Social, economic, and cultural environment and human health
Human existence and the social environment
Urban industrialism as a health revolution
Global capitalism and the social environment of nation-states
Society and nation designating boundaries for the impact of the social environment on health
The social environment and the expressive body
Macro- and micro-arenas of the social environment
The insulating properties of family relationships
The anatomy of the social environment within the nation-state
Economy in the social environment
Polity in the social environment
Culture in the social environment
Human existence and the social environment
Human beings are complex organisms. Aside from the material complexity of the body itself, they possess the capacity to think, communicate, reason, feel emotion, hold beliefs, care for others, and act upon their environment in purposeful, productive, and destructive ways. The term social being denotes this sentient intelligent dimension of the human animal with its investment of social experience and cultural understanding. This investment represents the presence of the social environment within every person. It includes moral sentiments defining good and bad thoughts, feelings and conduct, ideologies including religious and secular beliefs, and knowledge as well as the entire repertoire of cultural symbols and their meaning, including language. As Peter Berger (1964) nicely expressed it, ‘the human being resides in the social environment and the social environment resides within the human being’.
Society has an objective as well as a subjective reality. As a structure external to individuals, the social environment has many facets. Among the most important for public health is the cumulative impact that our species has made upon the natural world. This includes the exploitation of the world’s territory and resources leading to the extinction of many other species and the damaging effects of efforts to improve human livelihood on global ecology. Humankind has altered the ‘natural’ environment extensively enough to disturb significantly both global climate and intercontinental ecology (Crosby 1986). This is the broadest global sense in which the habitat of modern humanity can be described as a social environment. There is no doubt that the process whereby humankind increased its dominion of nature has been associated with a ‘great leap forward’ in the health of the species, although there is a downside to this.
The period of most rapid change in human health status is equivalent to what historians call the Modern Era. This is the period since 1500 in which industrial capitalist urban civilization was born and disseminated throughout the world. The latest stage is the development of a spectacular technology of global communication ushering in the Internet Age. The ascent of capitalist civilization produced a ‘great transformation’ of the material conditions of human existence (Polanyi 1946). It was also associated with a process of European conquest and colonization of most of the world’s territory, with the extinction of many other species as well as entire aboriginal peoples in some areas, with ferocious world wars, genocidal ethnic cleansing, and the development of a technology of mass destruction. On the plus side, the industrial mode of livelihood was born out of a scientific and technological revolution, which created the conditions for every (surviving) descendant of the human species to develop their potentiality to the full. The realization of this promise is so far restricted to developed nations and even there significant inequalities remain. In the era of industrial capitalist civilization, the volume of global material resources produced to support human life has risen beyond all previous measure, although their distribution among those peoples who survived the transition to the new global order is highly unequal. This is the first and foremost principle of the relationship between the social environment and human health.
Urban industrialism is the mode of livelihood created by the forces of market capitalism over the last two to three centuries. It is far and away the healthiest form of social organization known in human history. Although it has been directly associated with the formation of densely populated anonymous urban and suburban industrial communities, the health status of the populations who dwell in these places has risen to new record levels of vitality.
Among indicators used to measure the distribution of health in a population, only one—mortality—can be used with any degree of precision to study trends over time between and within societies. Alternative indicators—morbidity or stature—are more useful for studying intranational variation and even then they can only be used with caution. Morbidity is the most methodologically problematic of all possible health status indicators because, as a complex medico-sociological variable itself, its meaning is influenced by the same economic and normative factors that help shape health outcomes. Thus, for example, the higher morbidity recorded by women is probably more a reflection of gender norms dictating economic roles than any difference in the risk of disease. Men of working age appear to suffer lower rates of morbidity but higher rates of mortality, suggesting that the direct risk of disease itself is not perfectly correlated with the same factors that predispose people to see themselves as unhealthy or in need of medical advice or treatment (Hart 1982). Morbidity, whether self-reported or medically reported, has an important motivational aspect that limits its utility as an objective (rather than subjective) health status indicator. Stature is another possible objective measure of health status. It is closely correlated with longevity and has the additional advantage of being a measure of the living not the dead (Marmot et al. 1984; Floud et al. 1990). It has yet to become a routine health status indicator in official statistics and, although in time its use is likely to increase, so far few societies produce systematic series of height differentials in the population. Average height is not exclusively dependent on socio-economic factors, nor is it correlated with international longevity differentials. Although average height in Japan increased rapidly in the second half of the twentieth century, it remains below that of many other industrial populations whose rates of infant mortality and age-specific death are much less favourable. The rationale for using mortality to measure the distribution of health in a population is first and foremost the availability of data, both historical and contemporary. Age-specific mortality is a measure of human durability, and within a population it reflects the distribution of human vitality, immune status, and nutritional welfare. More research is needed on the links between mortality and lifetime morbidity; therefore mortality will continue to be used, with good reason, as the principal indicator of population health status.
In Tokyo, which is the capital of Japan and one of the most densely populated cities in the world, male and female longevities in 1999 were 76 and 82 years respectively and are projected to rise even higher in the decade ahead. The gap of 6 years favouring female over male longevity is close to the average found in all industrial populations. It reverses the direction of vital fortunes found in earlier human communities where gender differences in the average age of death favoured males by about 5 years (Cohen and Armelagos 1984).
Urban industrialism as a health revolution
Rising life expectancy is the best gauge of the health-promoting quality of urban industrialism. The northwestern corner of Europe, where the world’s first urban industrial communities appeared in the nineteenth century, blazed the trail of the modern health revolution. In Sweden, the Netherlands, and Britain, more than two decades had been added to mean longevity before the antibiotic age commenced in the late 1940s. These nations developed the means—the knowledge, the technology, the political will—to make the city as, if not more, salubrious than the countryside. The transition may be dated to the 1920s. Before this rural communities in new industrializing nations contained most of the ‘healthy’ districts.
Subsequently, rural/urban health differences disappeared just as surely as urban/rural lifestyles converged in the industrializing nations of Western Europe and in Neo-European New World settlements. The term Neo-European was used by Alfred Crosby (1986) in his book Ecological Imperialism to depict the descent of the populations who colonized the temperate territories of the North America, Australia, and New Zealand.
The term ‘healthy’ districts was coined by William Farr (1885); they were not exclusively rural, but also included middle-class suburbs such as nineteenth-century Hampstead. The higher rate of death in urban areas reflected specific hygienic risks and also the higher poverty of resident labouring populations. The recent epidemiological history of less-developed (i.e. Third World) societies does not conform to the pattern established in Europe in the nineteenth and early twentieth centuries. By 1950, chemotherapy and modern vaccination had created a much more rapid and individuated means for avoiding the risk of infective and parasitic disease. As access to modern preventive medicine is much greater in metropolitan areas, the urban populations of developing countries tend to record better health status than their rural counterparts. Cities are also the places where urban governmental and administrative elites reside and where they provide for themselves and their retainers all the accoutrements of the Western lifestyle, including high-tech hospitals.
The health-generating potential of the modern city depends on the extent to which urban growth is a true product of industrialization. There are today many large sprawling cities in less-developed nations where living standards, environmental hygiene, and life chances are extremely poor. This urban development is specifically associated with the administrative/political functions of the nation-state and not necessarily connected to or reflective of fundamental processes of socio-economic development, which impact on the material conditions of the population at large. In these places, the ruling elite may enjoy a Western standard of living using scarce national resources to erect the infrastructure of a Western way of life, including hospitals equipped with the latest mechanical gadgets. These urban communities are not founded on a process of economic development, which incorporates the entire population, and they are not appropriately subsumed under the term urban industrial civilization. The latter development is a population-wide phenomenon that encompasses the living conditions of all citizens wherever they live. Even in rural areas, industrial peoples participate in the ‘urban’ lifestyle of the nation.
Modern urban society is healthier by far than any habitat spontaneously encountered in nature. The imaginary existence of the ‘noble savage’ and even his actual depiction by some modern day anthropologists (Sahlins 1974)—free of exploitation by others, free of repressive social moralities, free from the stresses and strains of clocks and timetables—romanticizes the life of our earliest human ancestors. Clues from Palaeolithic demography reveal the body of and industrial human to be twice as durable as that of his Stone Age ancestor. The respective comparison with Stone Age woman is even more favourable to her present-day counterpart (Roosevelt 1984). Whatever the measure—stature or longevity—life in modern society far exceeds the level of welfare achieved before the dawn of civilization, or at any subsequent point during the last 5000 years of recorded history.
The critical feature in the improvement of health, which accompanied the ascent of urban industrial civilization, was the virtual elimination of infective and parasitic disease. This is known as the epidemiological transition and its proportional causes remain a matter of academic controversy. Several factors contributed, among them improvements in: nutritional status, public and personal hygiene, living standards generally, the care of infants and children, and the status and rights of women. Although there is some evidence that the early technology of vaccination may have contributed to the decline of smallpox, the contribution of individual medical therapy was very limited and in some respects may even have been negative. The great transformation in human health was primarily the product of socially engineered changes in the environment; it was a matter of reducing the risks of exposure either by erecting barriers to infection or by raising the immune status of people.
The elimination of the threat of infective disease improved the durability of the human body and made way for a proportionate increase in degenerative disease. Degenerative disease is connected with the ageing of the human body and its various parts. Indeed, it might be thought of as a medical classification of the various processes by which human organs progressively lose their effectiveness. Fries and Crapo (1981) coined the term ‘universal disease’ to highlight this fact and to press home the point that postponement not prevention should be the goal of public health policy. In the present day, the social stratification of health status and survival (by nation, class, race, and gender) is a reflection of social inequalities in the postponement of universal disease allied to differential exposure to the risk of accidents and violence.
Global capitalism and the social environment of nation-states
Urban industrialism must not be thought of as an optional mode of social organization encountered in certain prosperous European, Neo-European (North America, Australia), and Asian nations. It is not simply a design for social organization to be admired, aspired to, and freely adopted. It is a worldwide system of social stratification, dominated by a ‘rich man’s club’, which sets the terms for participation in the global economy.
Social stratification refers to the division of a population into a hierarchy defined by wealth and/or status. Stratification according to economic resources is called class, while status refers to social division based on cultural scales of value. In practice the two forms of stratification go hand in hand because the best resourced people exert a powerful influence over the construction of social meanings. An individual’s location within a stratification order may vary according to the population frame of reference. A working-class Briton would be located near the apex of a global stratification order but near the bottom of the hierarchy in a national population.
Another way of putting this is that urban industrialism is a product of capitalism, which is the international system of financing production and trade, whose principal stimulus is the profit motive. Although some nations make more systematic attempts to regulate the capitalist forces of production and distribution within their territories (see below), capitalism recognizes no national boundaries.
Its international character is not a recent development. From its earliest beginnings the profit motive has been the most significant force in globalization. It sponsored the Columbian exchanges, the Atlantic slave trade, and the Louisiana Purchase, in its infancy, it may even be credited with stimulating the Black Death. The long shadow effects of early capitalist enterprise between the sixteenth and nineteenth centuries continues to haunt race relations globally. In the United States, they remain the leading factor shaping the pattern of health inequalities (see Fig 1 and Fig 8 below).
