1. SOCIAL INEQUALITIES IN HEALTH, ILLNESS AND DISEASE: CLASS AND ETHNICITY
Questions:
Why are some people healthy and others not?
Who is more likely to get sick? Who dies?
How can we explain the differences?

2. WHY ARE SOME PEOPLE HEALTHY AND OTHERS NOT?
In Canada, for example, despite the implementation of a national health care system, designed to reduce health inequalities, these inequalities still persist.
While there is some recognition that health inequalities exist, there is an ongoing debate as to how to explain these differences as a prelude to addressing the problem.

3. These four explanations are:
The Black Report (1982), an evaluation of Britain's National Health Service and its impact on the health of the population, highlighted four different types of explanation for class differences in health.
These four explanations are:
measurement artifact
natural or social selection
cultural/behavioural differences
structural/materialists

4. Measurement Artifact Explanation
This explanation argues that class‑related health differences are merely the result of the biases involved in the measurement and recording processes.
Certain measures both of class and of health are bias and of imperfect validity.
Sometimes this may be due to the relative size of the occupational class groups.

5. Measurement artifact …
The premise of this argument is that everybody’s health is getting better, and that the widening inequalities are caused by a small, shrinking group in the poorest occupational classes (Wilkinson, 1997; Evans et al., 1994).

6. Measurement artifact - Critique
This explanation has been widely dismissed on the grounds that there is a clear gradient of health disparity across occupational groups, and that this is not a "poor/non-poor" distinction.
Rather, it is a continuous inverse relationship between social class and health status.

7. For example:
Data from the Multiple Risk Factor Intervention Trial (MRFIT) in the US enabled more than 300,000 men to be grouped into twelve income categories according to median family income.

8. The results at the end of the trial showed that incomes and death rates were so closely related across all categories that it made no difference to the positions of eleven out of twelve groupings whether they were ranked according to ascending income or descending death rates (Smith et al. 1992).

9. The gradient in mortality ran across the whole income range from the poorest to the richest.
Consequently, the artefact argument does not offer any better clarity to the complexities of health inequalities in society and so cannot be sustained.

10. Natural or Social Selection Explanation
It is argued here that perhaps class differences result from human biological differences, rather than that the human biological differences result from the class inequities.

11. Natural or social selection …
One view is that resources are unequally available to people in different social classes
This cause changes in human biology so that the poorer classes, lacking adequate nutrients, clean drinking water, safe working conditions, and the like are more likely to become ill.

12. Natural or social selection - Competing View
The competing view is that people suffer from ill health first and then drop down in the social class hierarchy.
Illness itself, because of resultant disability, unemployment, or demotion, according to this argument, causes the decline in social class.

13. This phenomenon known as the “drift hypothesis" explain that less healthy people tend to drift down the social hierarchy.
While there is some evidence to support this explanation i.e., illness certainly may cause a drop in class level for some (e.g., mental illness)

14. Most of the data suggests that relatively few sick professionals experience downward occupational changes (Townsend and Davison, 1990).
The impact of ill health on downward mobility is very slight and tends to be limited to certain sexes and age groups, namely, men in their later middle age.

15. Poor health does effect social mobility, but the size of the effect is too small to account for very much of the overall health differences (Wilkinson, 1997)
The two remaining (structural/materialist and cultural/behavioural) explanations of health inequalities have received considerable attention.

16. Cultural/Behavioural Explanation
Class (and here minority racial and ethnic status groups are also relevant) does cause illness
The explanation stipulates that the mechanism through which this occurs is class differences in lifestyle preferences and behaviours

17. Cultural/Behavioural Explanation …
Lifestyle preferences and behaviours include such things as:
the consumption of harmful commodities (refined foods, tobacco, alcohol)
leisure‑time exercise
the use of preventive health measures such as contraception
'safe sex'
prenatal monitoring
vaccination.

18. Cultural/Behavioural Explanation …
This explanation implies that lifestyle behaviours are the result of a number of individual, free‑choice decisions (i.e., lifestyle choices are voluntary and people are expected to engage in the ones that are healthy).
This explanation implies that people harm themselves and their children by adopting health-damaging and reckless lifestyles.

19. Cultural/Behavioural Explanation …
The suggestion is that because of the culture of poverty, those in the poorer classes choose to live for today, to ignore preventive health guidelines, and to indulge themselves in smoking and eating fatty, rich foods, all the while lying around on the couch and neglecting to exercise.

20. Cultural/Behavioural Explanation …
Here, the individual is used as the unit of analysis implying that personal characteristics such as personality type or intelligence, determine their health behaviour.
This notion tends to absolve the social structure of responsibility.

21. Cultural/Behavioural Explanation - Critique
The problem with this notion is that individual decision‑making must always be seen in the context of the social structure and of the constraints that impede the behaviours of the people placed in different locations in the social structure.

22. Critique …
Furthermore, there is no evidence that the lower classes or minorities tend uniformly to fail to practice good health habits.
To take just one example, class is inversely related to alcohol consumption and alcoholism.

23. Cultural/Behavioural Explanation – Policy Implications
Recent health policy interventions which focus on lifestyles choices such as, smoking or cancer originate from the behavioural explanation of health inequalities.
While it is true that some health threatening lifestyle behaviours do have a social class gradient, this explanation has been heavily criticized by opponents because it tends to" blame the victim".

24. Policy Implications …
Studies have also shown that the gradient is not sufficiently steep, nor the behaviours threatening enough to account for the social class gradient in mortality (Townsend and Davison, 1990; Wilkinson, 1997).
For example, Wilkinson (1997) explains how people of lower SES people often choose health damaging behaviours such as smoking, and how this may be explained by a materialist perspective within a context characterized by low income and poor housing.

25. Structural/Materialist Explanation
The structural/materialist explanation emphasizes the role of economic and associated sociocultural factors in the distribution of health and well-being.
The idea is that there are direct and indirect links between material/economic deprivation and health (Curtis and Taket, 1996; Wilkinson, 1997).

26. Structural/Materialist Explanation …
In short, the fundamental political, economic and consumptive patterns of society confer a number of advantages to certain segments of society.
This pattern is evidenced by people in lower SES being exposed to relatively unhealthy and risky environments.

27. Structural/Materialist Explanation …
Wilkinson (1997) argues that poverty is the most important determinant of health as people in lower SES continue to be disadvantaged in terms of the risks to ill health.
Poor people may face material constraints on gaining access to information on healthy choices (diets/lifestyle), longer distances to health facilities and work.

28. Structural/Materialist Explanation …
The authors of the Black Report prefer the materialist explanation, which sees health as the result of political‑economic differences or differences in the way members of different social classes are constrained to lead their lives.
Those who support the behavioural explanation object to the materialist explanation on the grounds that many current health problems such as cancer are associated with high-risk activities (e.g., smoking) which are avoidable.