1. Previous chapters have set out the problems of defining and measuring inequalities of health and have described contemporary inequalities. In this chapter we will attempt to draw conclusions about trends, especially during the last 30 years. For want of other data of a comparable kind covering a span of decades rather than a few years, mortality data will be given most attention. After a brief overview of general changes we will discuss in turn the data for men of economically active ages, women of economically active ages, children and elderly people.

DECLINE IN DEATH RATES

2. For about 100 years mortality rates for both sexes, taking one decade with the next, have declined. Figure 3.1 shows the trends, after discounting for changes that have taken place in the age-structure of the population. It will be seen that the rates for males have remained markedly higher than for females, and in recent decades the difference has become relatively greater. This is shown more clearly in Figure 3.2. Even since 1946 the excess of the male over the female rate has increased at all ages – and especially between the ages of 10 and 30. Although attempts have been made to explain the difference between the sexes comparatively little systematic work exists. Research has often concentrated on explaining the health experience of a single sex. We consider that this is unsatisfactory whenever it would be relevant to study the experience of both sexes. We also consider that as a consequence some social inequalities may have been overlooked or minimised. Even when comparisons have been undertaken they have sometimes been made crudely, perhaps because of the shortage of well-grounded studies. For example, an MRC report took the view that mortality from bronchitis among men in the coal industry owed little to direct occupational effects, and more to general socio-economic or environmental factors, because a high correlation between the bronchitis SMRs for men and those for their wives had been observed (Medical Research Council, 1966, pp 101-102). But others pointed out that the exposure of some working wives to comparable occupational hazards as well as the exposure of families to some of the dust, and the effects of dust, picked up by the men, seemed likely to have been underestimated. (McLaughlin, 1966, and Higgins, 1959; as quoted by OPCS, 1978, P-32).

Figure 3.1 Death Rates (standardised to 1901 population): England and Wales

Death Rates (Standardised to 1901 population) England and Wales

Source: McKeown, T. The Role of Medicine, London, Nuffield Provincial Hospitals Trust 1976 p.30

Figure 3.2

Historical change in the risk of death for males and females throughout the lifetime

Historical Chjange in the risk of death for males and females throughout the lifetime (male death rates expressed as a percentage of female rates)

3.3. The aetiology of the mortality and morbidity differences between men and women remains to be disentangled. Women suffer uniquely from some diseases: there have been major changes in the last 50 years in their experiences of childbearing and of paid employment, and there have been changes too in the pattern of personal, married and family life outside employment. Such factors must be assumed to play some part. Certainly the amount of waking time spent outside paid employment has increased, and more families spend parts of the year on holiday far away from their local environment. It would be wrong, for example, to assume too readily that all wives share the same living conditions or even standards as their husbands. Some men have the advantage, for example, not only of a preferential diet at home but subsidised meals at work. Where both husband and wife are in paid employment the meals they get in the day, as well as working conditions and the nature of the work, may be radically different. These general reservations have to be borne in mind in examining certain types of mortality date – as for example correlations between SMRs for occupational orders for married men and their wives; and between cause-specific SMRs for married men and those for married women grouped according to their husbands occupation order, which are included among the indices of an association between occupation and mortality listed by the OPCS (OPCS, op cit., 1978, pp.68-70).

Men of Economically active ages

3.4. Table 3.1 summarises statistical data produced in the Registrar General’s Decennial Supplements about the trends in inequality in male mortality, as measured by the relative changes in the mortality of different “social” or more strictly “occupational” classes. The table shows the mortality of different classes relative to the national rate.

3.5. The unadjusted data cannot be taken at face value and require careful discussion. After a long period of decline in inequality the statistics appear to suggest that a sharp change took place in the 1950s which persisted into the 1970s. Between 1949-53 and 1959-63 inequality between occupational classes in mortality experience appeared to have widened. Indeed in the supplement published in 1971 the Registrar General stated, “the social class gradient increases with successive censuses so that in 1959-63 the Standardised Mortality Ratio for social class I was only about half that of social class V”. (Registrar General’s Decennial Supplement, England and Wales, 1961, 1971, p.22) However, changes were introduced in 1960 in the classification of occupations and these account for most of the change in the relative mortality experience of classes I and V indicated by the unadjusted data in Table 3.1. In 1961 approximately 26 per cent of occupations were allocated to a class different from that to which they would have been allocated on the 1950 classification (Ibid, p.19).