Contemporary intercontinental and international health inequalities reflect patterns of uneven social and economic development, which are themselves the product of the historical circumstances of the emergence and evolution of industrial capitalist civilization and its colonial outreach. Industrial capitalism is a societal phenomenon. It is the third great mode of social organization in human history—the Palaeolithic, the agrarian, and the industrial. Its proximate origins are conventionally dated to the eighteenth century and the location of its birth is northwestern Europe. In the two succeeding centuries, it became a global phenomenon, eclipsing substantial alternative experiments with industrial social organization, in particular Eastern European communism. As we enter the third millennium, and as the People’s Republic of China continues to pursue economic and social reforms designed to create a market society, there appear to be no significant alternative agendas for designing a ‘productive’ and prosperous social environment, although the healthiest less-developed nations/regions are conspicuously not those where market forces have been permitted to ‘let rip’ the social fabric of communal life (Jeffrey 1978).
Society and nation designating boundaries for the impact of the social environment on health
Until recently sociologists have tended to equate society with the nation-state, thereby producing a series of individual social formations for comparative analysis. Given that much of the evidence of the relationship between health and social relationships has been assembled within this framework, the nation-state is the default unit of comparison. However, the boundaries of a society and the social forces operating on human health cannot be assumed unproblematically to be contiguous with the boundaries of the nation-state. At an empirical level this fact has been known for centuries, as epidemiological exchange was the first dramatic, indeed devastating, evidence of the social forces of globalization in the early modern era. A growing body of scholarship in historical epidemiology testifies to the part played by disease as a force of historical change (Zinserr 1965; McNeill 1977; Watts 1997).
It is only very recently, however, that analytic sociological and political science perspectives have become sensitive to the fact that forces shaping social life do not originate and cannot be contained within individual nation-states. Even within national populations, there may be very significant regional variations in living conditions and health. The geography of health inequality has been monitored in Britain for over a century (OPCS 1978) and it shows no declining tendency (Dorling 1997). In the United States (Fig. 1) regional inequalities are so significant that health and survival chances in some regions are no better than in the less-developed nations of the Third World.
Fig. 1 Regional inequalities in health in the United States. (Data from Murray et al. 1998.)
In 1990 a life expectancy gap of more than 15 years separated the worst and the best counties in the United States. Ironically, one of the unhealthiest counties, where male survival chances are below the level of many Third World communities, turns out to be Washington, DC—the capital of the richest nation in the world. This extraordinary observation is testimony to the power of race as a factor of health inequality, for Washington is a black city and it is race that primarily underlies the distribution in Fig. 1. Figure 1 is a striking demonstration that the social dimension of the environment overwhelms the natural/physical dimension, for it is evidently the persisting social inequalities from the legacy of slavery in the United States which ranks Washington as the second most unhealthy territory in the nation.
Knowledge of territorial differentials within nation-states highlights the difficulties of drawing the boundary for analysing the impact of the social environment on health. Even so, nationality is an empirically significant division in health status. A comparison between, for example, Japan and the United Kingdom demonstrates that significant variation is found among highly developed industrial nations (Marmot and Davey Smith 1989). Even among the dozen or so nation-states located within the neighbourhood of northwestern Europe, there are notable differences in mortality risk that appear to be strongly connected with varying patterns of gender relations and with distinctive national patterns of disease and premature death (Hart 1989a) (Fig. 2).
Fig. 2 Gender and survival in Western Europe.
The social environment and the expressive body
The range and scope of human qualities—psychic, emotional, somatic—virtually defies artificial scientific classification and anatomy, yet some sense must be made of the interactive sequences that make up the life process (James and Gabe 1996). The term ‘expressive body’ has been suggested as a means to capture the continuous and causally connected interchange between fundamentally different biochemical, psychological, and social processes entailed in human existence (Freund 1990). The question of how this interaction manifests itself in the processes of human development and daily interaction, and how it may be implicated in the processes of human vitality and disease are the most critical issues for the sociology of health and beyond that for the theory and practice of medicine (Evans et al. 1994).
The recognition that a socio-psychosomatic interchange plays a fundamental part in the health of human beings is a very old idea in medical thought, although it has taken a back seat to the biomechanical model in modern era.
Before the biomechanical paradigm began the ascent to its present contemporary pre-eminence, medical researchers and thinkers believed that this somatic dynamism must be powered by one or more vital spirits. For Plato, the heart was the source of the human spirit, although he also recognized the brain as the seat of reason (intellectual and sentient life) and the liver as the seat of appetite (the manufacturing base of the life process). A similar perspective frame of understanding was accepted from the times of Hippocrates (fifth century BC) to the eve of the modern mechanical era. William Harvey (1580–1656), a determined empiricist who first proved that the heart recycled the blood, remained committed to Platonic and Aristotelian ideas that vitality was a spirited phenomenon, that the body possessed a soul, and that physiological, emotional, and mental processes operated together in the management of somatic existence. These beliefs were the foundation of the Galenic paradigm, which captured and held the medical imagination in Europe from before the birth of Christ to the early modern era. They began to lose credibility in the sixteenth century as the machine age dawned. René Descartes is the figure most often associated with end of the Galenic paradigm in Western medical theory. His mechanical perspective left no room for the soul in bodily processes. In fact, Descartes rejected the idea that a human spirit directed bodily motion or function in any way at all. In the Cartesian paradigm, the soul did not even have a material existence. The human body was like a mechanical automaton powered by the heart and initially triggered by a divine switch. As Wear (1995, p. 340) puts it, ‘… Descartes’ heart was like a mechanical engine which gave motion to the rest of the body. It was started by God, who put the initial heat into the heart, but God was acceptable to the mechanical philosophers’. Mind–body dualism was the legacy of Cartesian philosophy in medicine. It refers to the marked modern medical tendency to divide human experience into psychic and somatic arenas and to treat them autonomously. The depersonalized and socially anonymous body gradually became the most suitable object of observation and intervention.
The dominant contemporary paradigm of health is depicted as biological and mechanistic because of a virtually exclusive focus on the physiological and biochemical properties of human being and an associated tendency to objectify the body as a kind of machine which needs servicing, diagnosis and repair (McKeown 1976, p. xiv).
If the human body is a machine, it is far more sophisticated and versatile than any mechanism devised by humankind—an alimentary system transforms food fuel into energy and bodily repair materials, a sensory apparatus provides a continuous service of appraising and surveillance, an immune system works to repel noxious agents, a finely tuned muscular system permits motion and intricate movement, a brain and nervous system provides apparatus for learning, detection, judgement, speech, and communication, and a neuroendocrinal apparatus serves as an integrative mail service. All these extraordinary properties of the human being are interlinked by emotional mechanisms that articulate mental awareness and calculation with somatic and other vital processes.
This is medical materialism, and for much of the twentieth century it has nurtured an interventionist approach with a heavy reliance on machine technology and the biochemical manipulation of bodily processes. Although degenerative disease offers limited scope for curative intervention, the biomedical model has also spawned an energetic search for material risk factors, primarily elements of consumption or exposure deemed dangerous for survival. The next frontier for the biomedical paradigm is the decoding of the human genome, opening the door to the genetic manipulation of human tissue—ambitiously envisaged as the final solution for eliminating the material substance of disease. Although a knowledge of the massive influence of social organization and relationships on the distribution of health and disease within populations raises serious doubts about the future efficacy of genetic therapy for universal disease, there is no shortage of investors willing to fund the hugely expensive research effort required to anatomize human DNA. Fries and Crapo (1981) used the term ‘universal disease’ to highlight the normality of degenerate diseases.
The incentive is profit. The medico-industrial complex is the most profitable sector of contemporary global capitalism and private investment in genetic research is not the product of philanthropic impulse. Biogenetic companies are attractive to investors who hope to share in the profits expected from patenting the mysteries of the human genome and from the development of new techniques of biochemical intervention, which are expected to follow (Relman 1990).
The biomedical model embodies the materialist theory of disease and death. The human body is a material thing, disease has a real tangible appearance, and the most urgent and effective therapies are directed towards reversing or transforming pathogenic materiality. The aggregate impact of therapies developed through the biomedical paradigm on universal disease is surprisingly small. Faith is mostly sustained through a mystified understanding of medicine’s past triumphs, an expectation that the future will yield rich rewards, and finally that this is the scientific, indeed the only sensible, approach to the management of human health in the modern era. In this perspective the body is abstracted from the other components of human experience—the emotional, the mental, and the social. Medical materialism shares a kindred spirit with sociological materialism, which also recognizes diet, living standards, working conditions, and housing (the material outcome of class, race, gender inequality) as the primary vectors of health and disease originating in the social environment.
The social theory of Karl Marx is known as materialism because he insisted that human beings are first and foremost material beings. This conclusion is based on the fact that the satisfaction of material needs in particular food is the primary requirement of daily existence. ‘I eat, therefore I am'; my consciousness, my psychological state must therefore be secondary to my physical state. This classic blend of social and medical theory worked more effectively before and during the epidemiological transition; its explanatory limitations have been more exposed in the second half of the twentieth century as the mortal threat of acute and chronic infective and parasitic disease was substantially diluted in industrial societies. Even so, the direct impact of the material environment on the risk of disease and premature death remains a significant feature of the interaction between health and the social environment.
A ‘holistic’ conception of how the social environment impacts on human health calls for inclusion of all the life processes of human existence in the chain of causation. In other words, future progress in social medicine probably requires a substitution of the term social being for human body in order to decipher the epidemiological interaction of biochemical, emotional, psychological, and social life processes. Figure 3 charts the four principal components of human experience as a series of interacting spheres which show the potential array of categorically different forces implicated in the health of human beings.
Fig. 3 The interactive processes of human health: society, psyche, emotion, and soma.
Society is the surrounding sphere in Fig. 3. Its historically derived structure is the context for the biographical life of individuals. Soma is the corpus of the human being, the material substance that tends to be the exclusive focus of orthodox medical research and practice. Soma is a dynamic rather than a fixed thing. It literally emerges at conception through the bonding of sperm and ovum, and its dynamic potential is rapidly realized within a remarkable 20-week process of embryogenesis and organogenesis. Even before birth, fetal development appears to be powered by its own logic of physiological development and is capable of adjusting to uterine constraints and opportunities (Barker 1994). The mature fetus is ready to attempt parturition at 40 weeks, although the dynamic of somatic growth (including weight gain and the achievement of stature) continues after birth until about the age of 16 years (Tanner 1978). When growth is complete, the human body ‘works’ to maintain life processes with minimal conscious management on the part of the sentient owner. The inherently dynamic character of the human body is evidenced in its apparently autonomous self-regulating and self-repairing properties. But the human body cannot survive without the sentient intervention of its owner or a caring parent or guardian.
Human existence entails a continuous process of mental calculation and communication, and much of it is based on the acquisition of cultural knowledge stored in the recesses of the mind. The ancients understood that the brain was the seat of reason and mental calculation. Modern researchers have gone much further in ‘mapping’ the various territories of the brain responsible for the government of human interaction and the inclusive formative activities of self, identity, intellect, personality, motivation, language, education, skill, knowledge, speech, and beliefs. Every minute of every day, the brain goes to work orchestrating decisions about appropriate action one after the other in rapid succession. Many of these decisions concern safety and have immediate vital relevance for ego and for other people. Modern urban society raises the stakes in this regard and at the same time reveals the enormous intellectual prowess of every human being, no matter what their measured IQ (Elias 1978). The safe operation of a modern freeway depends upon a vast interchange of skilful and sentient co-operation. Driving an automobile is a complex skill yet it is easily learned by an average human being, showing just how far many unskilled modern jobs underrate the potential capacities of the people who perform them (Blackburn and Mann 1979).
