Poverty, illness and inequality I

We often think that poverty is inevitable, and many people (think that they) know by itself that poverty is a cause of illness and social problems. The poor are always with us, they say, rather misreading Deuteronomy and St Matthew. Attitudes today are rather different from Victorian times, when the poor were seen as either ‘deserving’ or ‘non deserving’, groupings which were subjective and moralising. If you were ‘deserving’, you got into the workhouse; too bad if you were deemed ‘undeserving’. You only have to think of Fagin, Nancy, and Bill Sikes in Dickens’ Oliver Twist (poverty, theft, murder), or Mimi in Puccini’s La Bohème (poverty, TB); for a mid-20th century view, try watching the BBC series Call the Midwife.

Poverty is classified as absolute or relative. Absolute poverty is an income of less than $1.25 per day, and refers to what are usually called developing countries; in such countries the problems are of starvation, disease and survival. The improvements that public health efforts in the western world have brought aren’t common in such populations. Relative poverty, in the UK, is defined as an income less than 60% of the median income. In the UK, the median income is £26664, so that the ‘poverty line’ is about £16,000 per annum. In N Ireland the respective  figures are £21836, and £13100. A worker, on 40 hours per week at minimum wage of £6.50/hour, and working for 52 weeks, can expect a gross income, before any benefits, of £13250. (It also follows from this definition of relative poverty, that such poverty per se cannot be eradicated.)

Before settled agriculture, people lived as hunter-gatherers, in groups of up to 150. There are still ‘primitive’ tribes who live like this, yet such tribes have remarkable social integration, an absence of crime amongst the members; children are entirely safe, and are treated as precious by all—perhaps because their paternity is uncertain.

Before the industrial revolution, most people lived and worked in the country, in agriculture. The revolution brought mass production of material goods, or “stuff”, mass migration to cities, slums, overcrowding, very long working days. The exploitation of children and child labour, sending little boys up chimneys. And thus poverty, overcrowding, foetid atmosphere, rampant infection, and the inevitability of disease. Hardly an improvement from life in a rural hovel. Like the agricultural revolution, the industrial revolution has been called simultaneously both the greatest and the worst of all human innovations. The concept of “childhood” is a Victorian invention, concatenated with increasing education and ideals of purity and innocence.

Poverty in the mid-Victorian times and in the bourgeois mind was certainly associated with disease and criminality; the major improvements in health then (as they still do) came not from the treatment of individuals, but from improvements in public health. These included a clean, safe supply of drinking water, proper sanitation, food hygiene, refuse removal, and immunisation against smallpox. (Immunisation against other diseases came much later.) Even though the Victorians at this stage didn’t know about ‘germs’, some of them realised that some diseases, such as cholera, were water borne, rather than being caused by bad air and miasmas. The anaesthetist John Snow is said to have halted an outbreak of cholera in London’s Soho, by removing the handle of a communal water pump. A little earlier, Semmelweiss realised, from the results of a simple epidemiological study, that doctors coming directly from post mortems on maternity patients who had died of childbed fever were infecting the patients they then examined; he insisted that the physicians should wash their hands in disinfectant. He didn’t really in convincing his colleagues; perhaps calling them ‘murderers’ wasn’t tactful. Semmelweiss died in an insane asylum.

The next major health improvements came with immunisation against common infectious diseases, such as polio, measles, rubella, and pertussis, together with antibiotics. These great improvements in the control of infectious diseases are known as an ‘epidemiological transition’. The grossly polluted air in cities wasn’t addressed until after the London ‘pea-soupers’ of the 1950s and the recognition that they were associated with a very marked increase in deaths from respiratory illnesses.

Attention then turned to the diseases of “affluence” such as heart disease and cancer—though the apparent increase in these diseases was also related to greater longevity. What are called “life style choices” were implicated in these diseases, with the “usual suspects”, as Captain Renault might have called them, including smoking, poor diet, lack of exercise , stress, and alcohol. (Professor Sir Richard Doll originally thought that the great rise in lung cancer was related to tar and road works; the totally unexpected link to cigarette smoking took him by surprise.)

Heart disease was long felt to be a disease of executives, the rich, and somehow related to or caused by ‘stress’. To confirm this, investigators began a long-term study of civil servants—the Whitehall I study. (Its results were confirmed by the later Whitehall II study, which included women.) The expectation was that men in the highest levels of the civil service would have the biggest rates of heart attacks; but, to their surprise, investigators found exactly the opposite. Men in the lowest grades, such as messengers and door keepers had rates of heart disease and death three times higher than men in the highest grade.

Further analysis of these studies also showed that the lowest grade workers had not only more heart disease, but also more of some cancers, lung disease, digestive disease, depression, suicide. Was this difference the result of lifestyle, poverty or ‘low status’? Remember that all the people surveyed were employed, and weren’t in poverty. Researchers concluded that obesity and lack of exercise in the low status jobs were not enough to explain the differences; what else was going on?

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