THE SUNDAY TELEGRAPH – 26 February 1995
Sick statistics syndrome. Is poverty really the cause of ill-health?
MY FIRST job as a newly qualified doctor included supervising the last remaining tuberculosis cases in the East End of London. It was not very arduous. The patients were, virtually to a man, alcoholic down-and-outs who, when the weather grew too cold or they became too ill, would turn up in the casualty department. A chest X-ray would invariably show large cavitating holes in the lungs and, when examined under a microscope, the sputum would be teeming with TB bacilli.
Following admission for treatment, they would rapidly put on weight and the cavities in their lungs begin to shrink with the anti-TB drugs. But after a couple of months, bored by the constraints of hospital life, they would discharge themselves, and, once back on the streets, their TB would flare up again. They would then have to be readmitted and the cycle would repeat itself until they either moved away from the area – or died, usually around the age of 50.
This was also the life expectancy of the working class a century ago and, in a sense, my patients were something of a historical curiosity: a throw-back to the time when Charles Booth and Seebohm Rowntree conducted their famous surveys. These showed how a large slice of the population were living in absolute poverty and how their appalling housing, overcrowding and poor diet could only too readily explain, as with my TB patients, their poor health and limited life expectancy.
The lives and untimely deaths of my patients are therefore a useful yardstick against which to assess the repeated claims that in contemporary Britain poverty remains a significant cause of ill health.
There is no doubt that for every age group and for every illness – heart disease, cancer, strokes and accidents – there is a consistent social-class gradient, with the unskilled faring, on average, twice as badly as the professional middle class. Last week’s Panorama programme made much of the two-fold difference in infant mortality rates, which was presented as a monstrous injustice and one which the Government should be making strenuous efforts to reduce.
This particular statistic has always intrigued me, because in everyday general practice it is very difficult to discern its basis. Nowadays, a death in infancy is very rare from one year’s end to the next, and when it does tragically occur, it seems just as likely to afflict the rich as the poor. Clearly, it would help to know what exactly are the causes of these childhood deaths before blaming "poverty". Quite extraordinarily, however, in hundreds of articles on the subject over the past 10 years, nobody has analysed the relevant data in detail. So, armed with my pocket calculator, I did it myself and found the following.
Three categories of disease account almost entirely for the differential in infant mortality: congenital anomalies caused by faulty genes; prematurity where the birth of a baby before its lungs are fully developed results in the life-threatening respiratory distress syndrome; and cot death. These are all slightly commoner in babies born into working-class households, but none is readily attributable to poverty. Their causes are, for the most part, unknown, with the exception of cot death, now known to be strongly influenced by sleeping position.
But this is not the only example of the misleading use of statistics. The Panorama programme also emphasised how the health gap between rich and poor is widening, reflecting the widening economic differential between the social classes over the past decade.
Superficially, this seems to be true. Thus a study published in December last year in the British Medical Journal showed how, during the Eighties, the difference in mortality rates between the most affluent and deprived areas in Glasgow had increased. But this was not because the most deprived had become less healthy, not a bit of it. With one exception, rates of all common illnesses have declined markedly among all social classes; it is just that they have declined faster among the affluent than the deprived. Hence, in relative terms, the health gap may seem to be widening, but in absolute terms it is getting narrower.
That, however, is not the end of the story. As revealed in the most recent Rowntree report of a fortnight ago, the health and quality of life for a minority in Britain has indeed deteriorated over the past decade. The one exception to the overall improvement in the health of the most deprived in Glasgow has been among males aged 20-29, for whom deaths from suicide and "undetermined" causes has increased by a third.
Further, the Royal College of Physicians has recently reported that the number of families accepted as being statutorily homeless rose from 76,000 in 1980 to 179,000 in 1992. Many of these end up in b & b accommodation where the children have high rates of infectious illness, lack of space inhibits their natural development and accidents are common, due to hazards such as kettles at floor level.
The serious charge against those who misuse statistics to falsely attribute health inequalities in Britian to "poverty" is that they divert attention away from the need for intelligent social policies to address these substantial problems.
Copyright: Telegraph Group Ltd