The intersection of mind and body is emotion. The fact that the body is emotionally reflexive is often witnessed in the course of social interaction even though human beings learn to manage and conceal the outward signs. The most visible manifestation is tears, a body fluid secreted in response to feelings of sadness, which reveals clearly how social events trigger biochemical bodily reactions (Katz 1999). The word expression meaning emission, release as well as verbal representation, captures the multifaceted character of communication, although the opportunity for catharsis is restricted by the etiquette of social interaction, which frequently dictates that emotional reactions be bottled up or otherwise transformed in polite society (Elias 1978). The body’s emotional work might be consequently understood as the material equivalent of Freud’s repressed unconscious. In this vein, we might conclude that rational man may be the primary victim if the requirement to withhold or disguise feelings is a cultural requirement more frequently imposed on the masculine than on the feminine social persona (Gilligan 1982).
A number of researchers have explored the possible contribution of managed emotions to the origins of modern disease (Totman 1979), and some have suggested that cultural variations in permissiveness of emotional response may explain distinctive national and ethnic epidemiological distributions (Arsenian and Arsenian 1948; Paulley 1975). These interactions open up a potentially vast field of sociomedical research, which some believe will prove particularly important in explaining persisting social inequalities in health (Sapolsky 1991). In Fig. 3, the tripartite structure of the human self is pictured by, located in, and encompassed by a social environment. Later in the chapter, considerable space is devoted to a delineation of the social environment as a series of macro- to microspheres enclosing and thereby shaping the unique biographical experience of individual human beings.
The Enlightenment planted two important ideas that shaped future research on the fate of individuals in society. The first draws an analogy with a tabula rasa to capture the plasticity of human formation and to illustrate the power of society’s agents of socialization and child development—the family, the school, the church, the mass media, the medical system, and the state (Sagan 1996). Children will be what society wills them to be. The second recognizes that the composition of every human being represents a unique configuration of biographical contingencies; no one human being is ever the exact clone of another. The permutation of social, psychic, emotional, and somatic experience in a single person produces a unique configuration of human characteristics. At the same time, the macro- and microspheres of the social environment discharge a number of systematic forces, which either unify or divide the social group. Gender, race, and class are the pre-eminent axes of social stratification. They give rise to a series of overlapping hierarchies of social relationships that shape the context and outcome of everyday life. On a daily basis the expressive body experiences itself in and through these relationships, aiming for and sometimes, but not always, achieving material satisfaction, freedom from pain, emotional tranquillity, and self-reaffirmation (Collins 1990; Freund 1990; Williams 1998). In this ongoing way, society intersects with the psycho-emotional and biochemical processes that make up human existence. The multifaceted model of a human being captured in the concept of the expressive body offers a fruitful framework for surveying all the potential points of intersection between health and the social environment.
Macro- and micro-arenas of the social environment
The expressive body experiences the social environment as a series of enclosed spheres, which may possess insulating powers of varying magnitude. Figure 4 illustrates these relationships.
Fig. 4 Spheres of the social environment influencing individual biography.
The outer and the inner rims of Fig. 4 represent a series of enveloping spheres around an inner core representing individual existence. Note that the human being is identified as a biographical phenomenon. The expressive body has its own unique physiological, psychic, and social histories, whose interaction determines the chances of survival. In the debate about the causes of systematic health inequalities within populations, the issue of biography has received considerable attention. Researchers have clashed over the relative importance of early ‘formative’ experience. There is a strong a priori case for assigning additional weight to the first two decades (including fetal life) in the formation of the expressive body. Apart from anything else, physical stature is determined by the age of about 16 to 17 years, and, as this is strongly correlated with survival rates within national populations, the quantity and quality of child rearing resources seems to be an unassailable ingredient of adult health experience (Tanner 1978). The work of David Barker and colleagues highlighting the very earliest fetal phases of human development has a growing influence on this debate (Barker 1994).
Another important point to note is that the outermost sphere extends the boundary of the social environment beyond the nation-state. The most significant and widest forms of health inequality originate in this outermost macrosphere, i.e. the global sphere. While a longevity gap of only a few years separates human durability between the industrial nation-states, the gap between more and less-developed societies is up to three decades. While these inequalities seem remote and disconnected to the experience of First World peoples, they are not. The process of industrialization was preceded by and depended on the expropriation and colonization of non-European territories, and living standards in First World nations still depend heavily on an unbalanced global trade in primary commodities and an unequal exploitation of the Earth’s atmospheric, oceanic, and geological resources (Smith 1999).
Two of the enclosing spheres in Fig. 4 contribute disproportionately to the impact of the social environment on human health. These are the sphere of the nation-state and the sphere of the household, sociologically known as the public and private spheres of the social environment respectively. Societal development in the modern era may be equated with increasing enlargement of the scope of the public sphere. In pre-industrial societies (historic and contemporary), the public sphere is far less extensive in its outreach functions and the private sphere provides a far larger volume of individual material and emotional needs. The governance of social relationships within private life is subject to ecclesiastical and civil law but, in practice, a male authority figure in the private sphere enjoys a considerable ‘natural right’ to supervise and discipline his family and household. The historical facts of patriarchal domination in the private sphere explain why the private sphere is frequently singled out for analytical primacy in contemporary feminist analyses of gender inequality. The expansion of the public sphere is associated with a diminution of the idea of ‘natural patriarchal rights’ and an increase in legally defined individual rights. This is manifested in the increasingly interventionist role of the nation-state supervising relationships in the private sphere, in particular marriage and parenthood. Therefore the relative size and scope of the two spheres varies greatly between societies at different levels of social and economic development. The importance of the public sphere of the social environment will be discussed in greater detail shortly, with most attention given to industrial nation-states where it is highly developed.
Between the outer rim and the personal existence of the expressive body are a series of potentially insulating layers. The social institutions of the nation-state play an important part in either exposing or protecting life chances within their territories. This is the most important factor in the macrosocial environment. Nation-states are power structures. If they are democratically constituted, they ostensibly represent the interests and will of the people and their remit is to provide and manage a social infrastructure to safeguard the well being of the population. Public health legislation and institutions are a prime example of how the nation-state carries out this responsibility. Indeed the historical record of the first industrial societies indicates that pressures to inaugurate public health reforms played a crucial part in consolidating national governmental structures and public authorities in the late nineteenth century (Rosen 1958; Rosenberg 1975; de Swann 1988). This happened because private interests were neither disposed to inaugurate the integrated urban sanitation and communication projects that literally ‘paved the way’ for the healthy city nor possessed of sufficient territorial authority to do so. Modern governments interpret their responsibility for the public health in more or less expansive ways. Embracing a relatively narrow biomedical understanding of their responsibility for public health, they may see their remit as a duty to insure the population against the chances and consequences of disease by organizing access to comprehensive medical care. Among the mature industrial nation-states, the United States is the only exception to the rule that access to medical care should be set apart from the profit sector of the economy and organized by the national government. A broader sociomedical perspective on the public health reinforces a more integrated policy programme linking access to health care to income maintenance, full employment, and other social services (see below).
A regional sphere of the social environment is also distinguished in Fig. 4. This is more evident in nation-states with large territories and populations. In such cases, the national territory may represent past processes of geopolitical amalgamation involving distinct ethnic and linguistic communities. This legacy may be reflected in future patterns of race and ethnic stratification in the national population and in the distribution of health. This is true of many European nations, including Britain, Belgium, Spain, and France, and in each case regional health variations still bear the legacy of economic and cultural history. This refers to cultural legacies before the twentieth century (e.g. England, Wales, Scotland, Ireland).
The United States, which is the most populous industrial capitalist society, displays substantial regional inequalities in health and survival across its large territory. Strong hints of the way that this is articulated to the history of race relations in the United States are highlighted in Fig. 1, which also shows how, even within regions, other locality variables may be important in shaping survival chances. In the second half of the twentieth century, processes of migration, suburbanization, and deindustrialization combined to enhance the health risks of inner cities, rendering them once more (as in the late nineteenth century) the unhealthiest spaces in the national territory. Urban–rural inequalities in health today are far less a function of deficient sanitation and much more a direct reflection of real estate values and the impoverished economic status of the inner-city populations. These trends have enhanced the value of location variables as means of measuring the distribution of inequalities in health.
The sphere of networks and neighbourhood in Fig. 4 is the outer enclosure of the microsphere of the social environment. The term ‘neighbourhood’ suggests a propensity for fellowship among residentially contiguous households and individuals. In an earlier era this propensity may have found expression in the shared communal facilities, such as the local church, which could orchestrate supportive and charitable activity. Processes of secularization, allied to the increased mobility and growing diversity of local populations, has diminished the scope of the voluntary work performed by neighbours for one another through churches and other forms of local association. Even so, the neighbourhood still represents a potentially important agency of social support and social control, providing informal help and setting limits of tolerance for idiosyncratic, unruly, and, more importantly, aggressive behaviour in the local vicinity. This potential has generally been realized through informal mechanisms, and its effectiveness depends on the extent to which neighbours identify with and recognize a mutual responsibility to one another.
The extent of mutuality in a neighbourhood depends on a number of factors. Residential stability is one, shaping the opportunity for neighbours to get to know one another. The local age and sex structure determines how depopulated the neighbourhood becomes during the working day and physical/commercial neighbourhood features may either encourage or discourage pedestrian activity, which also shapes the chance of daily/weekly encounters and the formation of relationships between people who live near one another. In recent times, new formal mechanisms of mutual insurance have developed. The form they take depends on the prosperity of the community. More prosperous neighbourhoods have erected barriers and gates to regulate access to their property and private security firms to police it. In less prosperous communities, rising anxiety about the risk of crime and fear of strangers has encouraged neighbours to form watch committees to look out for and report suspicious persons and incidents. These developments may reflect the diminution of the informal power of local ties and increasing anonymity of modern life. In the latter sense, it is worth noting that the downside of ‘old-style’ close-knit ethnically homogeneous neighbourhood is that they may also operate as an instrument of intolerance, closing ranks to marginalize immigrants and to stigmatize unfamiliar and/or innovative lifestyles.
Even when the immediate residential environment is relatively anonymous, a significant layer of neighbourhood affiliation and support may still envelop the individual or household. Sociologists and anthropologists developed the concept of the social network to depict the ties that bind groups of people together in settings where individuals might otherwise appear socially isolated (Bott 1957). Networks may be organized around kinship, friendship, shared ethnicity, religion, work, school, hobbies, and political affiliation, and they may provide a considerable range of services (economic, emotional, spiritual, and psychosocial) for their members. The extraordinary importance of networks (kinship, friendship, ethnicity) in negotiating livelihood opportunities for new migrants in urban situations has been extensively documented all over the world, and it speaks to the enormous potential for small-scale communal activism and exchange in the pursuit of mutual well being.
An enormous number of examples might be presented to illustrate the capacity for self-organization among social groups, ranging from the friendly societies of nineteenth-century Britain (Gosden 1973) to the rotating credit associations of East Asia (Light et al. 1990; Ardener and Burman 1996). The role of kinship and ethnic networks in provisioning the individual in modern metropolitan communities is well documented by urban sociologists (Waldinger and Borzorgmehr 1996).
