfare and education initiatives more than on any changes likely to be produced by the health system.

Key wordsmpoverty, social class, mortality trends, demographic trends in poverty, single mother, aged, unemployed, ethnic/racial minorities the disabled

Knowledge of an associat ion between social class and health has a long history. An tonovsky [1] has re- viewed much of this l i terature and a recent paper by Schellekens [2] adds to this by not ing class differences in mortal i ty in two Dutch villages in the eighteenth century. The Dutch data shows that the upper-class group living in these villages had more than a 10-year advantage in life expectancy and half the rate of early chi ldhood mortal i ty of the lower class group. As will repeatedly be noted, relative class inequalities in many developed countries are similar to those ob- served 200 years ago in these two Dutch villages.

Inequalit ies in life chances (specifically mortal i ty rates) associated with an individual 's location within his:her socioeconomic system have been a consistent concern of those interested in health and illness. This interest is derived from perhaps three reactions to the available evidence. Firstly, there is the issue of social justice and a concern with health inequalities as a measurable manifesta t ion of the magni tude of this injustice. Discussions of the magni tude of health and other inequalities have had (and cont inue to have) a powerful impact on legislation and social action.

Secondly, there has been a theoretical and concep- tual interest in the demons t ra t ion of socioeconomic health inequalities. This interest includes a concern with the quality and accuracy of the data and with the specific causes of health inequalities. Despite a pro- lific l i terature it is still unclear why socioeconomic differences in mortal i ty (and morbidi ty) are so con- sistently observed.

Thirdly, there are the compet ing or ientat ions of those who advocate policies which are intended to reduce the magni tude of socioeconomically produced health inequalities. At least three strategies are dis- cernible; those that would support an extensive pro- gramme of health education, disease prevention and communi ty intervention; those that would seek to increase the accessibility to and quality of medical services and those who perceive that the most effec- tive way of reducing health inequalities lies in initiat- ives in the welfare and educat ion sectors of society.

Socioeconomically determined health inequalities have been of central concern in the past and in the context of future demographic and economic trends, such inequalities will cont inue to be of importance. These trends point to a cont inuing and significant deter iorat ion in the relative health circumstances of those at the most d isadvantaged level of the socioeco- nomic hierarchy.

PATTERNS AND TRENDS IN THE ASSOCIATION BETWEEN SOCIOECONOMIC STATUS ANt)

MORTALITY

Here we consider trends and pat terns in the associ- at ion between socioeconomic status and mortali ty, in order to provide the context for a subsequent discus- sion of the likely health impact of predicted changes in socioeconomic inequality in a number of the developed countries. Three concerns will be devel- oped in this discussion: the selection or choice of

157

Page 2: Health and poverty: Past, present and prospects for the future

15N JAKt M. NAJMAN

indicators of socioeconomic status or class: a con- sideration of the magni tude of the association be- tween socioeconomic status and mortal i ty: and changes over time in the differential between the morta l i ty rates experienced by the highest and lowest s o c i o e c o n o n l i c g r o u p s .

iNI)ICATORN OF SOCIOECONOMIC STATt;S OR SOCIAl. CI,ASS

Following the writings of Marx [3], Weber [41 and many others, there lmve been a prol iferat ion of studies indicating that an individual 's life chances and lifestyle can be intimaicly related to thai person 's location within the economic and occupat ional strata of society. A more-or-less consistent pa t tern of results has emerged despite the use of various and sometimes weakly correlated measures of socioeconomic status [5, 6]. This consistency has tended to lead some researchers to disregard impor tan t deficiencies in the use of occupat ional class as a measure of social stratification. Primarily these deficiencies are:

the lack of an unders tanding of what occu- pat ional class means with respect to an individual 's educat ion, occupat ion and income [7]. Jones and Cameron ha~c gone further and described social class classifications as 'banal" and lacking tiny, clear critcria iS].

the reliance on cmployment as a basis l~r al locating someone to an occupational class when the majori ty of tile populal ion, and major subgroups of the popula t ion (e.g. women) contain many who are not employed. This has led sonic to search for quite indirect indicators of social class, such its whether a car is accessible [9].

the reliance on employment categories when over 75'Ii, of all deaths occur after the age of 65, an age aftcr ~h ich a person 's occupat ional activities are likely to bc of limited relevance [7. 10].

