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Public Health

HEALTH AND SOCIAL CLASSADDRESSING a conference of the British Sociological

Association on Jan. 24, Dr. J. N. MoRRis, director of theMedical Research Council’s Social Medicine ResearchUnit at the London Hospital, touched on three problems.

CONDITIONS ASSOCIATED WITH POVERTY

As is now well known (Dr. Morris began) infant-

mortality rates have been falling in all classes since 1911when the first of these analyses was made; but so far,according to the Registrar General, there is no evidenceof a narrowing of the gap between the social classes:

Rates per 1000 live births.

" Social class," in the scheme of the General RegisterOffice, is based on job-skill and status, which in turn arecorrelated, if only broadly, with education, money income,general standing in the community, and residence. Mostof the designing of

" social class " was done fifty years ago,but " class " remains a highly effective if crude techniquefor the analysis of the social economics of our society.Classes I (the upper professional and business families)and v (unskilled labourers) seem to be reducing theirinfant mortality in fairly equal proportion, although it isprobably easier for a fall to occur from high rates thanfrom low, and class v has much higher rates than class I.

Classes n, III, and iv are also showing similar reductions.Through war and peace, slump and boom, harsher daysand Welfare State, infant-mortality rates have descendedalong these tramlines.

It is tolerably certain that class differences-they aresubstantial-in size of family and in the ages at whichmothers bear children play unimportant parts in thesesurprising trends. Two main hypotheses have beenadvanced in explanation.One is culture lag-that it will take longer for the less edu-

cated sections of the population to benefit from the newerknowledge of child-rearing and to take full advantage of ser-vices provided and of the advances in medical science. Again,although there has been a substantial rise in the wages of thepoorest, and some general levelling of current money incomesand ways of living since 1940, gross differences remain in the" capital " goods of different classes, such as housing amenitiesif not actual living-space. The healthiness of the mother whomay have spent her own childhood in very different circum-stances from today has also to be considered in such historicalcomparisons.Another explanation emphasises social mobility-the rapid

turnover and changing composition of social classes. (AsGlass and his colleagues have shown, our class structure isanything but rigid and there is considerable mobility up anddown the social scale.) The interesting suggestion by Illsleyand others is that the healthier move up and the unfit down,so that in a kind of obstetric or pelvic meritocracy social class Iis continually being invigorated and producing low death-rates while class v, which anyhow is contracting in size, collects

those of each generation who cannot cope-physiologically orsocially. But there are consistent inequalities between theinfant-mortality rates of particular occupations-let alonebetween social classes-that continue over the years-e.g.,miners (always high) v. textile workers (not so high) v. clerks(always low). Such an explanation must needs postulate atidiness in social and biological rearrangement beyond our ownimagining, or, even, our colleagues’ computation. ,There is very little information on the genetic aspects

of the whole problem. Clinical field studies among thefamilies of a variety of occupations and localities are

urgently needed.For example, coalminers now have about the highest

earnings of all workers-they are affluent enough-but theyalso have about the highest infant mortality; which is againstso much we believed and hoped in the 1930s. (Perhaps theCoal Board needs a Member for Maternity and Child Welfare-or will the National Union of Mineworkers set an example ?There are precedents, if in unexpected places.) Social scien-tists are strangely reluctant to enter this field which seems anideal one for " multisciplinary ". study. The very few socio-logical surveys that have been done in coalmining communities,as in Yorkshire, raise issues about family life and parentalroles, about values and aspirations, about the extent to

which " middle-class " attitudes are and are not spreading,that from the first are directly relevant to studies of infantmortality.The simple question-raising and elementary social

criticism illustrated in these figures of infant mortalityare a good example of the value of the analysis by occupa-tion and social class made possible by the General RegisterOffice in an age when the simple and the elementary areno longer fashionable.