The contribution of supportive networks to personal health and survival is also very substantial. Social networks are enveloping sets of relationships through which individuals develop their identities, which in turn shape the motivation to act in accordance with a sense of self and lifestyle. Networks may thus act to reinforce both positive and negative patterns of ‘health behaviour’ (Cockerham et al. 1997). Bott (1957) made a simple yet striking sociological discovery about social networks in a study of the family in London in the 1950s. Using a ‘knitting analogy’, she showed that the tension of a family’s social network was linked to the sexual division of labour in the household. Close-knit networks, where all participants know one another so that lines of affiliation cut across the entire network, were found in conjunction with a gender-segregated division of labour. Loose-knit networks, more anonymous with mutually exclusive lines of affiliation, were associated with a relatively gender-free division of family labour. Bott developed the terminology of segregated, complementary, and joint conjugal roles to depict variations in the marital relationship associated with close- and loose-knit networks. Joint conjugal roles are the centrepiece of companionate marriage in which gender division is significantly diluted. Husbands and wives participate together in work and leisure, and in the 1950s they were predominantly associated with middle-class family life. Companionate marriage is part of a trend of gender convergence in the twentieth century that carries major significance for health; the fact that its development is linked to social networks points to the wider epidemiological significance of these social groupings.
The 1950s was a fertile period for new theoretical insights about the scope for social affiliation in urban situations. Sociologists and historians had long imagined the industrial city to be a relatively anonymous environment—a social terrain created for the ‘individuated social persona’ of industrial capitalism free to devise his or her own lifestyle. The classic statement was Wirth’s Urbanism as a Way of Life (1938). This view of the city as a site of social anonymity was always at some odds with ethnographic evidence gathered in studies of immigrant communities, especially in the United States (Lal 1990). Bott’s (1957) research also pointed out that networks did not have to be close-knit and local to provide members with a sense of social connectedness and support in urban populations. As new means of communication emerged during the twentieth century, the scope for developing and maintaining far-flung networks has proportionately increased. If this trend has tended to diminish the significance of local close-knit networks in the management of everyday life, additional pressures may have been felt on the core relationship in the private sphere of life—marriage.
Research like Bott’s exposed two problems with this conception. It emphasized the continued vibrancy of close-knit networks in urban industrial situations and the fact that the support they provided could act as a barrier to innovative behaviour. A loose-knit network offered more space for innovative development of lifestyle, such as gender-neutral conjugality, because the web of social affiliations was less dense and less able to sanction deviant, i.e. novel, behaviour. These insights hold important lessons for understanding the stimulus for and barriers to the development of innovative forms of ‘healthy behaviour’.
A number of researchers have demonstrated the preservative effect of immersion in networks based on kinship, friendship, and local association, including church membership. One of the most quoted studies found a mortality differential of more than 2.5:1 between people who scored low and high on an index of social affiliation (Berkman and Syme 1979). This is profoundly important evidence of the interconnectedness of mind and body in society, revealing the severe limitations of the biomedical model approach to the explanation of systematic social variations in the postponement of universal disease (see above). However, social networks, particularly the close-knit variety, may also exert a negative effect on survival.
The gang is a close-knit social network, a setting within the microsocial environment in which young men seek to earn a ‘respectable’ identity by exposing themselves to an elevated risk of violent death (Courtwright 1996). This is one component of the pattern of excess male mortality in the second and third decades of a lifetime (see Fig. 2). The gang illustrates the sociology of death from accidental and violent causes, i.e. the way it is articulated to the social environment in a systematic and comprehensible fashion. The rate of violent death is not an aggregate of random events; however, it flows from class-based cultures of masculinity which construct the identities and motivations of adolescent and young adult men, propelling them into at-risk behaviours of varying severity. This is one example where social capital arising out of membership in social networks must be located on the deficit side of the health and survival equation (Buford 1993).
Thus membership of social networks may either enhance or diminish survival chances. Gang networks are an extreme example of the diminishing effect. A more routine instance of the negative health consequences of the social network is the barrier that membership may erect towards behavioural change. Once again it is easier to come up with examples of male social networks that have deleterious health consequences. The British television series Men Behaving Badly invariably involves the consumption of alcoholic beverages. The association has probably held from time immemorial and in diverse cultural settings everywhere. The reform of male drunkenness as a primary object of social and health improvement was associated with the Temperance Movement in Protestant nations in the nineteenth and early twentieth century. The extent of its success was partly a function of the rising consumption of cigarettes—tobacco was the best friend of temperance. Drinking and smoking are the two known primary contemporary medical risk factors that diminish survival chances, and shifting patterns of class consumption have made an important contribution to the worsening trend of class mortality gradients (Fig. 6). In the case of drinking, the decline of consumption involved separating men from customary patterns of male sociability, i.e. close-knit male social networks based on the pub. The consumption of alcohol among Protestant males fell steadily through the early twentieth century and one of the most important factors in the trend was the emergence of companionate marriage, which increasingly redirected male leisure away from the public house (the pub) and towards the private home (Hart 1989b).
The insulating properties of family relationships
The most significant layer of microsocial insulation between the individual and the outermost impersonal spheres of the social environment is the household or family. This is the private sphere of social life. Sociologists differ in their valuation of the private sphere as a font of emotional and psychic well being. Mid-twentieth-century structural functionalism associated with Talcott Parsons theorized it as an arena of intimacy and mutual interdependence set apart from the cash nexus, where services are provided free and relationships are not shaped by market principles.
Later feminist-influenced critiques were more likely to point to the scope for inequality in private-sphere relations and to highlight the family as a site of patriarchal privilege and female oppression (e.g. Barrett and McIntosh 1982). There is empirical support for both sides of this argument. The use of reasonable chastisement by male household heads to discipline wives and children was historically sanctioned by law in Western culture. Although resort to violence within the family has been progressively criminalized, reports of its incidence remain very high, and the private space of family life provides an ideal arena for its concealment. Observers disagree in their interpretation of contemporary statistics of domestic abuse. In the face of static or upward trends, more pessimistic accounts argue that, despite legal reform, nothing has changed. More optimistic accounts stress the difficulties of interpretation, seeing the same trends as evidence of rising intolerance of violent acts and the greater willingness of both victims and law-enforcement officers to report cases, apprehend perpetrators, and inflate statistics.
The original French version of structural functionalism developed by one of sociology’s founders, Emile Durkheim, is rather less sentimental in its depiction of private-sphere relationships. The half-century separating Durkheim and Parsons saw substantial shifts in the conjugal relationship in the direction of what has been called companionate marriage. This social change coloured Parson’s understanding of the essence of social relationships within the family, emphasizing sentimental over disciplinarian norms.
Whatever the relative merit of these opposed interpretations, there is a great deal of evidence pointing to the health-promoting potential of private-sphere relationships. Individuals of all ages living in contexts where they enjoy the unconditional commitment of parents, spouses, and siblings, or their non-kin equivalents, derive a substantial health dividend. Among these relationships, the clearest evidence exists for marriage. Married people of both sexes record death rates well below the rates of the unattached and the benefits rise with decreasing social class (OPCS 1978, p. 34).
Although there may be some selective (into and out of marriage) effect in the statistical record (Hu and Goldman 1990; Goldman and Hu 1993), the differential power of marital status promoting survival in different nations does not suggest that it may be simply explained as a statistical artefact. The most dramatic evidence of marriage’s preservative effect has emerged recently in Eastern Europe. Here, in the midst of a health crisis linked to societal reconstruction and popularly associated with pollution, marital status has stood out as the most important means of insulating individual men and women from a sharply rising risk of death. This is further proof of the necessity of employing the expressive body as a model of human health as well as critical evidence that the microsocial environment offers a substantial means of insulation in contexts of societal stress, i.e. major upheaval in the outer public sphere of the social environment and even a deteriorating atmospheric environment (Hajdu et al. 1995; Watson 1995).
The anatomy of the social environment within the nation-state
How does the social environment vary between nations in ways that determine marginal differences in health status? To answer to this question, it is useful to build an anatomy of national society specifying the structural features of the environment for human development and survival. This is attempted in Fig. 5, which identifies three primary spheres of the social environment—economy, polity, and culture. In this chapter these three spheres encompassing economic, political, and cultural influences are subsumed under the heading of the social, which is taken as the comprehensive frame of analysis.
Fig. 5 Culture, economy, and polity as factors in human health.
Economy in the social environment
Economy refers to social institutions concerned with the production and distribution of livelihood and the reproduction of the population. The earliest economists (Smith, Malthus, Ricardo) were much more conscious of the fact that production and reproduction were two sides of the same coin. In the eighteenth century, demography (political arithmetic) was firmly established at the centre of economic analysis and nobody doubted that population was a primary factor of production and consumption (Rathbone 1924; Routh 1975). Their twentieth-century counterparts, focused on the international workings of the capitalist system, have long ago detached the material processes of making the next generation from their perspective of the logic of economic life. From the perspective of the public health, classical political economy is the more appropriate paradigm.
The economy includes the population organized into households and the work performed there (including procreation), the social institutions of the market and private property, the aggregate wealth of the population, including productive resources and plant in agriculture and manufacturing industries, occupational organizations, including trade unions and professions, and government legislation and regulatory agencies, including national treasuries, policy-making agencies, and occupational health and safety inspectorates. Economists use the term ‘national income’ to measure the aggregate earnings of a national economy, and sociologists use the term ‘class’ to refer to the hierarchy of wealth and income groups formed by its unequal ownership and distribution among the population. The term ‘gross national product (GNP) per capita’ refers to the value of national income divided by the number of people in the population. Measures of GNP always exaggerate average income because they assume that every one receives an equal share. In practice, the distribution of income is highly unequal in all industrial societies. Typically, a small but very rich group monopolizes a large share of national income, whereas a substantial proportion of the population receives income below the poverty standard. The last quarter of the twentieth century witnessed an accentuation of income inequality in Western capitalist societies. In the United States between 1965 and 1995, the share of total income going to the richest 5 per cent of the families in the national population increased from 15.5 to 20.1 per cent. Over the same period the upper quintile of the income distribution increased its share from 40 to 46 per cent. This redistribution to the very rich was accomplished mostly by tax-cutting measures at the expense of the lowest three quintiles. The income inequality trend in the United States is laid out in Table 1. It includes the Gini ratio, which indicates the proportion of income that would need to be redistributed to achieve parity between the five quintiles. In the four decades leading up to 1995, this increased from 0.356 to 0.426.
Table 1 Trends in income inequality among families in the United States, 1965–95
The growing research literature supporting the relative income hypothesis argues that the pattern of income inequalities laid out in Table 1 is the primary social vector of health inequality in industrial nation-states. Gravelle (1998) gives a succinct summary and critical evaluation of the relative income hypothesis.
Wilkinson (1992) regressed a combined estimate of male and female mortality on the distribution of family income for the nine OECD nations (Norway, Sweden. Switzerland, Netherlands, Austria, Canada, the United States, the United Kingdom, and Germany). He reported a correlation of 0.86 (p < 0.001) between life expectancy and the proportion of income received by the 70 per cent of the families with incomes below the third decile of the distribution. Inserting an additional control for GNP per capita increased the correlation to 0.91 per cent, enabling Wilkinson to suggest that three-quarters of the variation in longevity could be explained by differences in income inequality between the nine societies. Note the range of variations in the two correlated indices. Combined male and female life expectancy runs from about 73 to 76 years (a gap of 3 years), and the percentage of income going to the population below the upper three deciles of the income distribution varies from about 45 to 50 per cent (a range of 5 per cent). In regard to the latter, it must be noted that even in the most equal income distribution in the data set, only 50 per cent of the nation’s income goes to 70 per cent of families.