l ] ] i l jor s o u r c e s O1" occupat ional coding error which are part icularly substant ial when they are of most rele\,ance to health research. Thus there are inconsistencies between lifetime or usual occupat ion and last occupat ion [11] as recorded on death certifi- cates. In other research compar ing occupat ion coded t\~ice m b; months , while 81% of occupat ions x~cl-c assigned to the same class, only about 50% of those ill tile lowest social class on the lirst occasion reccixcd this Icvel on the second {cited in Osborn and Morr is [12]).

thai while broad occupat ional categories may remain the same oxer time it is clear that there have been major shifts in the occupat ional groups within a pariiculal + category. As lllsley and Baker [7] point out, the Registrar Genera l ' s Social Class I1 in the 1950s conta ined largcly t radesmen, shopkeepers, se- nior clerks and shop managers . Today this category is domina ted by an educated group of managers and technologists. A compar ison of the health of these

classes in the past and present is arguably nol con> paring like with like. Pamuk [13] has specifically addressed this deficiency in recent estirnatcs of British mortal i ty inequalities.

that while occupat ion may, in the past, have served to locate tin individual firmly within a socioe- conomic hierarchy the extent to which this is tile case today is in dispute, Thus persons of relatively low occupat ional s tanding, e.g. certain t radesmen in high demand occupations, may have substantial incomes and be able to buy a lilL'stylc land hcalth care) considerably more I'reel> than their white collar cotinterparts . In addit ion, with the rapid grox~.lh in the service and knox~ledgc industries ~.e ha \c an increasing number of persons who are well educated but with relatively modest incomes. In sum, there have been dramat ic changes in the character of ~ork and the types of occupat ions such that previous approaches to stratif'ymg occupat ions tire likel\ to be of less relevance today.

Class-based measures of socioeconomic inequality have been popular partly because the.~ are relatively easy to collect and partly because they can be associ- ated with a theoretical framework ~h ich can be used to "explain', at least conceptually, tin obserxed associ- ation. However, we contend that the deficiencies of class-based methods of socioeconomic stratification now outweigh their adxantagcs. To thc extent that class is used as Jill indicator of educational and incomc inequalities, it appears more uscl'ul to measure these educational and income inequalities directly. ]nconle and educat ion indicators of socio- economic location have the ad\antage that observed associat ions which are found to be causal ma 3 be addressed by' explicit policies through the xwlfare or educat ion sectors. Bx, coIl/rasl, class-based lllCasurc>, of inequalit> haxe little dirccl policy utility. It is. however, remarkable that despite clear deliciencics in t h c use o1 o c c t l p a l i o n a l class as a I n c a s n r c . c o n s i s t e n t

pat terns and trends ~i th mortal i t \ haxe been oh- served.

SOCIOECONOMI( ' INEQ[ AI,IFIEN B~ AGE ('ATEGOR1EN AND CAt SES OF I)I~A'|'H

SES-related mortal i ty inequalities have been ob- served for adults, youth aIld infants. Each of these will be considered in ttlrll using data taken I'ron~ countr ies which reflect a developed econo111> pat tern of mortal i ty.

For adults, various recent estimates suggest those in the lowest socioeconomic group haxe mortalit'~ rates approximately I t , It) _~-I nes those experienced by people in the highest socioeconomic group [14 17]. In an overview of these and other studies Mackenbach and M a t s [18] note that SES and r o o f tality rates arc inversely related in Jill countr ies for which they wcre able to obta in data, though not always to the same degree. Where a number of middle

Page 3: Health and poverty: Past, present and prospects for the future

Health and poverty 159

SES groups are included in the comparison, the evidence tends to suggest only a modest magnitude of mortality difference between them. These obser- vations have been confirmed for both males and females and suggestions that they reflect misclassifi- cation or other errors of coding can be rejected following longitudinal, prospective observations broadly confirming these estimates of inequality [19, 20]. Indeed the longitudinal data indicates that contrasting the mortality inequalities of more homo- geneous socioeconomic groups than those derived from the Registrar General 's classification produces estimates of inequality which are much greater than those derived from the broad class categories usually contrasted [21].

Generally the inverse SES-mortality gradient is found for most causes of death, and while there is variation from country to country, generally the strongest effects tend to be observed for accidents, poisoning and violence, and respiratory diseases [15, 16]. Age-specific comparisons suggest that the largest SES differences are observed in the 25-44 age group [14].

For youth the available SES data are somewhat less detailed but broadly consistent with data for adults. An SES differential has been observed and the association is strongest for accidents [22]. Blaxter [23], focusing on children in the 1-15 age group, notes that children in the lowest social class have 5-times the death rate of those in the highest class, and from fire. drownings and falls, there is a 10-times difference between the classes. Of course few children die from the causes of death most common in the elderly and consequently most of the SES inequality observed for children can be unambiguously associated with the social and physical environment in which the child lives.