Adult MortalityIn adults, among the diseases that show the traditional

poverty pattern-i.e., a substantially higher death-rateamong the economically under-privileged-recent historyis the same. Whether such diseases are declining (e.g.,rheumatic heart-disease and pulmonary tuberculosis) orjust beginning to decline (e.g., and lagging behind theStates, cancer of the stomach) or reportedly increasingsomewhat (e.g., bronchitis), class positions are unchanged.In 1949-53 there was as big a gap as before between thedeath-rates in social class I and social class v, as greatan excess in class v. And yet, as Rowntree showed,there had been a transformation in the nature, amountand distribution of poverty since the 1930s. Nor is this

picture of biological immobility in a highly fluid societyany less sharp if comparison is limited to class ill, theskilled and blackcoated, v. other workers or is extended totheir wives. General investigations, as of, " class v ",were badly wanted, and specific ones, as of occupationand gastric cancer-including insights from genetics andfrom social science as well as from medicine.

The Revolution in Childhood

But in children (Dr. Morris continued) the position isdifferent. Something of a revolution has taken place andwe can now speak of a closing of the gap between socialclasses, of greater equality in health. Thus the death-rateamong children from rheumatic heart-disease-he used toregard this as the most sensitive of the poverty indicators-has fallen most among the towns and villages of SouthWales which formerly had quite frightful rates, and moreamong the poorer communities generally than in the moreprosperous. At the very beginning of childhood, at

1-2 years of age, the gap in mortality between social

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class i and social class v is now only a fraction of what itwas twenty years ago:

MORTALITY PER 1000 AT 1-2 YEARS

Further search among the infant death-rates alreadyquoted has made it possible to locate the start of thisimprovement in the last three months of the first year oflife. The experience then has been quite different fromthat in the rest of infancy-a nice problem for p2ediatriciansand immunologists and students of growth:

POSTNEONATAL MORTALITY

Joint Inquiry, Social Medicine Research Unit and General Register Office.

It is possible further to say that all this change has takenplace since 1939.These exciting signs of another equality, and a new

quality, of our society-it may be the first such change inmodern history-can be discerned elsewhere. There islittle doubt from the data of Douglas and his colleaguesthat the story is the same in such a disease as chronic otitismedia. Very likely it is true also of the important groupof lower-respiratory infections. It may be that childrenare more responsive to the immediate environment thaninfants and the social and medical advances of recent

years have paid off rapidly. Pxdiatrics-and orthopxdics-and dermatology have already been transformed.

Rickets, from being the characteristic disease of VictorianEngland and endemic till the 1930s, is now an uncommondisorder of the metabolic ward. Are we getting to the lastlap in serious physical disease of childhood ? Will there bea wave of equality back into infancy and on to adult life ?

Dr. Morris then turned to two other problems, one inthe transition to adult life, the other of middle age. In

one, he said, it seems possible to explain some of the socialclass distribution, in the other to explain some of it away.

CONCENTRATION OF SCHIZOPHRENIA IN SOCIAL

CLASS V

First, he dealt with what he called a basic problem inthe epidemiology of mental disease, and of public health-the preponderance of schizophrenia among the unskilledyoung men of social class v. Originating in the ecologicalwork of Faris and Dunham before the war in Chicago, theobservation has been something of a storm centre eversince. The latest figures of Brooke were quite specificfor England and Wales:First Admissions for Schizophrenia (per 100,000 men aged 20 and over)

in 1949-53 in the five social classes

The concentration in class v is considerably greaterwhen men under 35 only are considered. Is it true ? Iftrue, is it due to movement downwards of the mentally illinto unskilled labour and social class v; and/or does thesocial and familial environment of social class v help toproduce a lot, an excess, of schizophrenia ?

Two colleagues of Dr. Morris’s in the Social MedicineResearch Unit are working on this problem.