3.6 Adjusted data for each class for 1959-63 were not given in the Supplement published in 1971. But estimates could be based upon information given in the text. Thus, mortality rates per 100,000 for all men and for men in class V in 1959-63 were given (Table D6) on the basis of both the 1950 and 1960 occupational classifications. These were given only for men in particular age-groups, but weighted totals for men of all ages could be calculated. One estimate was of 128 (substituting for the unadjusted figure of 143) for class V, the comparable figure for 1949-53 being 118 (Townsend, 1974). Although the Registrar General felt overall that it was “impossible to disentangle real differential changes in mortality in this context from apparent differences due to changes in classification” (Decennial Supplement for 1961, P.22), he went on to draw 2 rather important conclusions.

3.7 First, by looking at certain closed professional groups (for example, doctors, lawyers, teachers and clergy) it could be seen that “not all the improvement in social classes I and II is due to differences in classification”, (Ibid, p.22 and p.27). Second, ‘the most disturbing feature of the present results when compared with earlier analyses is the apparent deterioration in social class V …. Even when the rates are adjusted to the 1950 classification it is clear that class V men fared worse than average”. (Ibid, p.29).

Table 3.1 Mortality of men by occupational class (1931-1971)

(standardised mortality ratios)

Men aged 15-64
Occupational Class 1930-2 1949-53 1959 -63 unadjusted 1959 -63 adjusted 1970-2 unadjusted 1970-2 unadjusted
I Professional 90 86 76 75 77 75
II Managerial 94 92 81 81
III Skilled manual and non manual 97 101 100 104
IV Partly skilled 102 104 103 114
V Unskilled 111 118 143 127 137 121

Notes: a. Corrected figures as published in Registrar General’s Decennial Supplement, England and Wales, . 1961: Occupational Mortality Tables, London, HMSO, 1971, p.22

b. Occupations in 1959-63 and 1970-72 have been reclassified according to the 1950 classification.

3.8. The next decennial supplement, covering occupational mortality during 1970-72, shows little or no change in the mortality “advantage” of classes I and II, but though there was an improvement in the mortality of social class V, relative to other classes, this improvement fell short of restoring the position the class had reached in 1949-53, (OPCS, occupational Mortality, Decennial Supplement, 1970-72, England and Wales, 1978 p.174). And, compared with 1959-63, the mortality of class IV relative to other classes had deteriorated. The report on the years 1970-72 went on to point cut that the age-standardised death rate per 100,000 living at ages 15-64 (using all men in 1970-72 as the standard and after adjusting to the 1950 classification) had declined between the early 1960a and the early 1970s for class V men from 134 to 123, and therefore, according to this criterion, their health had improved “historically”. But this attempt to distinguish changes relative to a historical benchmark from those relative to class structure also demands qualification. The age-standardised death rate for class IV actually increased betveen the early 1960s and the early 1970s and the rate for class III declined only marginally. Table 3.2 gives the figures for the 3 periods for each class.

TABLE 3.2

Recent trends in death rates by occupational class

men aged 15-64 (England and Wales)

age-standardised death rate per 100,000 living at ages 15-64
Occupational Class 1951 1961 1971
I Professional 103 82 79
II Managerial 108 87 83
III Skilled manual and non manual 116 106 103
IV Partly skilled 119 108 113
V Unskilled 137 134 123

Note: Adjustments have been made by the OPCS to improve comparability between censuses.

Source: OPCS, Occupational Mortality, Decennial Supplement. 1970-72 England and Wales, London, HMSO, 1978, p.174 (supplemented by the OPCS).