Socioeconomic inequalities in child, infant and perinatal mortality have been the subject of an exten- sive literature. Despite some differences between countries and across some of the age categories, and the use of different and sometimes quite imprecise measures of social class or socioeconomic status, the general pattern of results is again remarkably consist- ent.

For the perinatal period the lowest SES groups manifest death rates between 1~, - and 2-times those of

*Data for Fig. I is derived from Pamuk [13] and Wilkinson [30] and follows personal communication with both authors. The figures for 1979 83 are estimated from data provided by Wilkinson. Estimates of the age standard- ized mortality rates in Fig. 1, for the "highest" and 'lowest" 1%, are derived from the "slope index of inequal- ity'. a regression line drawn through 143 occupations for which data is available over the period 1921 1983. In correspondence Pamuk suggests that these are conserva- tive estimates as the "real' values for social class V are above the regression line and for social class 1, below the regression line. Nevertheless such a comparison has the important advantage of providing a consistent compari- son over the time period involved.

the highest SES groups. This magnitude of effect has been observed in Australia [24], Britain [25] and using a crude Black/White surrogate class comparison, in the United States [26].

For the infant period (the first year of life) there appears to be an increase in SES mortality inequali- ties with differences as high as 4 and 5-times between the highest and lowest class in the postneonatal period (1 11 months) [27]. Australian data points to a consistently higher rate of neonatal and postneonatal mortality rate in the lowest SES group, with the lowest SES groups having a rate about l~-times that of the highest SES group [24]. Antonovsky and Bernstein [28] in an earlier review have found consist- ent differences in postneonatal mortality for France, Italy and Wales, as well as a number of American cities. Data on SES mortality inequalities past the first year of life is more difficult to find but where available tends to show differences which are both significant and of a substantial magnitude, particu- larly for those causes of death associated with motor vehicle accidents, accidents, poisonings and violence [29].

SOCIOECONOMIC FACTORS INFLUENCING CHANGES IN INEQUALITIES IN MORTALITY

While there have been substantial declines in adult, youth and infant mortality since the beginning of the 20th century, these declines have been neither consist- ent nor have all socioeconomic groups manifested a similar magnitude of decline. Here it must be noted that comparisons of SES mortality differentials were, in the early part of the century, comparisons largely of the impact of the infectious and communicable diseases. Today such comparisons predominantly in- volve chronic diseases (heart disease, stroke, cancer) as well as various types of accidents and self-inflicted injuries (suicide, homicide). In one sense then, it is remarkable that overall mortality ratios between the highest and lowest class groups have only varied some 30 or 40 percentage points from the early part of this century (that is until the most recent data set has become available).

Data on changes in relative SES mortality rates over time is limited but is sufficient in both quality and quantity to suggest an important recent increase in mortality differentials, mosl likely produced by an increase in the level of economic inequality in a number of Jeveloped countries.

Figure I * compares the age standardized mortality rates (ASMR) over the period 1921-3 to 1979-83 in England and Wales. All data are standardized to the 1951 population to enable direct comparison of changes over the 60-year period [13, 30]. The figure only includes data for those in the highest I% social class group, the mean (overall rate) for all classes combined and for the lowest 1% social class group. The mean mortality rate has declined consistently over this period, from 920 per 100,000 population in

S S M ~t~ 2 I

Page 4: Health and poverty: Past, present and prospects for the future

160 JAKE M . NAJMAN

1200

lOOO

I I

°~ 800 !

0 0 0 d 6oo 0

T 4 0 0

n

• Lowest SES (1%)

Highest SES (1%)

EZ~ Overall death rate

-I

. . . . L • -

il 200 I l L

• __L I ] 1921 3 1930-32 1949-53 1959-65 1970-2 1979-83

1921 3 3 0 - 3 2 4 9 - 5 3 5 9 - 6 3 7 0 - 7 2 7 9 - 8 3

( ' I / Lowest SES (1% ) 11057 955 708 720 724 678 T - - -

Overall death rote 1 9 2 0 845 638 577 565 478 /

[ Highest SES (1%) ~ 782 754 567 4 3 3 406 278

Fig. I. Agu standardized morhllitv ralcs 1921 S'4 [,,\daptcd f r o m P a n l u k ( Ic)85) a l l d W i l k i n s o n ( l<~s<h. l ( | ) a t a f o r Eng-

hind alld \Va]cs ASMR, to 1951.i

1921 3 t o 4 9 0 p e r lO0,O00popuhi t ionin 1979 83( th is represents almost a hal ' , ing of thc overall death rate). Over this sanle lime period the moan for the highest 1°0 social class group fell l'rom 782,100,000 to 278,100,000: the death rate R)r this group in 1979 83 \,~as almost one- third of the level in 1921 3. By contras t the death ratc for the lowest 1% social chiss group declined I'rorn It)57'100,000 in 1921 3 to