E. M. Goldberg is approaching it clinically by interviewingthe families of a representative series of young men admittedto hospital for schizophrenia, trying to get a picture of thefamily over three generations, from grandparents to the

patient and his sibs.S. L. Morrison, with the ever-ready help of the General

Register Office, has classified a national sample of schizo-phrenics aged 25-34 by occupation and social class, and thengone back to their birth certificates and classified the patients’fathers by their occupation and social class at the time of thebirth. The answers so far are pretty clear, and in agreement.There is a heavy concentration of patients in class v, but thefathers now (and when the patients were born) are quiteordinarily distributed among the social classes of the popula-tion. A downward drop of the patients from the parentalstatus because of their illness seems to be explaining theirpeculiar social-class distribution. Moreover, there is littleevidence in the clinical study that the patients have themselves" drifted " down at all: they seem rather to be non-starters intheir parental class after leaving school. This finding is verydifferent from that of Hollingshead and Redlich in NewHaven, where the fathers of the patients also were very muchwhat we would call social class v, and a means of cross-checkingwith the Yale workers having regard, for example, to diagnosiswill have to be found.

THE " NEW " DISEASES

The historical trends were highly interesting. The"newest" of all, poliomyelitis, shows a striking excess ofmortality (and presumably of incidence) in social classes Iand II (farmers!); which is very suggestive in light of theviews of Paul, for example, on the inverse relationship ofparalytic poliomyelitis to the level of sanitation and to therate of infant mortality. Coronary disease and leukxmia,which showed an excess of mortality in class I in 1930-2,now show a smaller one. Lung cancer and duodenal ulcer,which showed no trend with social class twenty years ago,now give evidence of rising mortality with descent in thesocial scale from class I to class v. How much the spreadof diagnostic standards through the population is

responsible for such changes it was impossible to estimate.

Social Class and Physical Activity’ of Work in CoronaryHeart-disease

Finally, Dr. Morris considered " coronary thrombosisthe most important of the conditions with a particularlyhigh mortality in class I, though there are technical snagsin accepting the actual figures published by the GeneralRegister Office. Even before the disease became epidemic,Osler had commented on " the remarkable fact " that

angina " is an affection of the better classes (imagineThe Lancet allowing anyone today to write of " the betterclasses "!). The similarity of food intake, including fatconsumption, animal and vegetable, processed andnatural, among the different sections of the populationsince 1940 makes it unlikely that nutrition is responsiblefor the class differences in mortality in 1949-53. Therecent national necropsy survey suggests that much of thesedifferences are in fact the product of the connectionbetween coronary heart-disease and physical activity ofwork. The higher the status, the more light jobs. Lightworkers of classes i-iv show the same rates of ischasmicmyocardial fibrosis in this survey and there is no variationwith social class among active workers or in heavy workers.An analysis has now been made of Occupational Mortalitydata, dealing with deaths actually ascribed to coronaryheart-disease, and grading the occupations wherever

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possible by the physical activity typically involved. (Thiskind of analysis would be more difficult in the futurebecause the General Register Office were reducing thenumber of occupations from 600 to 200 and thus increasingthe heterogeneity of many.) The main result was that lightworkers show similar death-rates at 45-54 years of age,whatever their class, and similar rates in classes I,11 and IIIat 55-64. Mortality among active workers does not varyat all with social class; and among heavy workers thereis a strong relationship only at 55-64 years of age:

MORTALITY FROM CORONARY HEART-DISEASE ACCORDING TO

OCCUPATION

Rates per 100,000 men, England and Wales, 1949-53.

That is to say, there is no trend with social class apartfrom physical activity of job at 45-54, and at 55-64 animportant one only in heavy workers. (Nor does inclusionof deaths from so-called " myocardial degeneration "make any difference.) The class distribution seems to bemainly dependent on the proportion of light and heavyworkers in each class. A reduction of muscular effort inwork is one of the striking features of both industrial revolu-tions and part of the change underlying all the other changes.

THE FUTURE

As the diseases of poverty, ignorance, and malnutritionrecede, we confront problems that are manifestly as

closely linked to the mode of life-but not in such manifestways. Moreover, there is no comfort that further socialprogress-a rising standard of living-will in time mitigateand abolish our problems. Here is considerable scope forthe expansion of social-medical inquiry, and Dr. Morrisappealed to his hearers to help.