3.9 The trend is clearly uneven, in terms of both historical decline in the absolute rates for each class and relativity between classes. Table 3-3 illustrates both these features for different age-groups. First, mortality rates for younger men declined during the whole period of more than 2 decades but the decline was arrested or even reversed for class III and classes IV and V combined for the 3 ten-year age-groups over 35. In the case of men aged 45-64 mortality rates in 1970-72 were either the same as or worse tbom those in 1949-53. During the 1960s a deterioration in the rates for men aged 35-54 in classes III, IV and V (and little or no improvement for older men in these classes) took place.

3.10 Second for each 10 year age group the mortality rates of men in classes III, IV, and V worsened during these 2 decades relative to men in classes I and II.

Table 3.3

Mortality rates per 100,000 and as percentage of rates for occupational classes I and II (1951-71, England and Wales, men and married women)

Occupational class Age Men rates per 100,000 Married Women rates per 100,000
1949-53 1959-63 1970-2 1949-53 1959-63 1970-2
I and II
25-34 124 81 72 85 51 42
III
148 100 90 114 64 51
IV and V
180 143 141 141 77 68
I and II
35-44 226 175 169 170 123 118
III
276 234 256 201 160 154
IV and V
331 300 305 226 186 193
I and II
45-54 712 544 554 427 323 337
III
812 708 733 480 402 431
IV and V
895 842 894 513 455 510
I and II
55-64 2097 1804 1710 1098 818 837
III
2396 2218 2213 1202 1001 1059
IV and V
2339 2433 2409 1226 1129 1131
as per cent of I and II
I and II
25-34 100 100 100 100 100 100
III
119 123 125 134 125 121
IV and V
145 177 196 166 151 162
I and II
35-44 100 100 100 100 100 100
III
122 134 151 118 130 131
IV and V
146 171 180 133 151 164
I and II
45-54 100 100 100 100 100 100
III
114 130 132 112 124 128
IV and V
126 155 161 120 141 151
I and II
55-64 100 100 100 100 100 100
III
114 123 129 109 122 127
IV and V
112 135 141 112 138 135

Source: OPCS

Table 3.4 Changes in death rates by occupation and age (occupied and retired men)

Occupational Class 25-34 35-44 45-54 55-64
1951 1961 1971 1951 1961 1971 1951 1961 1971 1951 1961 1971
I 162 82 67 230 166 166 756 535 506 2347 1699 1676
II 114 81 74 225 177 170 704 545 565 2050 1820 1717
III 148 100 90 276 234 226 812 708 733 2396 2218 2213
IV 156 119 118 290 251 270 779 734 826 2103 2202 2301
V 214 202 199 386 436 391 1027 1119 1059 2567 2912 2635
All occupied and retired men 153 108 98 280 237 230 816 704 728 2312 2174 2145
I clergymen 123 42 57 223 109 178 654 409 573 2007 1437 2545
dentists 95 74 64 155 133 159 824 460 583 2320 1393 1608
physicians 140 103 98 230 202 235 736 653 555 2119 1929 1579
accountants 120 87 77 180 186 172 644 512 629 1903 1715 1947
II Teachers 82 72 65 181 134 131 509 412 445 1667 1299 1290
Artists 153 77 55 278 203 238 773 704 795 2180 2009 1953
Journalists, authors, etc. 147 126 102 252 226 237 944 561 644 2139 1658 1875
Innkeepers 162 165 109 422 398 322 1288 1010 1062 3395 3199 2842
III Commercial Travellers 92 87 82 229 187 183 687 592 678 2058 1904 1816
Police 67 61 68 225 152 152 773 610 516 3496 4654 6144
Bricklayers 136 77 79 254 203 205 713 684 705 2363 2104 2377
Boot and Shoe repairers 199 136 127 314 334 356 973 834 952 2559 2734 3374
IV Paintsprayers 142 93 118 324 283 282 791 780 805 2440 2332 2222
Postmen 110 70 52 217 174 142 758 517 563 2255 2166 1762
Telephone operators 208 253 170 308 340 488 1167 770 1040 2646 2914 2452
Fishermen 109 119 85 332 327 329 1055 1063 1444 2958 3184 3423
V Railway porters 155 125 98 335 339 191 905 964 854 2404 2365 2323
Office cleaners 72 157 88 383 285 246 840 794 759 1936 1940 1687
Dock labourers 178 110 151 328 265 243 994 947 904 2739 3053 3065

Source : OPCS

3.11 Classification of mortality by occupation serves only as an indicator of possible causes of inequalities. A large amount of work has concentrated on excess of particular causes of death within occupations or occupational orders, for example, textile workers and diseases of the blood, and miners and circulatory and respiratory diseases (the latest review is to be found in OPCS, 1978, op cit, chapter 5).