678'100.0()0 in 1979 83. a relatively modest decline. As Fig. I indicates, the A S M R for the lowest l({i,

social chtss group has not decreased snbstantiall} since the 1959 63 period, ~llilc in thai sanle time period the A S M R for the highest I% social chiss group has decreased by almost oncithird.

Onc mcthodologicaI problem noted with previous mortality compar isons has been the clnange m ihc composi t ion el" the chiss groupings m e r the tinle period thc compar isons arc considered. Pamuk [13] has limited her compar isons to a s tandard set ol" 143 occupations, Tile results shc obta ins suggest that the occupat ional composi t ion of tile classes makes no substant ial difference to the marc gcneral obser- vat ions noted prcviousl ' , and she comments that:

Nol onlx is there consistency between the trend lines produced using social classes and those produced using occupation units as the basis for analysis, but more impor- tantly, trends m inequalit~ I~l the adult populations and for inliints are broadly similar . . . For all three populations, the magniludc o1" rclativc inequalit} is greater in 1970 2 than at an} prc~ious point m lime . . [13, pp. 23 25],

While somewhat limited, data from some other cotintries confirms the trend to widening SES inequalities in mortal i ty rates. White and Black mortal i ty rates in the U.S.A. provide a crude but implicit class compar ison of mortal i ty inequalities. For adults such a compar ison shows a recent increase in Black male and t~male age s tandardized mortal i ty rates, but generally ii cont inuing decline in White mortal i ty rates. In t984 the difference in life expect- ancy between Blacks and Whites had declined to 5.6 years but by 1988 had increased to 6.4 years. Whether this differential between White and Black adult mor- tality rates decreases in the future or not is perhaps less impor tan t than the observat ion that the improve- nlcnt in liI'e expcctanc~ in the [J.N.A. ill the mid-1980s was gained dispropor t ionate ly by Whites. I JS .A. data also shows a modest increase in Black rehttivc to White infant deaths per 1000 live births and a parallel widening of the differential between rates of Bhtck and White underweight (2500g or less) babies [261. More recently published data on changes m Bhick versus White infant mortal i ty ratcs since 194t) shows thai while overall in[ant mortal i ty inequalities are presently the hirgest the.~ have c~cr been (Black infants have m e r twice the death rate o1 White il l 'ants), inequalities in neonatal mortal i t} (arguably those deaths most closely' associated with the ade- quacy e l medical services) have increased while m- equalities m thc pos tnconata l pcl-iod ha \c dcclincd since about 1960 (Fig. 2) [341

A trend to a widening Black 'Whi tc differential in inl~ults born of ]m~ bir thweight (a major predictor o1 perinatal n lor ta l i ty) has also boon reported for No;~ York over the period 1968 88 [35]. Here the researcher notes a dramat ic increase in Im~ bir th- weight babies to Blacks since 1984 and notes that fills is ti reverse of the pret iot ls trend. He argtics that tlw increase is a t t r ibutable to increased drug use b\ nlothers.

• Neonatal morio!ity

+ Post neonatal mortollt~

30 f ~JJ Infant mortal i ty

2 5 ' - i

(la

& # . . i O 15 • •

o

~" I0 g-

o5

0 L ~ J ~ [ L L l _ L J i 1940 1950 1960 1970 1980 !988

Y e a r

Marc recent data indicates that these inequalities Fig. 2. Bhick vs x~hile inlhnt mortality ratios (LI.SA. 1940 have since substantial ly increased [31 32]. to I~)~,~).