Subsequent publications by the same author and by others stimulated by his example have now produced a considerable number of papers reporting mortality–income inequality relationships of varying size and strength between both nations and states within the United States (Kawachi et al. 1999). The accumulating body of evidence has also fed a round of theoretical speculation on the utility of income inequality as an index of social cohesion and/or social capital (Wilkinson 1996; Kawachi et al. 1999). The unhealthy society thesis is relatively easy to subject to empirical test, and hence the growing body of published findings support the early claim that income inequality measures the corrosive tendencies of the social environment, although few have managed to reproduce the scale of association claimed by Wilkinson (1992). However, there are some curious features to the reported findings that cast doubt on their robustness. Judge (1995) attempted to replicate Wilkinson’s research using the same data and measures but added per capita income distribution in addition to the measure based on families. The use of per capita income greatly diminished the association between income inequality and life expectancy. For the population below the seventh decile of the income distribution, the correlation with life expectancy fell from 0.80 (p > 0.001) to 0.31 (not significant) when per capita measures were substituted for the family measure. Furthermore, still using the same data set, Judge also failed to find an association using alternative measures of income inequality such as the Gini coefficient. As Judge observes, the use of a measure of income distribution between families does not take account of differences in average family size between nations. Although Wilkinson (1995) has published a spirited response to this critique, he does not offer a persuasive explanation of why family income measures of inequality produce strongly significant associations while alternative measures do not. If the relative income hypothesis is valid and if the effect of income inequality is as strong as its proponents insist, one would expect to find robust results with all measures of income inequality on the same data set.
In this thesis, the issue is not about egalitarian versus inegalitarian societies—it is about marginal differences in extent of income inequality. The degree of income inequality varies between nation-states mainly in response to the relative autonomy of the market processes. The United States is probably the most unequal advanced industrial society, mainly because the market is a virtually sacred social institution and strong moral beliefs protect it from political intervention. Consequently, the social wage is very weakly developed. However, the general pattern of income inequalities depicted in Table 1 is a quite normal feature of all modern and postmodern industrial capitalist nations. An income distribution allocating about 5 to 6 per cent of total income to the poorest quintile and about 38 to 40 per cent to the richest is entirely orthodox.
Economic inequalities within nation-states are correlated with health and survival inequalities. The measurement of this effect over the course of the twentieth century is best reviewed using British data because the National Statistical Office established a methodology for monitoring occupational and social class mortality differentials early in the twentieth century. In these data, occupation is a proxy for income. Figure 6 charts the trend of class inequality in health in England and Wales since 1921.
Fig. 6 Trends in health inequality by social class in England and Wales, 1970 to 1993.
In 1970, there was a gap of about 7 years between the life expectancies of men classified in social class I and in social class V in Britain’s occupational class structure (OPCS 1978). This scale of inequality was nothing new, although it appears disquieting to those who expected that the National Health Service would equalize the burden of disease and neutralize inequalities in the length of life. Note how this understanding is derived from an abstract biomedical model of health. Over the course of the twentieth century, the Registrar General’s class divisions remained remarkably effective in identifying social inequalities in health, i.e. inequalities arising from the economic component of the social environment. The Registrar General’s social class scale is a sixfold grouping of occupations according to their general standing in the community. This rather imprecise mode of classification is actually based on a status definition—the volume of social prestige associated with an occupation. However, the scale is also clearly economic, it depends on occupational skills and credentials that determine the price of labour and the security of livelihood in the market. Naturally, over the course of the century the occupational structure changed significantly in response to technological innovation and the growing global division of labour, which led to the export of manufacturing jobs and the substitution of imports for home-produced raw materials such as coal. These developments changed the nature of work to a substantial degree, but they do not appear to have exerted a proportional impact on health inequalities. A government working group, convened to review progress in the health of the population in 1980, concluded that the class gap in health in Britain had probably worsened during the last quarter of the twentieth century (DHSS 1980). Subsequent research has borne out this conclusion and shown that the effect is not restricted to the United Kingdom (Marmot and McDowell 1986; Valkonen et al. 1990; Pappas et al. 1993).
Social class measures inequalities in the distribution of a nation’s wealth and annual income among the individuals and households who make up the population. It also includes inequalities in the relative cost of work to the individual worker, exposure to occupational hazards, occupational stressors, and hours of work. Class inequality has a number of forms, some more tangible than others. The most tangible is annual income and consumer power. This inequality is measured in material limitations on how people live and what kind of lifestyle choices they are empowered to make (Cockerham 1999). Related inequalities of occupational rights—protection and compensation for sickness, redundancy, and pensions—are equally important. The less intangible output of the class system is the distribution of status and prestige. The scale of differential earning and consumer power is simultaneously a scale of social worth. It denotes the value of the individual worker in the total scheme of things, sending crystal-clear messages that some are more worthy than others. Wilkinson (1996) identifies this psychosocial production of the economy as the more significant source of social inequality in health in post-epidemiological transition contexts. He suggests that hierarchical social relations arising from income inequality have emerged as the most potent source of biomedical risk in an otherwise prosperous social environment.
The economies of individual nation-states exhibit distinctive characteristics that reflect the peculiarities of their economic history, including, where appropriate, the particularities of the nation’s transition to urban industrialism. Nations may exhibit economic specialisms that reflect geographical situation, geological resources, historical circumstances, or long-standing artisan or professional traditions. Sometimes, dramatic and destructive historical events can shift a national economy in new directions. This was the fate of Germany and Japan following their defeat in the Second World War. Both nations were brought to their knees by the combination of their own military ambitions and the subsequent Allied assault, leaving their industrial infrastructure severely damaged. As both were prevented from redeveloping their military capacity, their respective postwar programmes of technological research and development favoured the production of consumer goods in which they became global leaders. The victor nations (particularly the United States, France, and the United Kingdom), freed from the same restrictions, continued to put a premium on weapons research, ensuring that military production organized through highly developed capitalist industries remained a strong focus of the economy in these nations. The international arms trade is a highly profitable sphere of global capitalism with definite health and survival implications for national populations worldwide. The governments of less-developed nations are prolific consumers of Western armaments which are frequently used to police the nation-state and repress political opposition. The public health consequences of the international arms trade is a very important feature of global health inequalities. It enjoins the profits and material living standards of people engaged in armament production in prosperous nations with the death and disabilities endured by their deployment in less stable parts of the global social environment.
In a modern urban industrial nation, the economy is not autonomous; its operation is subject to forces emanating from the international capital market. Consequently, like a tsunami wave, economic events and trends on one side of the world can have knock-on effects on the other side where they are felt in the form of shifts (up and down) in the cost of living—in food, rents, interest, and wages. The international organization of economic life is a reminder that capitalism operates without consideration for the circumstances of individual nation-states. This may be one reason why reproductive issues have been removed from the economist’s consciousness and relocated in a separate discipline—demography. The separation of society’s two economic functions—production and reproduction—is a product of the individuating tendencies of industrial capitalism. It constitutes the critical flaw of capitalism as a model of effective organization of material existence within modern societies (Polanyi 1946).
The capitalist labour market is oriented to individuals rather than households. This feature has fuelled the enormous increase in personal autonomy experienced during the short but tumultuous history of capitalist civilization. Capitalist enterprises employ individuals, and the wages that they pay makes no allowance for the employee’s household and family responsibilities. A single adult with no children earns the same as a married man or women with any number of dependents. The same effect is witnessed at the level of the nation-state; the capitalist market contains no institutional mechanism to articulate the nation’s vital processes with its livelihood. Procreation is obviously a vital social function. The maintenance of a flow of people through the social fabric is a sine qua non of societal continuity. In precapitalist societies, production and reproduction were not distinguished. The household economy performed both social functions, and norms of kinship reciprocity made grandparents, parents, and children mutually interdependent.
Demographic historians have revealed how pre-industrial economies regulated the demographic process to protect the material conditions of existence. In England, this was achieved by severe sanctions against unmarried procreation and by varying the age at marriage. Late marriage age shortened the child-bearing career of the married female and operated as a preventive check on the rate of fertility (Wrigley and Schofield 1982).
The utilitarian logic of market capitalism is ultimately corrosive to the norms of family solidarity that underpinned the old procreative regime and wove it seamlessly with the livelihood system. The lack of any arrangement to orchestrate procreation with economic life goes unnoticed in capitalism’s early development. In the short to medium term, the old cultural imperatives continue to propel men and women into marriage and procreative ventures. Over the long term, the old norms are eroded as the individual wage worker emerges as the free agent of his or her own destiny, and as public and private pension schemes replace the expectation that the elder generations can rely on material support from the younger generation in old age. This development fundamentally shifts the motivation for procreation replacing utilitarian logic with expressive sentiment, undoubtedly a less certain base for population replacement.
Child bearing and child rearing represent substantial opportunity costs in the adult female life career and, given the increased fragility of marriage (Fuchs 1988), women cannot count on the unfailing future support of the father to shoulder the labour requirements of parenthood and to fund the considerable additional expenses of bringing a child into the world. This is part of the explanation for the declining popularity of marriage and the falling rate of fertility that has accompanied women’s incorporation in the labour force in recent decades. Ironically, the same process brings about a revaluation of children and childhood, which some observers include among the causes of the industrial era’s health revolution (Shorter 1976; Zelizer 1985; Sagan 1996).
Analysis of the health consequences of the vital flaw in capitalist society is underdeveloped. Statisticians working within the social medicine tradition have relied on measures of social stratification based principally on male occupational life. In doing so, they accepted the reality of patriarchal power and the argument that the level of the breadwinner’s wage was the primary determinant of household well being. The weakness here is the assumption of undifferentiated size. Material well being at home depends crucially on the ratio of people to space and resources. A manual worker’s wage packet goes much further in a household of four than it does in one of eight. The size of the sibling group is a major factor of household living standard; it has never been properly represented in the measurement of class inequalities in health. The force of this criticism has strengthened in the second half of the twentieth century as rising rates of marital dissolution fuelled the contiguous rise of single parenthood. This demographic development spells economic hardship for a sizeable proportion of the female and child population; it underlies the trend towards the feminization of poverty in the recent decades. The health consequences are very substantial. A recent study carried out among lone parents in Sweden reported a 70 per cent excess mortality rate among women rearing children alone (Ringback Weitoft et al. 2000). That a differential of such scope was reported for Sweden, whose welfare provision is more generous and more people friendly than any other nation, testifies to some highly negative contemporary trends that have never received the attention they deserve in the health inequalities literature.
Polity in the social environment
The impact of the forces of market capitalism upon the livelihood and procreation of a national population is mediated by government policies represented as polity in Fig. 5. Polity includes the apparatus of government, including the legal system, the institutions of economic management, and the welfare state (education, child care, health care, social security). In democratic nations it also includes political parties and associated ideologies and policies of citizenship and social justice. The political consciousness/activism of a national population is a further resource of the social environment setting the probability for popular activism over citizenship and other vital issues of everyday life. Citizenship refers to the claims (legal, political, economic) that individuals make of the nation-state, and there is huge variation in its content across the global universe of nation-states. Among modern democratic nations, there is more variation in the content of economic, than of legal or political citizenship. While the latter respectively guarantees equality before the law and the right to vote (both are universal features of the world’s mature capitalist nations), the former involves the guarantee of livelihood.
Economic citizenship refers to state recognition of the individual’s right to income maintenance and other basic components of living standards such as health care. There is considerable national variation in the institutional mechanisms of economic citizenship. In the aftermath of the Second World War, most Western European nations developed a welfare state apparatus that involved establishing policies to protect individuals and households from impersonal market forces. It has often been observed that the vanquished nations in the First and Second World Wars got revolutions, while those connected with the winning side got welfare states (Mann 1993). Revolutions happen when ruling elites lose their credibility and/or when the population is mobilized, even armed, and motivated to capture the apparatus of the state. These conditions were met and played an important part in the Russian Revolution. The Russian example explains why warfare represents a vulnerable interlude for ruling elites and why the military is a formidable political force in politics in less-developed societies.