3.12 In 1959-63 more class V men died at every age than in 1949-53, from cancer of the lung, vascular lesions of the central nervous system, arteriosclerotic and degenerative heart disease, motor vehicle accidents, and other accidents. Some diseases, like lung cancer and duodenal ulcers which showed no trend with social class, or, like coronary disease, an inverse trend 40 to 50 years ago, were by the 1960s producing higher mortality among social classes IV and V than I and II. In the report for 1959-63, there were 49 out of 85 separate causes of death applying to men (and 54 out of 87 applying to women) in which SMRs for classes IV and V were higher than for I and II. For only 4 causes of death among men (and 4 among married women) was the class gradient reversed. (See Table II in Registrar General’s Decennial Supplement (1959-63), op cit.).

3.13 Some comparison can be made with data for 1970-72. For 92 causes of death which were picked out for men aged 15-64 in the latest OPCS report the mortality ratios for both classes IV and V were higher than for I and II in as many as 68 – which represents a proportionate increase compared with 10 years earlier. For only 4 causes were mortality ratios for I and II higher than for IV and V:- accidents to motor vehicle drivers, malignant neoplasm of the skin, malignant neoplasm of the brain and polyarteritis nodosa and allied conditions (OPCS, 1978, op cit, Table 4A).

3.14 But it remains difficult to explain excess mortality in terms of occupation. This is not only because factors other than the effects of occupation contribute to premature illness and death. It is because both the lifetime and total effects of occupation have not been measured or are difficult to measure. There is mobility between occupations during life, which makes difficult proper evaluation of the specific effects upon health of particular occupations. Strictly, therefore a better measure is required of length of exposure to the effects of an occupation. Secondly, the definition of an occupation and of its conditions, involves a variety of factors, each of which are likely to be related to health. They include working indoors or outdoors , the proportion of time standing or walking about; the number of hours of work; working early or late hours-of the day, or varying times of work from week to week; degree of mental and physical exertion; dexterity or agility involved; degree of warmth, light, quiet, isolation, vibration and humidity; availability of different facilities (Toilet, first aid, telephone, cloakroom or locker for outdoor clothing; coffee and tea; meals); job security; earnings and fringe benefits. We consider that delineation and measurement of such factors will help to explain differences in the health experience of people in different occupations. And changes in the nature of work itself and in the distribution of different types of work working conditions, amenities, remuneration and fringe benefits, and not only changes in the degree of protection offered against specific risks of occupations, will explain trends in health experience. We recommend elsewhere that steps be taken in research and administrative statistics to improve our knowledge of both matters (Chapter 7).

3.15. This brief review of trends in mortality for men of economically active age shows:

i. there was greater inequality of mortality between occupational classes I and V both in 1970-72 and 1959-63 than in 1949-53;

ii. between 1959-63 and 1970-72 the mortality rates of different age-groups over 35 in occupational class III and classes IV and V combined, either deteriorated or showed little or no improvement; and relative to the mortality rates of occupational classes I and II they worsened.

Women of Economically Active Age

3.16. With reservations about occupational class I (numerically a very small category – less than 1 per cent of married women) the data set out in Table 3.5 show the same “spread” of mortality for married and single women as for men. For both married and single women in class IV, and for single women in class V mortality increased relative to women generally during the 1960s.

Table 3.5: Mortality of women by occupational class (1961-1971)(England and Wales)

Women aged 15-64
Married
Single
1959-63 1970-2 1959-63 1970-2
I 77 82 83 110
II 83 87 88 79
III non-manual 103 92 90 92
III manual 115 108
IV 105 119 108 114
V 141 135 121 138

Source: Registrar General’s Decemial Supplement: 1961 p91, 503. OPCS, Decennial Supplement,, 1970-72, p.211.