Page 5: Health and poverty: Past, present and prospects for the future

Health and poverty

Table I. Correlation coefficients (Pearson) between indicators of income inequality ~ and infant mortality and life expectancy h

161

Li~ L i~ Li~ Li~ expectancy expectancy

Infant expectancy expectancy at 65 at 65 mortality Males Females Males Females

Percentage of children in poverty 0.89* 0.28 0.28 -(I.14 - 0 . 1 9

Percentage of adults in poverty 0.74* 0.01 0.01 0.14 0.(17

Percentage of elderly in poverty 0.71 * 0.75* 0.84* -0 .83* -0.81 *

*P < 0.05. "Povert> is defined as an income below the official adjusted U.S. Government three-person poverty line, converted

into national currencies using OECD purchasing power parities. The U.S. poverty line is adjusted for such factors as famib size and is set, for the abo~e comparison, at 42% of the adjusted median income of the United States. There is a more-or-less explicit but arbitrary judgement being made here that persons below the poverty line are unable to purchase tile goods they need to survive at an acceptable level. Indeed it has been argued that the poverty line has been progressively reduced over the years- - for example in 1959 it was 57% of median U.S. t:amily income [371. Data is for eight countries (Australia, Canada, Fed. Rep. Germany, Norway, Sweden, Switzerland, United Kingdom and the United States). See Smeeding, Torrey and Rein [38].

blnfant mortality and life expectancy are all for 1988, taken from 1989 United Nations Demographic Yearbook [39].

Other data sources go part of the way to explaining this increase in U.S. infant and adult mortality inequalities by noting a recent but substantial in- crease in the proport ion of children and adults living in poverty in the United States [36]. Thus between 1978 and 1983 the rate of poverty for persons 18 years of age and under in the U.S.A. rose by about 50%, and by about 30% for persons 18 64 years of age [37]. The rate of poverty for the 65+ age group continued to decline reflecting improved social service benefits for this age group.

Thus there is some consistent data suggesting that despite a massive decline in overall mortality (from which all classes have benefitted), and major shifts over time in the causes of death, the relative position of the lowest class or socioeconomic group has deteriorated, particularly in the last decade or so.

Clearly no single factor or cause could account for these changes in mortality inequalities. Wilkinson [30] has, however, argued that parallel to the changes in class inequalities in mortality there have been changes in the relative economic circumstances of the classes. He notes that class mortality inequalities (in Britain) were lowest when Britain was experiencing economic difficulties but when in the case of the 1920 30s, there were substantial increases in welfare benefits and in the case of the 1940s, the war produced food rationing and full employment [30]. Wilkinson has gone further showing that, for the developed/ industrialized countries, the economic level of the country and life expectancy are not related, but there is a correlation of 0.83 between the income distri- bution (as a measure of economic inequality) and life expectancy [31]. He goes on to argue that:

changes in the percentage of people on low earnings ac- counted for somewhere between 8 and 15% of changes in occupational mortality [31, p, 405].

There are a number of data sources which confirm the validity of the above assertion. Table I presents figures derived from the Luxembourg Income Study which provides data on the level of child poverty,

adult poverty and poverty in the elderly for eight developed countries. These percentages are here correlated with the infant mortality rates and life expectancies for each of these countries. The strongest associations are for the percentage of chil- dren in poverty in each country and the infant mortality rate, and the percentage of the elderly in poverty and the life expectancy of both men and women in these countries. These figures and other studies reinforce the suggestion that the higher the proportion of the population living in poverty, the lower the overall life expectancy and the higher the death rate. Thus Wilkinson [31] has additionally shown that occupations which had the most rapid increase in incomes had the greatest mortality decline and those whose incomes fell had the least mortality decline. Vagero [40] has noted that Swedish SES mortality inequalities are of a lesser magnitude than those observed in Britain and has associated this with the more economically egalitarian character of Swedish society.

In sum the evidence suggests that socioeconomic inequalities may produce mortality inequalities in a society. As societies are subject to policies or demo- graphic forces which widen economic inequalities, so we may anticipate a widening of the difference be- tween the life chances of those at the highest and lowest levels in those societies.

D I S A G G R E G A T I N G POVERTY

The almost undiluted interest in class as a measure of socioeconomic inequality has, we argue, distracted health researcher and policy makers from developing and advocating policies which would diminish the association between mortality and poverty. One of the first steps in this direction is to identify the categories of persons who fall below the poverty line, their socio-demographic characteristics and the factors which are likely to contribute to an increase or decrease in the level of poverty.

Page 6: Health and poverty: Past, present and prospects for the future

162 JAKE M.

Table 2. Percenlage of persons living in poveriy in selected cotintries '' (Source: Smeeding, Torrey and Rein [35])

Children Adults Elderly

Auslralia 16.9 11't.5 19.2 ( 'anada 9 6 7.5 4.8 Fed. Rep. Germany 8.2 6.5 15.4 Norx~, ay 7.f~ 7. I 18.7 Sv~eden 5. I (~.7 2. I Su it,'crland 5. I 6.2 6.() United Kingdom 10.7 t'~.9 ~,7.0 {rnited States 17.1 10.1 16.1

"Absolute poverty reters to all people whose adjusled income ~, are belm~ the otticial U.S Government three- pe rson poxerty l ine.

