Editorial

Guest Editorial: Vulnerability to sickness and disease

Kevin White
Senior Lecturer, Department of Sociology, Australian National University, Canberra, ACT

PP: 5

Article Text

Medical knowledge and practices in our society focus on individuals and their bodies. This is in part because of the powerful role of Western scientific medicine in the treatment of serious disease. But it is also in part a reflection of the individualism that characterises Western society. We tend to think of individuals being responsible for their own states of health, either as a consequence of their biology, or of their lifestyle choices. Such an approach, however, obscures the ways in which the organisation of society systematically produces and distributes disease (Lupton, 1994).

At least since the mid-nineteenth century, social commentators have been aware of the role of economic and social factors in shaping the health and illness of individuals. In 1845, for example, Frederick Engels (1974), Marx's collaborator, layed the foundations of a social understanding of sickness and disease. He documented the impact of economic factors, especially work in industrial capitalism, on an individual's health, the impact of patriarchal relations on women's health, and the role of ethnicity – in particular for the Irish – in producing disease. He also argued that medical models of disease systematically obscured these social processes by focusing on the individual and their biology.

Not surprisingly, there is a major debate about the argument that social organisation rather than individual behavior causes disease. Take for instance the Black Report, published by the British Department of Health and Social Services in 1980. In this report profound inequalities in health were demonstrated, to the extent that the then Conservative Prime Minister Margaret Thatcher embargoed it. It was only through Lord Black, using the privilege of the House of Lords, that it was released and subsequently published as Inequalities in Health: The Black Report and the Health Divide (Townsend and Davidson, 1988). In this report four different explanations of health inequality were reviewed and each of these explanations still has currency today. The report argued that explanations of health differences, which were an outcome of biased measurement tools, an outcome of natural selection or the product of lifestyle, were all inadequate to explain the differences between the richest and the poorest's health status. Rather the Report argued it was the material organisation of society and patterns of economic and political inequality that determined health differences (for the ongoing debate see Stevens et al. 2001).

Here, I chart recent developments in this broad sociological approach, synthesised into practical statements about the relationship between social structures and disease, both at the level of the population and as experienced by individuals (see White, 2002). To do this I draw on, and add to the work of the World Health Organization, which in 1998, brought together the best research on the social factors most important in determining the health of a population (Wilkinson and Marmot 1998). Framing the report was the overwhelming evidence for the limited impact of organized medicine in the prevention of disease, and the need for the transformation of social structures as the solution to the social, political and economic causes of patterns of disease.

Childhood patterns

'Important foundations of adult health are laid in prenatal life and early childhood. Slow growth and a lack of emotional support during this period raise the lifetime risk of poor physical health and reduce physical, cognitive and emotional functioning in adulthood. Poor social and economic circumstances present the greatest threat to a child's growth and launch the child on a low social and educational trajectory' (WHO Report: Wilkinson and Marmot, 1998, p 12).

Patterns of sickness and disease are laid down in childhood, and the impact of an underprivileged childhood on a person's health is not likely to be overcome in adulthood. If we start off in poor health we continue in poor health. Later medical interventions will not make up for the impact of poverty (and consequent poor nutrition, housing and clothing), a lack of health care and information for pregnant women, and lack of access to nursing care and advice following the birth of an infant. Life time patterns of health and disease are set down in the first years of life and, even if the individual experiences social mobility, they will not improve. In fact, the single best intervention that any government can make, to improve the health of its population, is the provision of universal, free care for mothers-to-be and new born infants (Shi, 1994).

Social exclusion, social support and stress

'Social and psychological circumstances can cause long-term stress. Continuing anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life have powerful effects on health. Such psychosocial risks accumulate during life and increase the chances of poor mental health and premature death' (WHO Report: Wilkinson and Marmot, 1998, p 10).

In later adult life, at the most general level, social exclusion, the lack of social support and exposure to stress are key causes of diseases and early mortality. These characteristics of individuals' social lives are in turn reflections of, and shape their participation in, the labour market. Thus issues of socio-economic status, social integration and health are all deeply intertwined. They can only be separated out analytically, and for any given individual, will form an interconnected mosaic that will determine how healthy they are in life and when they die.

The experiences of poverty, homelessness and unemployment – that is social exclusion from the basic minimums regarded as the norm in our society – have a major impact on health. Those already at high levels of risk to their health – the migrant, the indigenous population and the refugee – are at high risk of social exclusion and are put at extreme jeopardy of continuing poor health and early death. It is a tragedy of modern societies that social exclusion is concentrated on those with stigmatised medical conditions such as AIDS, mental illness and physical disability, resulting in an impoverished social life and early death for many individuals (Albrecht et al. 2001).

Being a part of a social network, having social support, in which one's self esteem and one's inter-personal relationships are valued, has been demonstrated to be a significant factor in preventing early death and vulnerability to disease. Good social support results in a whole range of beneficial health outcomes, from carrying a successful pregnancy through to recovery from heart attack. Lack of social support is intertwined with social exclusion, both of which are shaped by inequalities of income. The consequence is a sicker, shorter life.