3.17. Table 3.6 gives more detailed information for different age-groups. Except among the youngest age-groups the “spread” of inequality among married and single women in narrower than among men. But among some age-groups the inequalities between those in classes I and II and those in classes IV have grown. Between 1959-63 and 1970-72 it can be seen that SMRs for class IV deteriorated at all ages for men, married women and single women For class V the experience in the period is mixed, with a tendency, at least for men, for SMRs to increase at earlier ages and steadily decrease at older ages. An increase in SMRs of single women at some ages is noteworthy, but the small numbers of deaths involved has to be borne in mind, (eg only 15 at ages 15-24, and only 83 and 175 at ages 45-54, and 55-64).

Table 3.6 Trends in Standardised Mortality Ratios according to occupational class and age

Occupational Class 15-19 20-24 25-34 35-44 45-54 55-64
1959-1963 1970-1972 1959-1963 1970-1972 a 1959-1963 1970-1972 1959-1963 1970-1972 1959-1963 1970-1972 1959-1963 1970-1972
Men I 72 59 74 73 67 69 72 76 70 78 82
II 106 85 85 72 74 73 74 77 78 84 84
III nm/m 97 90 78/90 89 90/90 97 99/97 100 106/101 102 98/111
IV 118 100 137 107 118 104 117 104 115 101 112
V 142 149 164 181 199 181 169 158 147 134 128
Married Women I (38) (79) 76 83 79 75 82 78 83 76 83
II (41) (64) 82 76 81 79 80 82 83 85 91
III nm/m 97 97 85/97 99 92/100 102 93/108 102 91/111 102 92/120
IV (88) 92 115 103 119 106 121 104 120 106 118
V (159) 159 182 163 163 153 161 144 143 136 128
Single women I 97 79 132 (67) 96 82 76 86 115 83 117
II 103 70 105 56 63 65 69 82 69 99 83
III nm/m 78 72 91/80 74 72/83 73 76/81 86 86/92 104 102/126
IV 95 98 107 93 96 97 103 104 107 116 121
V 197 213 232 145 180 132 139 105 137 119 125

Source: Registrar General’s decennial Supplement (1959-63)… op cit, Tables 3A(i), 3B(i), and 3C(i)

a= 15-24

3.18. When causes of death are divided into 13 broad groups for women aged 15-64 there is markedly higher mortality among the partly skilled and unskilled classes (whether defined by their own or a husband’s occupation) in the case of:

i. infective and parasitic diseases;
ii. circulatory disease;
iii. respiratory disease;
iv. diseases of the genito-urinary system, and though less markedly;
v. congenital anomalies;
vi. diseases of the blood;
vii. endocrine and nutritional diseases, and
viii. diseases of the digestive system.

3.19.In the case of (ix) benign neoplasms there is no trend by class but in (x) mental disorders, (xi) diseases of the nervous system, (xii) malignant neoplasms and (xiii) accidents poisoning and violence, there was higher mortality in 1970-72 among classes I and II.

Infant Mortality

3.20 Inequality in mortality among infants reflects that among adults, for both England and Wales and Scotland. Table 3.7 shows that although deaths per 1,000 live births in England and Wales have diminished among all classes the relative excess in combined classes IV and V over I and II increased between 1959-63 and 1970-72. Inequality remained marked in 1975 (Morris, 1979, p.87). As the Court Committee commented, between 1950 and 1973 the perinatal mortality rate declined by 45% for those of professional and 49% for those of managerial class but by only 34% for those of unskilled manual class (Court Report, P7l).