The poverty line is admittedly tin arbitrary cri- terion, but the case for cising it rather than other criteria l\)r judging inequality levels, is quite strong. The official poverty threshold was developed by Orshansky in 1965 and has subsequently been adopted by the U.S. Government [41]. With statisti- cal adjustments for the size of the family and changes in the purchasing power of over time, as well as comparisons for different countries, it is possible to compare countries, and changes over time in a single country, to determine the changing rate of poverty. The measure was originally developed to determine the proport ion of families who are unable to obtain adequate nutrition [41]. It would be misleading, how- ever, to assume that those below the poverty level experience (only) nutritional deprivation. Rather the po\'ert> line selects a group for whom the income level is so lo~ that they must choose between such basic commodities as food, clothing and acconunodation. Regardless of the choice, those be- h)w the poverty line experience significant depri- vation in obtaining some of these basic commodities. Saunders and Whileford have discussed in some detail the issues underpinning lhe measurement of poverty [42].

Table 2 presents data from the kuxembourg lncomc Study (adapted from Smeeding, Torrey and Rein [38]). Three features of the data warrant detailed comment. Firstly, there are wide differences between countries in the levels of child, adult and elderl} poverty. Norway. for example, has a relatively low level of child poverty but a relatively high rate of poverty amongst the elderly. Secondly, the differences between poverty levels in different countries are quite substantiah with countries like S,acdcn and Switzerland having low levels of poverty in till age categories, while countries like Australia, thc United States and Great Britain have relatively high poverty levels, particularly for both children and adults. Thirdly, for some countries child poverty levels exceed those experi- enced by the elderly, while for others the reverse is the case.

Other data from Australia [43] and the United States [44] shows substantial fluctuations over time in the proportion o1" the population living in poverty. For Australia there appears to have been a more than

NAJMAN

doubling of the rate of child poverty since the early 1970s [43]. For the United States a longer time series is available, pointing to a massive decline in the poverty rate since 1940 reflecting a general improve- ment in the nation's wealth which has benefitted a broad cross-section of the community. There is. however, evidence of a more recent, relatively modest increase in the proport ion of the population living in poverty [45]. The increase in the rate of poverty among American children has been more substantial than that experienced by adults [36].

We may take from these figures the conclusion that while these countries have somewhat similar demo- graphic profiles and standards of living (for the bulk of the population), government policies and demo- graphic changes in the population have the capacity to markedly modify poverty levels for particular age groups.

Not all social groups are equally likely to experi- ence poverty, nor is any single policy response likely to deal with the different causes of poverty for different groups in society. The most effective ways ot" reducing the health consequences of poverty are likely to derive from direct efforts to reduce the level of poverty itself, and such a reduction is predicated on an understanding of the characteristics of the poor and the causes of their poverty. There are five social categories which together comprise the vast majority of those in poverty; single parents and their children, the aged, the unemployed, racial and ethnic minorities and the disabled. Demographic changes m the size of each of these categories of person will determine, in large part, the level of poverty in lhc developed countries.

Sinyfle parents

The major lector influencing recent changes in the level of poverty in a number of developing countries has been a change in family composition \~ith decreasing proportions of the population establishing two-parent households and massive increases in onc- parent- (usually female) headed filmilies. To a large extent the recent increase in child poverty experienced in Australia and the United States reflects an inadequate and insufficiently timely gove,nnaent response to this emerging demographic trend. While different in magnitude, the trends for Australia and the United States are illustrative.

In Australia there has been an increase in the proportion of the population which has nevcr married, up from 25.4% in 1976 to 29.8% of the population in 1989 [46]. In the United States 16.2% of the population were categorized as single m 1970 and 21.9% in 1988, a 35% increase [47]. In Great Britain similar proportions of the population were single in 1981 and 1989, but there has been an increase of the proportion of the population which reports their marital status as divorced [48]. In sum there has been a tendency in a number of developed

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Health and poverty 163

countries for an increase in the proportion of the population that are not presently married.*

Accompanying the above change has been a substantial increase in the rate of births to unmarried mothers. In the United States in 1960, 1 in 20 births were to unmarried mothers. By 1988 1 in 4 births were to unmarried mothers [34]. In Australia since the mid 1970s there has been a 50% increase in sole parents as a proportion of the population, the proportion going from 9.2% of the population in 1974 to 14.4% of the population in 1985 [49]. In a number of countries prevalent attitudes and behaviours have changed and there has clearly been an increase in the proportion of the population not married and in the extent to which women are prepared to have their children out-of-wedlock.