There is now extensive evidence that stress – in the sociological rather than psychological sense – of uncertainty about employment, lack of autonomy at work, and lack of a sense of autonomy over life events generally – has a major impact on the autonomic and immune systems. The experience of stress is socially induced and not a characteristic of an individual's psychic make-up. Put simply the social conditions experienced by individuals at the bottom of the labour market, and who thus experience greatest uncertainty about their future, are in a permanent state of 'fight or flight' response mode. This biological state makes them vulnerable to infection and disease (Peterson 1999). Indeed, the focus on stress by sociological researchers constitutes the formation of a new way of explaining the physical outcomes of social organisation on individuals and their bodies (Wilkinson 1996, 193).

Addictive behaviour and lifestyle choices

'Drug use is both a response to social breakdown and an important factor in worsening the resulting inequalities in health. . . . Alcohol dependence, illicit drug use and cigarette smoking are all closely associated with markers of social and economic disadvantage' (WHO Report: Wilkinson and Marmot, 1998, pp 22-23).

These sociological vulnerabilities – of social exclusion, lack of social support and stress – in turn lead to the adoption of poor lifestyle habits – of poor diet and addictive patterns of behaviour. Rates of addiction, for example, are highly correlated with other aspects of inequality. The poor, the disadvantaged, the unemployed and the homeless, as well as those in low status jobs, are most at risk of developing addictive behaviour. While addiction may be seen as an individual's response to social situations, from a sociological perspective, it is the social circumstances that bring about the individual's behaviour.

Like addictive behaviours, our diets are lifestyle choices that are determined by what is available to us. Consuming high fat, sugar rich and low fibre foods is determined by our income and educational level. White bread and refined white sugar (poor dietary 'choices') are cheaper than wholemeal bread and raw sugar (good dietary 'choices'). The poor are put at double jeopardy – what they can afford, and what is marketed for their consumption, is most deleterious to their health. Again, it is important to keep in mind that this is not an individual lifestyle choice, but the consequence of a structurally determined, and limited access to a, good diet.

Poverty and ethnicity

'Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death of those near the top' (WHO Report: Wilkinson and Marmot, 1998, p 8).

Social exclusion, lack of social support and the experience of stress are key determinants of disease, early death and of the likelihood of individuals adopting unhealthy lifestyles. In Australia, poverty and ethnicity combine in aboriginality to produce chronic disease and early death. These social factors can operate at the socio-psychological level, as individuals respond to the experience of life in an unequal society, within the limited range of options open to them. The structures of socio-economic inequality, gender and indigenous social status leave little scope for individuals to respond to their structural location. Socio-economic inequality, the combination of low status and poor income, in and of itself, causes sickness and disease. Townsend and his colleagues (Townsend and Davidson, 1988) found, in an examination of the 78 leading causes of death, that 65 are more common in manual compared with non-manual male workers. In other words, the further down the social hierarchy you are, the sicker you will become, and the sooner you will die. The interweaving of poverty, lack of education and poor social integration, results in diminished health at every stage of the life cycle. It is now clear that inequality of income – the difference between the richest and the poorest – is the single biggest factor in the development of poor health.

Gender

The WHO Report does not report directly on the role of gender in health and disease. However, we know that gender still plays an overwhelming role in the distribution of disease (Lane and Cibula, 2000). Women go to the doctor more, use more prescription drugs, and are hospitalised more than men. On the face of it this would lead one to conclude that women are sicker than men. However, from a sociological perspective this is not the case. Rather than being sicker, women in western societies are medicalised – that is normal aspects of their life cycle – menstruation, pregnancy and menopause – are turned into medical problems requiring medical supervision and intervention. Feminist sociologists have argued that medicine, in a patriarchal society, ensures that women conform to the social role ascribed to them: mother, domestic worker and wife. Unfortunately, where women increase their participation in the workforce, their sickness and disease patterns start to emulate men's, and in particular their lifespan shortens.

Morbidity: Genes, individuals and social structures

In our society, disease is thought to be an individual occurrence based purely in our biological makeup. Continuing inequalities in the pattern of chronic disease – despite medical developments over the nineteenth and twentieth centuries – are generally thought to be the product of either genetics or lifestyle. However, even if there is a genetic explanation (for a very limited number of diseases), this does not actually advance our health in any significant way. It may explain diseases, but it doesn't take into account our social location or the environmental factors which trigger the disease. Equally, there is little evidence for the role of lifestyle factors, conceptualised as independent from the individual's social position, as a cause of disease. Put simply our bodies are located in social structures which, by and large, determine our morbidity and mortality.

A sociological perspective on the causes of disease locates individuals' behaviour in institutional and structural contexts – that is, in terms of the structures of class, gender and ethnicity that shape their experience of life. No longer is it enough to claim that individuals need to modify their behaviour, or that increasing expenditure on health care technology will prevent disease. Rather, it is necessary to take into account societal influences, not as bothersome extras (getting in the road of real medicine) but as the major causative influence of disease.

Unequal societies result in unequal sickness and disease experiences, with those at the bottom getting sicker and dying sooner – from what are known to be preventable and modifiable social circumstances. The more equitable the distribution of wealth, the healthier the population. 'Egalitarianism is not just idealist politics, it is good health' (White 1991, 47).

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