Revolutionary situations are very infrequent in developed societies. When they do occur, the opportunity may arise for a complete overhaul of the social environment. The opportunities for introducing even partial societal reform are also infrequent and connected to major national emergencies such as occurred during the First and Second World Wars. It is no accident that the impetus not to merely talk about but actually to create the institutions of the welfare state can be dated to the 1940s. In pacific times, the chances of achieving major reforms of the social environment are far less. The welfare state developments of Western Europe represent a constrained reform of the social environment, designed to protect the populace from the harsher economic effects of market capitalism without banning the system altogether. As a Marxist analysis would put it, they represent the ransom paid by the ruling class to allow the capitalist system to continue.
By the early twentieth century, the necessity for public intervention to regulate the effects of capitalism within national economies was keenly appreciated. It was associated with a growing critical literature on the limitations, indeed potential long-term non-viability, of capitalism. In this era, the sphere of economic policy was necessarily widening, partly through the roller-coaster tendencies of international capitalism and partly through the pressure of the newly enfranchised working class. This was the era of the Great Crash (another major disruption), which was for many a sure sign that capitalism was on its knees. It was also the social environment in which the English economist John Maynard Keynes forged his economic theory of capitalism and his plan to save it from self-destruction (Skidelsky 1994). His intervention was timely for, although the closing quarter of the nineteenth century saw an unprecedented increase in living standards, by the 1920s an expanding electorate was acutely aware that capitalism was an extremely risky mode of population livelihood (Garraty 1978). Many had first-hand experience of the fact that exclusive dependence on wage and salaried income and on the market for the purchase of basic subsistence, left nothing to fall back on during times of economic recession and unemployment. Before the welfare state, periodic capitalist recession produced significant subsistence crises for a large part of the working class. Keynes’s solution to this inherent problem was to fashion the tools for government and multinational organizations to manage actively the capitalist economy both to save it from itself and to guarantee population livelihood. The management of the forces of capitalism within nation-states is a central purpose of government and the various institutions of the welfare state were designed to remove important areas of human well being, such as health from the pressures of market distribution.
The institutional structure of the welfare state is a fundamentally important part of the social environment in the mature urban industrial societies of Western Europe. It represents a halfway house to socialism—a series of mechanisms for guaranteeing individual livelihood and for safeguarding procreation within economies articulated to international capitalism. The guarantee of livelihood through the regulation of market forces within individual nations takes several forms. First, governments take responsibility for managing the business cycle to control the rate of economic growth, to balance the forces of supply and demand, and to protect national economic institutions from the winds of the global capitalist market. This is the preventive side of government policy. Ironically, nowadays it sometimes involves stimulating unemployment in order to cool an ‘overheated economy’, a solution unthinkable to earlier generations of politicians and populace with memories of the Great Depression. Other preventive policies orchestrated by the state are connected with maintaining the flow of and ensuring the subsistence needs and health of the population.
Most developed industrial nations have some sort of state-sponsored comprehensive health care system providing such services as family planning, prenatal care, obstetric assistance, and paediatric health care. These services developed in rudimentary form during the early twentieth century when the risk of infant death was as high as 1 in 10 even in the most prosperous nations. The development of infant welfare services was promoted by social reformers partly in response to eugenic speculation that the ‘quality’ of the race was being diminished by class-specific fertility decline and partly in response to sociomedical surveys charting the associations of infant mortality with poverty and low income (Dworkin 1987). The impulse for state intervention was the desire to improve the quality of the ‘race’ and in particular the nation’s manhood. This was era when European governments were still quite prepared to sacrifice significant numbers of young men in military campaigns.
The nation-state’s interest in promoting the developmental potential of the next generation is also manifested in publicly funded education. Compulsory education is a universal feature of urban industrial societies. In most places it came on to the statute books around the turn of the twentieth century partly in response to a felt need to educate recently enfranchised working-class voters. Reformers may also have been aware of the social control functions of schooling (keeping children off the streets and out of mischief), quite apart from its utility as a means for improving the literate and other skills of the work force, i.e. increasing the educational capital of the nation.
State intervention in the fields of both education and health care, whatever the ulterior motives, represent a significant investment in household living standards and a major opportunity for the state to play a part mitigating the impact of the market on the stratification order. Routh (1987) drew attention to early state initiatives in Sweden to eliminate unskilled occupations by actively promoting manufacturing firms that rely on skilled labour.
This ‘active labour market policy’, also known as the Rhen–Meidner model, was Sweden’s own version of Keynesian economic management. It involved a permissive orientation to strong wage pressures designed to put low-wage firms out of business. Coupled with well-funded state-sponsored relocation and retraining packages and with state-subsidized credit for ‘go-ahead’ firms, it maintained full employment and worker flexibility in the postwar decades. The right to a job was recognized by the state, but not the right to remain in a current regressive occupational situation (Esping-Anderson 1990). The trade unions in concert with the government pledged to reshape the occupational hierarchy by eliminating the lowest rungs of unskilled work and upgrading the occupational status of the entire work force. This remarkable redesign of the occupational structure called for collaboration between the state, the employers, and the trade unions, which might only have been feasible in a Scandinavian social democracy or possibly in corporate Japan (Dore 1987).
The curative side of government’s management of the economy involves distributing state benefits, pensions, and payments as substitutes for earned income and/or savings and insuring individuals and households against the threat of unemployment or other economic/health crisis. Social security is the general term and, except for the United States, it is also articulated within a state-sponsored system of comprehensive medical care. Social security and medical treatment have been interlinked in economic citizenship because ill health was always considered a primary cause of short-term unemployment and loss of earnings. Policy-makers reasoned that by providing free medical treatment and maintaining households through the economic crisis of illness, they could put an end to the relationship between disease and poverty. The classic statement of this relationship is found in the Beveridge Report which is the design document of the British welfare state. The National Health Service was the jewel in the crown of Britain’s welfare state, although disillusion had set in by the last quarter of the twentieth century. Additionally, the health care system played a social control function certifying the legitimacy of sickness and eligibility for compensation. Existing welfare states were designed during the closing decade of the era of infections, when people still understood disease as an acute and reversible episode.
Nation-states vary significantly in the scope of their social security provision and in their willingness to allow spheres of the social environment to become commodified, i.e. defined as fair game for capitalist enterprise. This represents the variable content of economic citizenship, i.e. the social wage, between nation-states. The social wage is the value of goods and services distributed by the state, outside the market system. It is designed both to remove services which are vital to human development, such as health and education, from market processes of distribution and to insure households against the risk of unemployment and loss of earnings through sickness and retirement. International variation in the value of the social wage among industrial nations tends to reflect divisions of contemporary economic morality and political culture as these emerged from democratic struggles between social classes and other groups in the early industrial era. These struggles were a central factor of the historical development of the social environment in different nations, and as such there is a degree of stability in the way national governments are disposed to exercise their policy-making powers. It might be said that the contemporary politics of (especially economic) citizenship is the lasting legacy of the way class conflict was ‘institutionalized’ in different parts of Europe in the first half of the twentieth century.
Esping Anderson (1990) has identified three types of ‘welfare state regime’ among advanced industrial nations: liberal welfare state, corporate-statist welfare state, and social democracy.
The liberal welfare state is targeted on the poor and offers a minimum means-tested safety net with some modest universal benefits. The principal intention is to uphold the work ethic and protect the sanctity of the market mechanism. Consequently, the benefits distributed are associated with public charity and stigma rather than social rights. Liberal systems also typically extend tax benefits for private welfare provision to create market incentives for the development of profit-oriented welfare schemes such as personal equity plans. The aim is to reinforce the norms of personal initiative and self-sufficiency. The archetype is the United States, with Australia, Canada, and the United Kingdom not far behind.
The corporate-statist welfare state emerges from within pre-existing strong large states. The word ‘corporate’ refers to the distinctive groups or elites, such as the church, the military, and the bureaucracy, which are incorporated and wield power within the state apparatus. The welfare policies that follow preserve the interests of groups represented in the state and therefore preserve the status quo rather than serving as a force for equality or progressive change. Thus redistributive impact is minimal, and benefits are distributed in forms that protect existing institutions such as the church and the family. The principle of subsidiarity (i.e. state intervention only when the coping capacity of traditional institutions such as the family is exhausted) is a dominant feature of welfare policies of this type, but the association of benefits with charity is not so pronounced or stigmatizing as in the liberal regime. These regimes are found in the Catholic nations of Austria, France, Italy, Germany, and Spain.
The social democracy model of the welfare state is a peculiar fusion of liberalism and socialism, i.e. it promotes both freedom and equality (Esping Anderson 1990, p.2). The liberalism part is the goal of increasing individual choice and independence. These welfare states strive to offer women, in particular, the right to choose paid work over the household; consequently, they support a large social services sector—indeed, the very process of extending choice to women supports a huge job creation programme of new occupations to replace the labour lost in women’s retreat from the private sphere. In effect, this development is a means of commodifying (paying for) domestic labour as women primarily take advantage of the new employment opportunities in child care and elderly care work. In their encouragement of employment, this type of state regime may also be described as a fusion of welfare and work.
Figure 7 compares the social class distribution of infant mortality in Sweden and in England and Wales to illustrate the potential health consequences of different welfare state regimes. In Sweden, a social democratic regime is associated with a virtual absence of class inequality; in England and Wales, a liberal regime preserves the familiar gradient along with the class inequalities which underpin it (Vagero and Lundberg 1989; Leon et al. 1992).
Fig. 7 Infant mortality in Sweden and England and Wales.
Social democratic regimes ‘pre-emptively socialize the costs of family-hood’ (Esping Anderson 1990). In other words, they may be thought of as supplying the missing link between the logic of production and reproduction. In so doing they also sponsor female autonomy and redistribute resources from men to women and children as well as between the classes. There is no lingering association with public charity. Welfare benefits are set at middle-class standards of consumption. The aim is to level up and to unite the interests of all in the concept and practice of the social wage. A single social insurance system covers the entire population. This crowds out the market and reinforces a broad consensus in favour of state benefits which are widely perceived as universal social rights. The home of this type of regime is Scandinavia—it includes Sweden, Denmark, and Norway.
The three forms of welfare state regime represent different approaches to the need to compensate individuals, families, and households from the limitations of the labour market as a livelihood system. Their geographical distribution in Western Europe suggests that common cultural elements may have played a part in their foundation. Half a century or more after their establishment, the expectations that they have encouraged in the populace are now an important feature of the politicocultural landscape of Europe, acting to shape the level of political consciousness, the terms of political debate, and the mobilization of popular opinion behind government policies.
Culture in the social environment
Culture encompasses the way of life of a social group. It includes the symbols and tools of communication (linguistic, musical, artistic), the technology of communication and of livelihood, cuisine and culinary traditions, mode of dress, the method and style of construction, religious, moral and political beliefs and values, the ethics of interpersonal relationships, healing ideologies and practices, and marriage and kinship norms. The term ‘ethnicity’ is sometimes used interchangeably with the term ‘culture’ to refer to the defining characteristics of a social group or population, and there is a tendency to associate both terms with traditional folkways, although culture is now emerging as an important theoretical concept of modern sociology. Ideologies of gender and race are included under the heading of culture along with the norms of social relationships they prescribe. The latter may involve more or less overt forms of discrimination, which when accompanied by power differentials produce an axis of social stratification.