3.21 Scottish trends are similar. During the 1960’s infant mortality rates of each occupational class continued to decline but the class gradient remained broadly the same. The same had been true of earlier decades ( Morris and Heady 1955)

Table 3.7 Trends in infant mortality by occupational class (England and Wales)

Ratios of actual to expected deaths of infants
1930-32 1949-53 1959-63 1970-72
I 53 63 73 66
II 73 73 77
III 94 97 98 94
IV 108 114 119 111
V 125 138 175
Infant deaths per 100 legitimate live births
I 32 19 12
II 46 22 14
III 59 28 16
IV 63 35 20
V 80 42 31

Source 1959-63 calculated by Julian Tudor Hart, Lancet 22/1/72 p192. 1970-72 OPCS

3.22 Neonatal and post-natal mortality rates for Scotland are shown in table 3.8. It can be seen that the neonatal rates for class V remained about twice as high, and the post-natal rates 6 times as high for class V as for class I in 1975, compared with 1946. In the period 1946-1960 there was some narrowing of the gap between I and V but a reversal of this trend for 1960-1975.

Table 3.8 Neonatal and Post natal Mortality rates (per 1000 live births) by occupational class (Scotland)

Mortality per 1000 live births % decrease
1946 1960 1975 1946-60 1960-75
Neonatal mortality
I 16.7 13 7.6 22 41
II 25 17.2 8.7 31 49
III 29.3 17.1 11.2 42 34
IV 31.1 20.7 10.8 33 38
V 36.9 21 14.6 43 30
Post-natal mortality
I 5.5 2.7 1.8 51 33
II 12.8 4.3 3.8 66 12
III 22 7.2 4.7 67 35
IV 29.3 10.2 5.1 65 50
V 36.1 12.8 10.8 64 16

3.33. Rates of infant mortality have maintained a steady pattern of decline in the post war era. This pattern of decline has been recorded for all occupational classes. Table 3.9 rises the trends for the different components of infant mortality for England. As elsewhere rates listed in Table 3-9 are not strictly comparable because the conventions of classification have changed. These changes mainly affect the figures for 1950 and 1964 but by grouping classes IV and V together the problems of changes of classification can be minimised and comparison enhanced.

3.34. The greatest improvements have been recorded in the rate of post-neo-natal mortality (death from the fifth week to the end of the first year of life) where in classes III to V as well as in the ‘illegitimate’ category rates have fallen by more than 60 per cent during the last quarter of a century. This decline represents a narrowing of the class differential between I plus II and the rest even though the rate for IV plus V and for illegitimate births in 1975-6 was still higher than the rate of I plus II in 1950. It should be noted that the data summarised in the table are collapsed into only 3 categories, compared with 6 in the decennial supplement for 1970-72.

3.35. For neo-natal mortality (death during the first month of life) the degree of improvement has been rather less. Occupational classes IV plus V have made the slowest progressand their failure to maintain parity with the result is particularly marked aver the last decade.

3.36. The same conclusion emerges from the trends for stillbirths. The greatest progress over the 25 year period was made by class I plus II and the least progress for IV plus V. These trends, along with those for neo-natal deaths represent a gradual widening of the gap between the 2 classes at the top and the bottom of the scale. The most recent annual data given below in Table 3.10 do not follow this trend and suggest a catching up process on the part of classes IV and V.

3.37 Over the 25 year period the percentage of illegitimate births has almost doubled. This statistical trend reflects to some extent, real changes in the social meaning of illegitimacy with something of a lessening of the stigma attached to being born outside of wedlock. A growing (but still tiny) minority of women today actually choose to remain unmarried and yet have children and such women are often highly educated and employed in secure and well-paid occupations. For these women, and their children, illegitimacy carries few of the sanctions and hardships which are traditionally associated with it and this pattern of social and cultural change may well have contributed to the fall in the high rate of mortality associated with illegitimate birth.

Table 3.9 Trends in infant mortality 1950-76 (rates per 1000 live births) England and Wales

rates per 1000 live births % improvement
Still Births 1950 1964 1975/6 1950/64 1964/76 overall 1950/76
I & II 18.9 11.8 7.8 38 34 59
III 21.5 15.6 9.8 27 37 53
IV & V 24.6 17.2 12 30 30 51
Illegitimate 29.3 21.3 12.7 27 40 57
Neonatal deaths (under 4 weeks)
I & II 13.7 9.2 7.9 33 14 42
III 15.9 11.8 9.3 26 21 42
IV & V 18.4 13.2 11.7 32 22 47
Illegitimate 28.4 19.3 15 32 22 47
Postneonatal deaths (1-11 months)
I & II 5.5 3.5 3 36 14 45
III 10.3 5.4 4 48 26 61
IV & V 15.1 7.6 6.1 50 20 60
Illegitimate 19.9 9.2 7.4 54 20 63
Illegitimate births as % of all live births 5.34 7.6 9.2 +42 +21 42

