During the later half of the 1970’s, the Labour government of the time commissioned the Working Group on Inequalities in Health. The purpose of the group, chaired by Sir Douglas Black, was to analyse the relationship between health conditions and social factors, and further make recommendations for those areas that required changes in policy. The report discovered that major differentials in mortality and morbidity existed in relation to social determinants (Shaw et al, 1999), however, the succeeding Conservative government attempted to dismiss the findings of the subsequent report.
When the report was eventually published by the DHSS in 1980, only 260 copies where made publicly available inciting huge media attention at the apparent cover-up (Abercrombie and Warde, 1994). As a result, much research has been done in recent years in relation to the evidence presented in Inequalities in Health: Report of a Working Group (DHSS, 1980) (commonly known as the Black Report), and despite previous attempts to suppress its findings, it has been widely accepted that the health inequalities identified within are apparent throughout modern society.
Research and theory within the field of sociology has indicated a wide range of influential factors, and in an attempt to encapsulate some of these elements, Thompson (2001) suggests that society is characterised by a range of social divisions, which are underpinned by ideologies that influence our actions and attitudes. These ideologies have the effect of creating and perpetuating inequality, discrimination and oppression. The purpose of this assignment is to analyse the significance of Thompson’s assertions as they relate to documentary evidence.
The evidence concerned will focus on selected aspects of social division within a multi-cultural society, and follow these constructs from concept, through to their immediate effects on the health of those involved. In addition, the assignment will further reflect upon how the knowledge base acquired from this analysis has facilitated an informed approach to anti-discriminatory practice within the social context of health care.
In order to substantiate Thompson’s ideas, it seems logical to first identify and define some of the fundamental concepts contained within, and in doing so, attempt to clarify the underlying principles. The basis of his theory focuses on the characteristics of society; so, it is necessary to first determine what constitutes a society. Society in itself is a dynamic entity, it is unique to specific regions and cultural interpretation, whilst constantly evolving and changing. The Oxford Dictionary (2001) provides a range of definitions, and this reflects its complex nature.
Primarily, it is depicted as ‘the sum of human conditions and activity regarded as a whole functioning interdependently’, whilst subsequent definitions describe it as a ‘social community’, ‘social mode of life’, or ‘the customs and organization of an ordered community’. These definitions emphasize different elements of a society, and although identified individually, in effect society is formed by a combination of all these factors. An enduring feature that distinguishes different societies is culture.
There are many genres of culture displayed throughout societies, and Barley (1995, cited in Curtis, 2003) describes it as ‘as a tool that defines reality for its members’, whilst Taylor’s (2003) description of socialisation provides an explanation of how such features of society influences individuals. He states that a society is built upon a common set of values and beliefs, which motivate certain behaviours, and as society evolves, it assumes characteristic behaviours as normal practice. Such views and conventions form the basis of culture within a society and provide a precept as to how people should conduct their behaviour.
Evidence of cultural diversity in the United Kingdom is readily available in the form of official national statistic publications. Figures correlated for the UK population Census 2001/2002 for example, verify that 7. 6 per cent of the population are of ethnic minority origin. These current figures reveal a 2. 1 per cent rise on the previous 1991 Census, and equate to approximately 4. 6 million UK residents who identified themselves as members of an ethnic group (Source: -Taylor and Field, 2003:65).
This trend highlights an increasing rise in the integration of ethnic minorities within the UK, however, Taylor and Field (2003) question the reliability of data presented in censuses, arguing that the official categories used are not well enough defined to give a satisfactory representation of ethnic groups. Although ethnicity is not a categorical representation of culture, this example is useful for raising the question of whether the categorisation of groups or individuals in this manner assumes a generalized view of a population, which is in fact diverse by nature.
If so, this has the effect of oppressing the diversity that is inherent in society, and typification in this manner can result in stereotyping, which generally has derogatory connotations, and can ultimately result in discrimination. This is an opinion acknowledged by Righton (1990, cited in Thompson, 2001), and this process stems from ideologies, which according to Thompson (2001) are common to society. The sociological view of society follows two predominant schools of thought, which come from macro and micro perspectives (Hinchliff et al, 1998).
Society as a social structure is a macro theory that views society as a structure constructed from a ‘network of social institutions and patterns of social relationships’, for example families, schools, hospitals and larger organizations such as the NHS (Taylor and Field, 2003:15). This perspective focuses on identifying the influence these structures have on the behaviour of individuals living within them, be it as a result of cultural belief systems (Idealist theory), or economic effects (Materialist theory).
Alternatively, micro perspectives offer a social action theory that studies the motivating forces that drive individuals’ actions, and refutes any indications that social ‘laws’ mould individual behaviour. The theory concentrates on the nature of individual experience, and attempts to explicate the behaviours and lifestyles adopted by individuals in this context (behavioural and cultural explanations) (Taylor and Field, 2003). There is an abundance of documentation supporting each of these sociological perspectives in their own right; however, both have their limitations in explaining behaviour within the wider context of social inequalities.