The measurement of gender inequalities in health in contemporary societies can be tricky. In a pre-industrial or industrializing social environment, the sex differential in mortality typically varies over the course of the lifetime. There is a substantial excess of male mortality in infancy and after middle age; female mortality is higher in childhood, adolescence, and during the childbearing years. This pattern is still typical of many less-developed societies where even the female infancy advantage is reversed. It disappears as a society modernizes. Excess male mortality becomes the statistical norm at all ages in a pattern that is found in all modern societies. With the evidence of historical hindsight, it may be deduced that the excess mortality of girls and young women in earlier eras and in contemporary pre-industrial populations is the product of social discrimination in favour of males. This judgement emerges from examining sex differences in survival among well-fed industrial populations where excess male mortality of at least 30 per cent is found in every age group. How other than through systematic differential female neglect could the apparent sex advantage be neutralized in former times? The usual answer to this question is childbirth. The ‘natural’ risk of maternal mortality is popularly and even professionally conceived as taking a huge toll of life before the emergence of obstetric medicine and procedures. In evoking a biological cause, this judgement equals sex not gender. It implies that the female body is a poorly developed instrument of procreation and that very large numbers of women lost their lives giving birth before the advance of modern obstetric medicine.
The contribution of maternal causes to female mortality before 1950 was much greater than it is today, but it was not large enough to explain the adverse ratio of female to male mortality in and before the nineteenth century (Schofield 1986; Loudon 1992). Nor could it explain the excess mortality of female infants and children. These unexplained features highlight the possibility that cultural norms of differential female neglect/deprivation might have underlain the typical pre-industrial pattern of sex mortality differentials. This is steadily eroded by the advance of industrialization, giving a strong impression that rising living standards impacting directly on the developmental growth processes of infants and children is the primary factor of change. If this is correct, the corollary is that pre-industrial norms of allocating nutritional resources within households may have systematically favoured male over the female offspring. The longer-term implication of these norms would be the impoverishment of the procreative prospects of the community, for the vitality of future generations depends on the growth chances of the female. In evaluating this cultural interpretation of sex mortality differentiation before the modern era, it is worth bearing in mind that we are not merely seeking to explain an absence of parity in childhood mortality risk, but a systematic reversal of what appears to be a ‘natural’ female advantage. A typical sex mortality differential among infants in an industrial population is 1.3:1 in favour of the female. The reversal of this advantage in conditions of nutritional scarcity strongly implies preferential male treatment. The probability that this was an important underlying cause is strengthened by our knowledge of sex-divided patterns of infant feeding and maternal care in pre-modern cultures of the twentieth century.
The foregoing interpretation is the leading example of gender as a factor of public health (Sen 1981; Shorter 1982). It is a routine sociodemographic feature of many less-developed societies. Differential female neglect, female infanticide, and even ‘woman/widow slaughter’ produce skewed sex ratios in a number of pre-industrial and industrializing communities today (Table 2). The effect of the unequal evaluation of the two sexes is not merely reflected in differential survival among the living but also makes its mark upon indices of reproduction—in particular, on fetal and infant mortality as the nutritional well being of the female child is an important factor of population health status. Gender discrimination in the allocation of food during the first decade of the lifetime results in a pattern of nutritional stratification within households, with serious implications for female childhood growth and later for fetal life chances (Barker 1994). Eliminating this situation does not necessarily require a feminist revolution, i.e. a rewriting of cultural norms to eliminate gender preferences. It can be accomplished through a systematic improvement in the conditions of nutritional status of the community as a whole. The cultural norms of male preference remain intact, but are they no longer manifested in nutritional status for as material scarcity gives way to sufficiency, if not affluence, male infants and children emerge as the more vulnerable sex with excess mortality rates of about 30 per cent. It is also possible for health status to improve even in the absence of material abundance if the ideological norms of gender inequality are reduced. This happened in Kerala, where a communist regime emerged from the collision of an indigenous matrilineal and a colonial patrilineal system. The British attempt to impose patrilineal legal rules on a matrilineal people in the early twentieth century acted to politicize the community and stimulated the establishment of a communist administration, which brought about a modern health revolution in a largely peasant society. Kerala is not among the most prosperous regions of India, but it is the healthiest and the female population is the most literate. In Table 2 the distribution of selected health status indicators in India during the 1990s shows just how powerful gender remains as a source of health stratification. Note how the sociodemographic profile of Kerala has more in common with a modern industrial society than with her territorial neighbours.
Table 2 Selected health status indicators for India
Race is another powerful cultural source of health inequality and, like gender, it is often thought of as a biological phenomenon (McBride 1991). The race differentiation of the human species in the twentieth century is the cultural product of late eighteenth- and nineteenth-century scholarship (Stepan 1982). The Oxford English Dictionary defines race as a social group descended from a common ancestor. Before the eighteenth century it was commonly used to designate class or status differences within a population. The inbred aristocracy of Europe perceived themselves as a branch of humanity set apart from the common people, whom they saw as a separate inferior race. Race became an anthropological classification during the nineteenth century as anthropologists in Darwinistic mode devised a definitive taxonomy of the human species (African, Asian, Caucasian) based on their continental origins and denoting their phenotypical characteristics. From within their European evolutionary perspective, the peoples of other continents were seen as weaker or inferior versions of humanity along a continuum of evolutionary progress. This was the ideological core of the great eugenic delusion; its legacy is racism, both pseudoscientific and popular. Today even the word race is blighted by association.
Race is perhaps the most powerful source of health inequality. This is true internationally and intranationally. If we operate with a continental racial division of humanity, the gap in life expectancy between different races is as much as 20 years. Within an industrial population containing significant representation of people with the same racial heritage, the survival gap is narrower but still the single most important source of health stratification. Table 3 lays out the key health status indicators for the six continents in 1996.
Table 3 Infant mortality and life expectancy in the global community in 1996
In a global perspective, the vital rates of Africa are the most disadvantaged. At the end of the twentieth century, life expectancy at birth is little more than five decades about the level achieved by northwestern Europe in 1900. African males were 11 years below the world average in 1996, and almost 20 years below the peoples of Europe and North America. The gap between Africa and the world’s most prosperous regions is even wider for females. The mean global level of female life expectancy in 1996 was 64.7 years, African females were 12 years behind, compared with the European female average, they were 25 years below. These huge differentials are fundamentally associated with global inequalities in social and economic development, with political unrest, internecine ethnic struggles, civil war, and genocide. In the last quarter of the twentieth century Africa has also emerged as the epicentre of the global AIDS epidemic, an outcome which Hooper (1999) has linked to an anti-polio campaign, which dispensed a million experimental oral vaccines partly developed from chimpanzee kidney tissue.
The widespread administration of an experimental oral vaccine would not have been contemplated in a European population. In Hooper’s (1999) gripping story of the possible connections between AIDS and European/North American public health efforts to develop an oral anti-polio vaccine in central Africa, researchers/practitioners clearly relaxed the standards they would have observed had the client population been European or North American. If Hooper’s persuasive account proves correct, this would represent the most devastating case of medical negligence in human history.
By the end of the twentieth century, a rate of life expectancy of about five decades was highly atypical because by then most nations had traversed the epidemiological transition. That the peoples of Africa had not yet negotiated this watershed of health history must mean that the benefits (technological and material) of human progress had not been shared with this significant fraction of humanity. The observation does not hold for all social groups who live in Africa. The white farmers of East and South Africa descended from European settlers of the nineteenth and early twentieth centuries record life expectancy on a par with the contemporary European average. They inhabit the same ecological terrain as their African farmworkers but their life chances have kept pace with the European norm and are a century ahead of their black fellow citizens. The gap is a measure of the relative social and economic advantages of Africa’s white former immigrant communities and it is testimony to the plasticity of human health and its responsiveness to relative economic and social well being.
By the end of the twentieth century, the population of the United States contained significant subpopulations of each of the global branches of humanity making it an appropriate context for measuring race inequalities in survival. Figure 8 charts race and sex differentials in survival in the American population in 1996 revealing the enormous gap in life chances between males and females of African-American descent and other races. Black males record the largest mortality excess but the chart also reveals a striking divergence in health between black females and white males. In every industrial population, male longevity lags behind female longevity by more than 6 years. In the United States race inequalities neutralize this socio-demographic universal, the life expectancy of a black female is approximately the same as a white male, an overall effect produced by disadvantaged mortality rates during the prime of life. The width of the gap in survival between black and white American citizens has changed relatively little during the course of the twentieth century. Black Americans lived for an average of 33 years in 1900, white Americans lived to a mean of 48 years. This was in the tubercular era, the early evening of the epidemiological transition. During the course of the twentieth century, the rate of mortality risk fell in both populations, principally through improvements in infant and child survival and through the continuing decline of infectious disease. Amidst all this progress, the gap between black and white persisted. The twentieth-century American longevity trend contains a simple but important empirical proof. It shows that race life expectancy differentials are not the product of eugenic potential, as they would have been conceived in the sociomedical racist ideology of 1910 (McBride 1991). Beginning from a lower level, African-Americans made relatively more progress in longevity during the last century. By 1996, they were approximately 15 to 16 years ahead of their ancestral populations in Africa but they remained 10 years behind their white compatriots. Once again we see the plasticity of human health and survival and the close correspondence between the social and economic standing of a racially defined population and its measured health status.
Fig. 8 Sex and race mortality differentials in the United States, 1995.
To a significant degree, the historical experience of African-Americans has been like a nightmare from which the group has only recently awakened and whose aftershocks are still felt in varying degree. During the twentieth century, African-Americans have made immense progress in the political struggle for social equality and in the process have dismantled institutional apartheid in American society. The Civil Rights Movement of the 1950s and 1960s is probably the most effectively organized and successful political struggle of American history and its long-term effect has been to diminish racist ideologies in the conduct of social life. However, the long shadow of race discrimination in the educational and occupational structures of American society has left an indelible mark on a large proportion of the African-American population, to which the continued gap in survival chances in Fig. 8 bears testimony.
Figure 8 also shows other significant race mortality differentials in the American population, which cannot be simply attributed to economic inequalities.
Other than in the black population, socio-economic race differentials in the United States census are not correlated with the pattern of mortality differentials in Fig. 8. The average income in the Asian and Hispanic populations is below the average white income.
Peoples of Asian descent in particular exhibit highly favourable health status. Compared with the continental averages displayed in Table 3, Asian-Americans are 12 to 15 years ahead of the population of Asia and they are as healthy as, if not healthier than, people who claim a ‘white’ racial heritage in the United States. This pattern suggests that health status is not a simple product of material living standards. Asian-Americans, principally Chinese and Japanese, are often depicted as the model minority of American society. During the twentieth century they have experienced upward mobility as an ethnic group overcoming institutional racism and discrimination, which was entrenched during the first half of the twentieth century, culminating in the internment of Japanese-Americans during the Second World War. During the closing decades of the twentieth century, the Asian-American population emerged at the top of the key indicators of achievement—life expectancy, education, occupation, and income. More recently, the population has become more diversified through the incorporation of immigrants from the Philippines, Laos, Vietnam, and Cambodia. This has tended to narrow the achievement gap between Asian-Americans and white Americans, although, even in its new diversity, the Asian-American community continues to stand out as the healthiest in the United States.
The social ascent of the Asian-American community as a whole suggests that economic factors on their own are not a sufficient determinant of above average health status. It is not a matter of explaining why selected talented people achieve above-average success; something is propelling the entire group towards greater prosperity, higher living standards, and longer life expectancy. This factor is clearly a property of the group norms falling under the heading of cultural or lifestyle factors. These include strong kinship solidarity, low divorce rates, stable family life, and a high value placed on education. These features of Asian-American values and lifestyle may be important preconditions for individuals to take advantage of opportunities in the American labour market, and they may exert equivalent influence over health and wealth.