Recent changes in Infant Mortality: 1975 and 1976

3.38. The most recent data published by OPCS on infant mortality is for the years 1975-76. (Occasional paper No 12, OPCS, 1978). These data are the first set to be published in a continuous series derived from a new linkage of birth and death registration. Table 3-10 presents the data for 1975 and for 1976. Occupational classes I and II and IV and V have been aggregated for purposes of comparison with the earlier ad hoc studies carried out during the fifties and sixties.

Table 3.10 Infant mortality by occupational class 1975-1976

rates per 1000 live legitimate births
rate per 1000 illegitimate births
occupational class
Other
Stillbirths I &II III IV & V I-V
1975 8 10.1 12.6 10.1 10.2 12.9
1976 7.7 9.6 11.3 9.4 8.3 12.6
% improvement 3.7% 4.9% 10.3% 6.9% 18.6% 2.3%
Perinatal (stillbirths and under 1 week)
1975 15 18.3 22.8 18.4 21.2 26.4
1976 13.9 16.8 20.5 16.8 22.12 24.3
% improvement 7.3% 8.2% 10.1% 8.7% 4.8% 8%
Neo-natal (under 4 weeks)
1975 8.4 9.8 12.3 9.9 12.9 16.1
1976 7.5 8.7 11.1 8.9 16.2 13.9
% improvement 10.7% 11.2% 9.8% 10.1% 25.6% 13.7%
Post neonatal (1-11 months)
1975 3.2 4.2 6.5 4.4 7.5 7.6
1976 2.7 3.8 5.8 4 8.9 7.1
% improvement 15.7% 9.5% 10.8% 9.1% -18.6% 6.6%
% fall in no of births 1975-6 -0.63% -4.09% -1.5% -2.59% -18.9% -2.05%

Source: Social and Biological Factors in Infant mortality 1975-76. OPCS

“Other” includes the armed forces, inadequately described occupations, persons who were unoccupied and occupations not stated. Note also between 1975 and 1976 the rate of unemployment in the UK (excluding school leavers) climbed from 3.9 to 5.4.

3.39. During 1975-76 rates of infant mortality continued to decline in all occupational classes. Up to the end of the first week of life the percentage improvement was somewhat higher in classes IV and V than other classes. For neo-natal mortality (death during the first month of life), there was less variation between the 5 classes and for post neo-natal mortality combined classes I and II showed the most improvement. It is always hazardous to draw inferences on the basis of results for only 2 years however and despite the decline in stillbirths among classes IV and V the trends in general in infant mortality do not yet suggest much change in the pattern of relative inequality of the last 2 decades.

3.40. Attention needs to be called to illegitimate births and “other” legitimate births in Table 3-10. Neonatal and post-neonatal mortality rates for these 2 categories are high. The latter category includes the armed forces, the unemployed and others who could not be assigned to an occupational class. Mortality rates during the period from the end of the first week to the end of the first year of life have currently increased by over a fifth. However, in 1975-76 an improvement occurred in the rate of stillbirth. How can such variations be explained? The “other” category accounted for 727 deaths in 1975 and 644 in 1976. The variations in the rates may be an artefact of the measurement process induced by the problematic nature of classification. On the other hand the category includes some seriously deprived families. Between 1975 and 19769 unemployment in Britain jumped to a level unknown previously in the period following the second World War, The numbers unemployed have remained substantially in excess of one million throughout the late 1970s and the number unemployed for 6 months or more has steadily increased. Perhaps the increase in infant mortality recorded here only among the category which includes the unemployed is a reflection of the way in which the economic “health” of the nation imposes upon the physical welfare of the new born in the manner suggested by Brenner. Brenner found that infant mortality rates in the United States were related to economic recessions, with a lag of from one to two years of the peak average mortality behind the peak of unemployment (Brenner 1973, p 155) The hypothesis specified that as a result of maternal deprivation or lack of medical care, in addition to psychological stress, economic decline would be associated with elevated infant mortality rates. More recent work is believed by Brenner to have confirmed “that undesirable changes such as unemployment and income loss are substantially more generative of pathology” (Brenner 1979, p22).