It is therefore becoming increasingly evident, particularly in light of the Black Report, which will be discussed later, that these theories are in reality inextricably linked. Thompson’s earlier suggestion supports this amalgamation of theories, and he remarks that, contemporary society is ‘characterised by differentiation’. The multiplicity of cultures, ethnicities, age ranges and sexual orientations within society demonstrates this diversity, and he concedes that diversity leads to individuals being categorised and subsequently placed in groups, this stratification then ‘forms the basis of the social structure’ (Thompson, 2001:17).
It has long been recognised that social divisions exist within society, and people are perceived in accordance with the division they fit into. The three major divisions that sociologists commonly focus on in relation to inequality are class, gender and ethnicity (Naidoo and Wills, 2001). These particular divisions are not explicit in social inequality, as disability and age are also indicated, however they are the most commonly documented.
For the purpose of this assignment, the socio-economic status is to be examined in more detail, as it incites political, economic and sociological consideration. Traditionally, social class has been used as a measure for socio-economic status by way of the Registrar Generals classification of occupation (Clarke, 2001). The system as a whole is believed to provide a general indication of not only occupation, but also social position, income, educational attainment and lifestyle (Clarke, 2001).
In contemporary society, this measurement system is often considered to be flawed, as figures are based upon a male being allocated as principle breadwinner within households comprising of couples. In an age where the traditional nuclear family constitutes only 26 per cent of household structures, it is fair to therefore assume that such classification is not representative of the population as a whole. Nevertheless, the majority of health surveys and mortality statistics are based upon this information, and they do offer a source of quantitative data by which health inequalities can be measured (Graham, 2001).
Thompson’s theory base would suggest that this social class structure is maintained by a capitalist ideology, a concept originally proposed by Karl Marx in the nineteenth century. Capitalism indicates that stratification is a result of a capitalist system that favours those with wealth (Moon and Gillespie, 1995), and in Thompson’s opinion, this ideology only serves to ‘justify, protect and reinforce’ these social divisions, thus legitimising social inequalities by normalising a system that distributes rewards unequally in accordance with wealth, status and power (Thompson, 2001:17).
In terms of health, such inequalities have a profound effect, and Shaw et al (2000i) maintain that poverty is the principle cause of inequalities in health. Despite Naidoo and Wills (2001) argument that materialist explanations cannot justify the influence culture has on social inequality, ideology is formed from the beliefs held within a society, and research has proven that there is in fact a direct link between poverty and health inequality.
A recent report on the indicators of poverty and social exclusion carried out by the Joseph Rowntree Foundation (2002) illustrates the economic inequalities between social classes. The report states that despite an improvement in the number of individuals on low incomes (a drop of 1. 5 million from 1997 to 2002), the gap between low and median incomes has remained constant throughout the 1990’s, continuing a steady trend of relative poverty throughout the UK.
As previously mentioned, the Black Report uncovered major differentials in mortality and morbidity, and it cites socio-economic status as one of the major contributing determinants (Abercrombie and Warde, 1994). According to Whitehead (1990), there are four principle explanations for health inequalities, artefact, social selection, structural/material and cultural/behavioural. For the purpose of space, aspect associated with the later two explanations will be examined in more detail as they relate to the social theories previously described.
There are a number of consequences related to social inequality, and the report indicated that one determinant of mortality is poverty. A structural explanation for poverty suggests that inequalities exist because people from lower classes are exposed to unhealthier conditions. This explanation focuses on how the structure of social classes determines the opportunities available for those in the lower classes. For example poorer accommodation, lower income, and exposure to more physical and environmental hazards.
Mortality remains a common indicator for assessing health across a large cross section of the population, as it is one of the few truly objective measurements available. As explained by Shaw et al (1999) a lack of money has a direct impact on the ability of those on low incomes to buy or access goods and services necessary for well-being. On a wider scale, the World Health organisation (WHO, 1998) provides evidence of mortality on a worldwide level, and the figures displayed show a comparison of mortality rates in terms of causation in developed and developing countries.
The statistics show that in 1997, death as a result of infectious and parasitic disease accounted for 43 per cent of deaths in the developing world as a opposed to only 1 per cent in the developed world. These figures would suggest that in societies that have a weaker economic structure, for example third world countries, the resources required to reduce the occurrence of preventable diseases such as tuberculosis, is simply not available as it is in countries such as the UK.
Cultural differences may also be a determining factor, as underdeveloped countries do not have the available resources to implement health education measures. For example, routine immunisation programmes have not been customarily employed or recognised in third world countries, it is only in recent years, with the emergence of world wide health promotion strategies that the WHO has propagated these measures as a necessity (Clarke, 2001). On a more localised scale, studies of the UK have also indicated that socio-economic status has a direct impact on mortality.