Childbearing out-of-wedlock has not increased equally in all social and economic groups. Rather some minority groups manifest this pattern to a substantially greater extent. In 1988 in the United States, while almost 4 in 5 white children lived in two-parent families, only 2 in 5 black children were in similar circumstances. Educational differences are also important here with less educated persons more likely to have their children out-of-wedlock [45].

Poverty levels for sole mothers and their children are extraordinarily high. One report suggests that 61% of all children in these circumstances experience poverty [34], while other reports indicate that "families with children headed by unmarried persons accounted for 51% of the total increase in the number of poor persons" [34, p. 1175] in the United States.

The increase in deferral of marriage, divorce rates and out-of-wedlock births, represent existing and continuing general demographic trends. From the perspective of the health of the population, the key issue is not the extent to which these trends are likely to continue (and thereby drive increasing numbers into poverty), but the extent to which governments have responded in a way which assists these parents and their children to move out of the poverty cat- egory. Here the data indicates that the governments of Australia, the United States, and to a lesser extent Canada, have been ineffective in responding to these continuing demographic changes.

The aged

That sector of the population satisfying the age qualification for receiving the pension will continue to grow. In the United Kingdom those in the pension-

*While these figures can be used to reflect demographic changes in some countries, in other countries there is the joint registration of births, and out-of-wedlock child- bearing is so common, and addressed satisfactorily through the welfare system--that such persons cannot be accurately categorized as disadvantaged. Personal communication, Pamuk E.

able age category comprised 6.2% of the population in 1901, 9.6% in 1931, 16,2% in 1971 and 17.6% in 1981 [48].

As Table 2 indicates, the proportion of the elderly living in poverty varies widely from country-to- country. In the United Kingdom over one-third of the elderly are living in poverty, and it is likely that as the size of this sector of the population increases, so will the level of overall poverty in that country.

However, the example of the United States (as well as the Scandinavian countries) indicates that improved social service benefits can remove many of the aged from the category of living in absolute poverty. Superannuation and retirement programs (government supported usually) have the capacity to massively reduce the level of poverty in the aged/elderly group.

The unemployed

Unemployment rates in a number of the developed countries have fluctuated through a wide band since the mid 19708. In Australia the rate peaked at around 10% of the working population in 1983, has since declined to around 6% and has recently begun to rise again [49]. In the United States the peak level of unemployment (in recent times) was in 1983 at 9.6%, and this has since declined to 5.5% in 1988 [47]. In Britain the peak appears to have been in 1981, with a decline apparent since this time [48]. There is also evidence that the recent economic recession has led to an increase in unemployment in both the U.S.A. and Britain.

While it appears that the unemployed are not likely to add greatly to future levels of poverty, some important features of the changing employ- ment patterns must be noted. Changes in patterns of work have meant that relatively unskilled jobs are being lost and to some extent being replaced by employment in more skilled areas such as computing and service provision. Thus unemployment is proportionately most severe for those who are least skilled and least educated. For many of those who are unskilled this involves being placed in long-term unemployment. It is the increase in the rate of long-term unem- ployed [45] often living in economically depressed neighbourhoods, that should be of greatest concern to health workers. Counterbalancing these trends have been some general improvements in social security benefits for the unemployed, though these are insufficient on the whole, to remove the unemployed from those categorized as living in poverty.

The future of employment growth is not promising. Developments in technology point to a reduced need for workers in many industries. There is reason to expect that the unemployment rate will remain rela- tively high and may increase in the medium term as the trend is for people to be replaced with more efficient technology. For the medium term future,

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164 JAKE M. NAJMAN

however, unemployment is not likely to add greatly to the poverty level in most developed countries.

Racial and ethnic mim~ritics

Many of those living in poverty have multiple disadvantages and it is not possible to determine which of these is primarily responsible for their membership of the qiving-in-poverly' category. In the United States, for children tinder 18, 43.7% of Black children. 36.2% of Hispanic children and 14.8% of white children are living in poverty [34]. White children tend to experience short-term poverty while Black children are more likely to experience long- term poverty. This pattern of inequality based on race is compounded by the high rates of unemployment and massive rates of single parenthood in the racial and ethnic minorit} group [34].

In Australia the Aborigine population have high chronic unemployment levcls and the worst health of tiny known group. A large proport ion of Aborigines are unemployed and survive solely' on social security benefits.