The populations of modern industrial nations are seldom composed of a single ethnic group or characterized by a uniform homogeneous culture. Although the formation of the national state itself exerts a pressure towards national solidarity, shared identity, and therefore cultural uniformity, the survival and coexistence of a number of distinctive cultures is quite feasible. In recent decades, growing tolerance of cultural diversity has made it easier for ethnic subcultures to persist at least in some limited sense in mature nation-states. In newly emerging nation-states establishing their identity, the opposite conditions prevail and are manifested in ferocious struggles of ethnic cleansing with portentous public health consequences.
Cultural beliefs and practices, even within an ethnically homogeneous population, are the product of historical experience and frequently incorporate a diverse collection of other people’s technology, food, language, and ideas. The English language is a blend of Germanic, Romance, and other languages. The Japanese use Chinese Kanji as their written script. These examples represent centuries of acculturation occurring through processes of migration, assimilation, trade, and conquest. Culture is clearly a blended historical phenomenon, and in the modern era the global pressure towards cultural uniformity is immense. It is felt most strongly within industrial nations fully articulated into the international capitalist economy, although virtually no corner of the globe is now immune to its influence. Culinary culture, the conception of what is good to eat (Harris 1985), reveals the enormous impact that global capitalism has exerted on the material culture of peoples worldwide. As diet is also a leading medical risk factor for universal disease, it provides an appropriate vehicle for illustrating what is involved in the relationship between health and culture.
The European diet, although regionally distinctive in many ways, has undergone a complete transformation in the modern era principally through the import and incorporation of New World foods. Although the voyages of the conquistadors were primarily stimulated by the quest for precious goods—gold and spices—the main material bounty brought to Europe, and thence to the rest of the world, was new crops, especially maize and the potato. New World staples, along with stimulants and narcotics, completely transformed the culinary and drug cultures of nineteenth-century Europe with important health and social implications in both the short and long term (Schivelbusch 1992). Today, tobacco is the single most important medical risk factor and it is worth reflecting that its consumption in Europe has a social history. The production of tobacco, along with sugar and cotton, bound the fate of the European industrial working class to that the indigenous peoples of America and Africa who were killed off and/or transported as slave labour to make way for and to work the plantations of the New World (Mintz 1985). This is one foundation of the urban industrial social environment that receives little attention in the contemporary debate on health disparities.
Diet and culinary traditions provide a good example of both cultural flexibility and inflexibility. The tomato is the defining ingredient of Italian cooking, which we think of as the immemorial ubiquitous ingredient, yet it only truly entered the cuisine in the nineteenth century (Toussaint-Samat 1994). The pomodoro appeared in Italy in the sixteenth century but its use was confined to a salad vegetable (as it remained in northern countries). It took more than two centuries for this highly nutritious and health-promoting fruit to be made the central ingredient of the cuisine. Even more surprising is the length of time it took for Europeans to latch on to the potato. Only the Irish quickly appreciated the nutritional and technological advantages of the New World crop, although they would later pay a heavy price for their cultural flexibility (Salaman 1949).
Irish agriculture became a virtual monoculture. The potato provided an economic rationale for subdividing land and maintaining rural communities at a very basic subsistence level. The consequence was a subsistence crisis of worse than medieval proportions when Phytophthora infestans destroyed the entire crop in 1845, with knock-on effects in the following years. There were as many as a million deaths in Ireland from the potato blight, which swept across Europe causing economic distress in all poor communities that had developed a dependence on the potato. The best source on the history of the potato is still Salaman’s History and Social Influence of the Potato (Salaman 1949, pp. 188–345). The best historical image of the potato as a food of the poor is van Gogh’s painting The Potato Eaters.
Elsewhere in Europe, the suspicion that potatoes were poisonous (it belongs to the same genus as the deadly nightshade) held fast for a number of centuries. Although it was grown as an ornamental plant and consumed as a delicacy by the rich, it did not become a field crop for human consumption until the late eighteenth century in most places. Slowly the potato caught on, first as animal or prison fodder, and then as a food of last resort in famines and among the poor. By the early twentieth century, the potato was a central feature of the urban industrial diet in northwestern Europe; its intensive cultivation saved the British population from food shortages during Hitler’s blockade of transatlantic trade in the Second World War (Salaman 1949; Drummond and Wilbraham 1994).
The culinary cultures of industrial peoples have been further revolutionized in the last 50 years through international trade and investment. Fast-food and convenience food industries have transformed the content of meals and the manner of their preparation and consumption. In North America especially, the act of eating has been increasingly detached from its social context and broader purpose, and reduced to a functional activity that may be combined with other tasks in a tight time budget. In the process, not only food but the act of eating itself has been turned into a commodity, a thing to be bought and sold, stripped of its former commensal functions. The driving force in the dissolution of traditional culinary culture is the profit motive. Capitalism grows and prospers by invading and commodifying realms of social life previously outside its orbit. In the case of food and eating, its success is partly predicated on other processes detaching individuals from reliance on primary groups for the provision of daily subsistence. It is not all plain sailing. In recent years a significant backlash against the industrialization of food has emerged, especially in Western Europe. Consumers evince a growing mistrust in the wholesomeness and even safety of food. The ‘mad cow disease’ panic in the United Kingdom did much to undermine trust in both scientists and government, and has left a strong anxiety about ‘unnatural’ interventions in the food chain. Currently, the focus of this anxiety is genetically modified food.
The power of the capitalist mode of production as a force shaping and reshaping cultures of consumption is an appropriate example for illustrating the links between daily practices that influence health and currents of change emanating from the social environment. Most of the important medical risk factors that physicians have isolated as causes of disease are drawn from commodities purchased for daily subsistence and mood management. The forces directing modern food and drug cultures have a global propulsion. McDonald’s sets the standard of modern food and eating from Budapest to Beijing, from Marrakech to Moscow. It is an illusion to believe that the decision to maintain or adopt a nutritious diet is simply a matter of rational choice on the part of the well-informed and appropriately educated consumer. As Harris (1985) puts it: ‘Food must be good to think as well as good to eat and the global food industry makes no attempt to disguise its interests in shaping the perception of style in the matter of food and eating’.
Some nations appear to have been more successful than others at insulating traditional food cultures from the rationalizing forces of market capitalism. The Japanese diet is frequently held up as a food tradition especially suited to the needs of modern sedentary human (Marmot and Davey-Smith 1989), as is the Mediterranean diet (Spiller 1991). Both are claimed to diminish the pace of industrialism’s leading universal disease—cardiovascular degeneration. Interestingly in both contexts, consumption of other seemingly dangerous commodities—cigarettes and alcohol—run directly opposite to modern health recommendations. The drinking culture of Japan has been held up as a stress-reducing strategy. Matsumoto (1970), searching the social environment for reasons for the low rates of coronary heart disease in Japan, settled on the consumption of sake in group settings:
Drinking together remains for the Japanese an indispensable means of creating group intimacy accompanied by the greater release of emotions from everyday formalities. a man who will not partake of alcoholic drink with the group is one not to be trusted. (Matsumoto 1970, pp. 22–3)
This feature of Japanese culture is hardly unique. The same pattern of male sociability organized around the consumption of alcoholic beverages was widespread in Protestant Europe in the nineteenth and early twentieth centuries and remains intact in Eastern Europe, especially Russia, where it is currently seen as the principal proximate cause of the dramatic descent of life expectancy during the last quarter of the twentieth century. The drinking culture of northwestern, i.e. Protestant, Europe was reformed between 1850 and 1950 through an effective temperance campaign, which eventually forced legislation controlling the sale and consumption of alcohol. The Temperance Movement was an international phenomenon, principally located and successful in Protestant nations, and aimed at extending the new cultural values associated with the Protestant work ethic and sobriety to the male working class. Its ultimate success was connected to a number of other economic and cultural changes and also to a technological innovation—a machine for the mass production of cigarettes. Between 1870 and 1930, a substantial decline in the consumption of alcohol in Britain was matched by a concurrent increase in the consumption of cigarettes (Hart 1989a).
Cultural change with significant health consequences can occur in response to both external and internal pressures, and there may be both winners and losers from the process. In Britain, the declining consumption of alcohol by men may have resulted in less domestic violence and a strengthening of family finances with women and children as the principal beneficiaries. To the extent that it was also associated with the rise of smoking in men, the long-term effect may be measured in the rising trend of lung cancer and other smoking-related disease.
The reform of Protestant men’s drinking culture was a multifaceted process with a number of unintended consequences. If Matsumoto is right about Japan, one negative effect may have been to deprive the industrial male working class of a primary stress-reducing strategy. To an important degree this might be construed as the manifest intention—the imposition of a sober rational model of masculinity dedicated to his work. As Ehrenreich (1983) points out, the coronary-prone personality identified by American cardiologists in the mid-twentieth century bears more than a passing resemblance to the model of manhood associated with the Protestant ethic (Friedmann and Rosenhan 1968). This observation highlights the interwoven character of cultural forms, in this case gender relations, the organization of work, and patterns of narcotic consumption. It also reveals that cultural change occurs through initiatives in the political and economic realms and with the consent of the primary groups that orchestrate everyday life. In so doing, it changes the patterns of relationships within those groups.
Culture is an important feature of the social environment. It influences health in a number of ways. These include the following: religious beliefs and commitments shaping procreative ideologies and household formation; kinship sentiment, marriage, and the role of the family in processes of social support; industrial culture and the tenor of relationships in the workplace (Dore 1987); political culture and the differential insulating powers of welfare state regimes. Each of the examples listed here is the outcome of specific historical ingredients and contingencies, for culture is an inherently dynamic component of the social environment. The survival of a cultural form depends on public allegiance and its continued capacity to provide meaning and to shape motivation. Sustaining the loyalty of each new generation as it moves through the transition to adult life is the critical test; the emergence of oppositional youth cultures in the latter half of the twentieth century raised new challenges for sustaining distinctive national ways of seeing and acting upon the social environment.
Karl Marx reduced culture to an ideological superstructure resting upon and reflective of an economic base, which was the foundation of society. He predicted that the capitalist mode of production would destroy pre-existing cultural forms and install its own cultural superstructure. As the global market extends its reach over the territory of the globe, incorporating an expanding proportion of the world’s population, the fate of traditional culture looks bleak from a Marxist perspective. International capitalism is a restless machine ever intent on substituting its own vision of the good life in opposition to lifestyles evolved from quite different origins. It is not just a matter of commercial interests marketing the Western way of life through Hollywood movies, popular music, Western consumer goods, blue jeans, and fast food. Equally important is the promise of economic autonomy and personal liberation from bonds of kinship. In this dual way, capitalism consciously and unconsciously maintains its mission to reshape humanity in its own image.
Against these formidable international economic and social forces for change, the resilience of authentic cultural forms depends crucially on the political infrastructure of nation-states, either singly or in combination (e.g. the European Union), and on the mobilization of political initiatives to maintain an independent power over the development of the social environment and the use of public policy to direct change in ways that protect the health of the population. The profession of public health operates within the social environment and is a potentially powerful factor of health promotion. It was among the founding features of polity, and the extent of its contemporary effectiveness depends on a savvy understanding of the source, range, and scope of influences emanating from the social environment and determining the people’s health. This chapter has aimed to provide an overview of these influences and to encourage the profession to adopt an expansive framework of analysis incorporating economic, political, and cultural processes, which does not stop short at the boundary of the nation-state.
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