The Independent Inquiry into Inequalities in Health (DOH, 1998) submitted a report that investigates many of issues raised in the Black Report. Commonly known as the Acheson Report, the study maintains that there is an increasing differential in mortality rates between the highest and lowest of the social classes. The figures contained within the report illustrate that between the years of 1986 to 1992, in classes IV/V, 764 and 418 deaths occurred per 100,000 people for men and women respectively in comparison with 455 and 270 per 100,000 people in classes I/II.
Despite a fall in total deaths within these ranges from the earlier statistics collated between 1976 and 1981, the report determines that the ratio of deaths between classes IV/V and I/II has risen from 1. 53 to 1. 68 for men, and from 1. 50 to 1. 55 for women. These rates are age standardised, and indicate that class inequality in terms of morbidity is consistent across age ranges. Further to these figures, the report concedes that in addition to material and structural explanations such as income, health related behaviour is also indicated as a determinant of health inequalities.
The report states that behaviour such as smoking and alcohol consumption is more prevalent within the lower classes, demonstrating cultural trends. The report cites that ‘there is a clear social class gradient for both men and women in the proportion who smoke’, and in terms of statistics, this equates to 12 per cent of professional men who smoke in comparison with 41 per cent of men whose occupation is of an unskilled manual nature.
For women, these figures equal 11 per cent to 36 per cent. Further indication points to health inequalities as a result of poor diet and less exercise in lower classes. All of these determinants are consistent with the inequalities displayed by mortality rates in relation to social class, and this evidence supports Whitehead’s assertion that ‘there are life-style differences between social classes which are related to health’. (Black et al and Whitehead, 1994:50).
As previously stated, all of these determinants have far reaching implications in terms of health, however, health is not merely an issue of sickness and death, there is a wider perspective that also incorporates psychological well-being as an indicator. The World Health Organisation recognised this issue as far back as 1948, and describes health as ‘a complete state of physical, mental and social well-being and not merely the absence of disease and infirmity’ (cited in Moon and Gillespie, 1995:92).
This move away from a medicalised vision of health and illness supports a holistic approach as advocated in a nursing and health care environment. Thompson (1998:115) acknowledges the considerations of an ideological concept of health, and states that this ‘has wide ranging implications with regards to inequality, discrimination and oppression’. To put this issue into context, a reflection from experience is to be used as a constructive example. The reflection is not descriptive of a particular incident as such, but more of a pattern of attitude that may be perceived as synonymous to discrimination.
In order to gain some community experience in the early stages of my branch year, I was assigned a one week placement with a health visitor within a local area that is considered affluent. My initial inclination was that the people I would encounter would have relatively few concerns in terms of social problems, however, as the placement progressed, I assumed a raised awareness that such an opinion is in fact a fallacy, associated with my own perception of individuals from the upper classes.
During the course of my time visiting individuals within this particular community, I encountered a twelve-year-old girl who had recently become a mother, a young woman whose husband had recently left her, shortly after the birth of her second child, and a family who was coming to terms with the fact that the stepfather had been sexually abusing the youngest son. To encounter such a range of sad circumstances within a week was especially disturbing to me, particularly in light of the fact that I had initially presumed that such situations were predominantly a feature of deprived areas.
I voiced these concerns to my mentor, and she told me that this was a common misconception of such areas. She went on to explain that many years in such areas had made her somewhat cynical, however she conceded that in her experience, it was not the fact that such incidents did not happen in affluent areas, but that many of the individuals within upper classes are more adept at hiding such problems. She concluded that this was in order to maintain the upper class ideology that ‘the rich are above such scandalous performances’.
This experience made me aware that in the same way it is possible to discriminate against individuals or groups due to their status as underprivileged, it is also possible to discriminate against those who are privileged, by assuming that their needs are not as great. This has armed me with an understanding that careful observation should be taken when assessing the needs of any individual, regardless of social position, and careful consideration must be taken beforehand in order to avoid making assumptions that could be viewed as stereotypical.
To conclude, it is evident that inequality and discrimination is inherent in contemporary society, and despite a raised awareness of this fact, little progress seems to be being made in reducing their occurrence. Anti-discriminatory practice is only effective if we actively strive to eliminate discrimination, rather than simply acknowledge its existence, and sit in agreement that such views are unacceptable (Thompson, 2001).
To reverse the principles of Thompson’s theory, health care professionals within a large social structure such as the NHS, are in a good position to provide a basis for tackling the wider issue of discrimination. Taking an active role in anti-discriminatory practice will hopefully filter through thus influencing cultural ideologies, for to quote the political maxim cited by Thompson (2001:25), ‘if you are not part of the solution, you must be part of the problem’.