While prospects of the above situation dramati- cally changing are lemote, there is also little reason to predict any substantial growth in this sector of the population. Thus racial and ethnic minorities ~ill constitute ti relatively stable (possibly declining) pro- portion of those living in poverty. Of course as visible minorities become increasingly invohed in political activity, there is the possibility of achieving govern- ment p lograms more direcll',, targeted to thcir needs.

rDe di.~ahlcd

Most pcrsons who arc disabled 4re unable to obtain full-time employment. With few exceptions, this group is condenmed to permanent abject poverty. Their needs lk~r medical and other resources arc substantial and their prospects for gaining employn len t tit a t inle o f high unenlpioynlcnt, are r c n l o t e .

Existing demographic and medical trends point to a continuing increase m tile propo r t i on o f the dis- abled surviving with significant disabilities. Tills group represents the success of the medical care system in prolonging life. Their numbers land their proport ion of the total population) arc likely to continue to increase, albeit at ~l slow rate. More active efforts by government to bring this group into the mainstream of society, arc a pressing need.

tleallh and poverty. Pa,s,r, present and.timbre

Irrespective of whether we consider tile elderly, working-age adults or child.infant:perinatal mor- tality, data from previous centuries and decades points to a persistent and consistent pattern of higher mortality rates fi)r the economically most disadvan- taged. All socioeconomic groups in developed countries have benefitted from the improved standard of living evident in the latter part of the 20th century,

but some economic groups have benefitted relatively more than others. Some government (economic) policies have been etfective in reducing the mortality, differential between socioeconomic groups, while other policies have contributed to an increase in this differential.

Mortali ty inequalities are presently of a greater magnitude than ever previously recorded in England and Wales, and increasing in some other places. Taking the most reliable data presently available, adult and infant mortality rates of the most disadvan- taged are about twice or more those of the most advantaged. Where a recent increase in mortality inequalities between the classes has been observed, this can be causally linked to a parallel increase in the proport ion of people living m poverty' in that CO U n t ry.

In recent times reductions in the level of poverty have followed two trends. The first has been IBr a general improvement m the standard of living produced by economic growth. The second has re- stilled from improved welfare, education and health serxices, a recent trend being to target these to the needs of specific disadvantaged groups.

However. we now observe two newer trends xYhich have the capacity to continue the recent increase in socioeconomic inequalities in mortality. The first of these is a conservative response to the economic recession. This has, at the least, Nmited governments ' willingness to further extend services, and tit the most, led governments to withdraw serxices or reduce tile level of benefit. While thcse urc likely to be relatively temporary retreats, the5 will ha~e a more advcrsc impact on those aheady most disadvantaged.

At the same time there tire a number of ongoing demographic changes increasing those immbers in particular categories of poverty. There are increased numbers of single parents Inow the largest sector of tile poor}, an aging population, and increases in tile rate of those living with a disabilit?. Wc now confront the probability of a sustained increase in tile ,-tile of po,~ert} in a nmnber of de;eloped cotintries.

IlL as we argue, tile demographic trend is lbr an increase ill the proportion of tile population lixing in poverty, then ,a.e suggest that such an increase, on tile best evidence we prcscnfl$ have a~ailable, will lead to an increase in ttle mortality inequalities between socioeconomic groups. Such an increase contributing to a further deterioration m the relative health circumstances of rich Lind poor. educated and tin- educated, White and Black lntlsl be viewed as a serioLis problem.

We haxc argued that three t~pes of polic 3 re- sponses have been advocated with the specific ann of redtlcing mortality inequalities. The first, an extensive progranmle of health education and disease preven- tion, is of limited utility. Typically such programmes tire more effective for the more educated sectors of the population and, in any c~ent, they generally produce only a modest proportional change in behaviour. The

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Health and poverty 165

second, increased accessibil i ty to medica l services, is unlikely to achieve the desi red changes . Thus in Grea t Britain, where heal th services are relatively accessible to all, there have been some o f the largest differentials and increases in mor ta l i ty inequali t ies . The third policy op t ion , using the welfare sys tem to m o r e effectively reduce the income gap be tween rich and poor , s u p p o r t e d by a renewed emphase s in the edu- ca t ion sys tem to educa te the p o o r and retrain the u n e m p l o y e d , appear s to offer the only way o f p roduc- ing a subs tant ia l reduc t ion in soc ioeconomic inequal- ities in mor ta l i ty .

If the p r imary object ive o f hea l th worker s is to save lives, then the evidence suggests that work ing t owards a change in the welfare sys tem represents the mos t effective s t ra tegy present ly available. It is t owards the ach ievement o f this object ive that heal th worker s should direct a grea ter p r o p o r t i o n o f their energies in the future.

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