SmogACCORDING to some observers, the smog in parts of the

North-West of England last week was the worst in livingmemory. The demand for hospital beds increased

sharply.In Salford the foggy period was characterised by a wide-

spread smoky haze with a visibility of never more than200 yards; the smoke averaged 120 mg. per 100 c.m.

and sulphur dioxide 35 parts per 100 million. Late on Jan. 29 theaverage smoke content was 415 mg. per 100 c.m. After beingleft overnight the smoke stains were too dense to permit ofmeasurement, but the amount of sulphur dioxide was foundto be 109 parts per 100 million-i.e., about six times normal.On the morning of Jan. 30 the smoke and sulphur dioxidelevels were 478 mg. per 100 c.m. and 164 parts per 100 million-i.e., about eight times the normal January average.The demand for hospital beds necessitated putting into

operation "

emergency " plans whereby hospitals refusedcertain non-urgent cases. The demand for beds wasparticularly great in respect of elderly women. Moreover,acute respiratory disorders in patients already occupyingbeds in acute hospitals resulted in an increase in thenumber of " blocked " beds.The public are increasingly conscious of the nuisance

of loss occasioned by smog; and, if newspaper columnsare an indication, public opinion is now decisively in

favour of a speed-up in the implementation of the CleanAir Act, 1956. But, curiously enough, the " black areas "-where fogs are most frequent and where the mortalityand morbidity from chest disease is highest-are the areaswhere there have been fewest applications to the Ministerof Housing and Local Government for confirmation of" smoke control " orders.

Smoke ControlMr. Henry Brooke, Minister of Housing and Local Govern-

ment, would like to make faster progress in removing thesmoke pall from the " black areas " of England and Wales. Hehas asked councils in these areas to inform him by the end ofJune how long it will take to deal with their domestic smokeproblems, what smoke-control orders will be needed, and theirorder of priority. He is asking for five-year phased programmes.

In the last two years more than 125 local authorities in

England and Wales have decided to use their powers under theClean Air Act to make smoke-control orders. 33 of these ordersare now in operation, and over 190 more have been confirmedby the Minister or are being prepared. Nearly 232,000 build-ings and some 39,000 acres of land are, or will be, covered bythem.

The Widdicombe File

LII. STILL WAITINGMY DEAR JOE,

I was sorry to hear that you hadn’t been appointedto the job at the Elsewhere General Hospital-thoughfor their sake, not for yours. Their hierarchical systemmay be defensible in theory, but it means that one canbe on the staff for thirty years before having full clinicalresponsibility for one’s patients. You’d have been justthe man to challenge that idea, but your chances of successwould have been slim. Even if you’d won, the victorywould have been pyrrhic, and the ulcer you’ve developedin your seven years as Senior Registrar would havebecome intolerable.Allow me to congratulate you on what I hear privately

was a narrow escape. Even the best of friendships can’tstand the strain of much good advice, but do acceptthis piece-you really must see the place before you apply.I know it means travelling all over the country, and thatnot many Regional Boards will pay for your expenses ona preliminary survey. So you’ll be out of pocket, and thechildren may have to go without new shoes for anothermonth. All the same, the money will be well spent.

" When am I going to get a job ? "

you ask. You’vehad your Fellowship ten years, and a respectable Master-ship for three, and your academic record is good. You’vebeen long enough at a good provincial centre to have lostthe fine gloss of your London teaching hospital, and tohave developed an appetite and considerable ability forhard work. I think you must be 37 or 38, and so longas your present chief is prepared to push hard (somearen’t, you know) the outlook should not be too bad.

For one thing, you’ve been on the market so long thatyour continued presence is an embarrassment to yourseniors. This may be turned to account by appearing atmeetings and conferences. If you can read a paper, somuch the better. If not, you can tactfully remind variouspeople of your existence.Of course one can’t please everyone. For some time I

wrote nothing, because I’d nothing worth writing. Mythen chief pointed out the great gap this left in an applica-tion, so I dutifully scraped out the bottom of the bucket,