Maternal Mortality

3.41 The trend by occupational class of maternal mortality are shown in table 3.11. During a period of less than a decade mortality fell by more than a third. Although that of class I fell less sharply than other classes inequality between the more numerous class II and classes Iv and V remained about the same. The table shows that mortality among women in class V was nearly double that in classes I and II.

Table 3.11 Maternal mortality by occupational class: married women 15 and over (England Wales)

Rate per 100,000 births
Occupational class 1962-65 1970-72 % decline
I 16 13 -19
II 22 11 -50
III non-manual 23 13 -39
III manual 15
IV 32 19 -41
V 44 23 -48
All married women 26 16 -38

Mortality of Children

3.42 The ratio of class V to class I deaths is higher in the first to the twelfth months of life than in later years of childhood. The OPCS report for 1970-72 shows than in infancy (after the first month) the ratio was 4.2 for males and 5.0 for females (OPCS, 1978, op. cit., Table 7.7). As table 3.12 shows this ratio is lower at older ages. The trends by class among children of different age have varied. Between one and four years of age there has been a small reduction in the class differential (especially for girls), little or no change between the ages of 5 and 9 and an increase in the differential between the ages of 10 and 14. Excepting stillbirths, fewer females than males in 1970-72 died in childhood in every age-group and class.

Table 3.12 Mortality of children 1-14 by occupational class (England)

Age
1-4
5-9
10-14
Occupational Class 1959-63 1970-2 1959-63 1970-2 1959-63 1970-2
males females males females males females
I 69 61 57 33 28 27 30 28 21
II 73 62 54 35 31 24 29 31 21
III non- manual 89 75 62 41 39 27 31 35 21
III 76 62 42 27 35 21
IV 93 93 84 41 44 33 30 40 26
V 154 129 109 67 69 43 41 56 33
V as % of I 223 211 191 203 246 159 137 200 157

3.43 For boys aged 1-14, mortality ratioes for classes IV and V in 1970-72 were both nigher than for classes I and II for 23 of 38 causes of death, compared with only one cause (asthma) where the ratios were lower. For girls the corresponding figures were 22 and 0 respectively.

The elderly

3.44 The occupational class differential in mortality diminishes in the late 30s and 40s and further diminishes as the pensionable ages are approaches. But classification by occupation becomes less meaningful for the elderly. Information about occupation and cause of death recorded on the death certificates of persons of 75 years and over is sometimes imprecise or inaccurate. In the case of widows, especially if dying in the late seventies or afterwards, they may be classified according to the last occupation of husbands dying many years earlier. This may be a weak indicator of life chances and lifestyles over lengthy periods. Again there is evidence that men who had worked for some years before retirement in unskilled occupations tend nonetheless to be listed at death as having worked in skilled occupations if in fact that had been the case previously in their lives (OPCS, 1978, op cit, P.7).

3.45. It is hoped that more reliable data for the elderly will emerge from the longditudinal survey being carried out by the OPCS. Some of the first results have been given above in Chapter 2 (Table 2.10). For men the class gradient corresponds quite closely with that based on less reliable information for 1959-63 and published in a previous Decennial Supplement (Registrar General’s Decennial Supplement, 1959-63 op cit, Table 3A(i)). At that stage the data for 1949-53 and 1959-63, even taking account of changes of classification, indicated relative deterioration in the rates for class V men aged 65-74 (as for younger age groups). (Ibid, p.24).

3.46. Data about the mortality of men aged 65-74 in individual occupations in 1970-72 shows there were very large differences between some groups of manual workers and some groups of non manual workers. For example, the mortality ratio for former miners and quarrymen was 149 gas, coke and chemicals makers 150, and furnaces, forge, foundry and rolling mill workers 162, compared with administrators and managers with a ratio of 88 and professional, technical workers and artists with a ratio of 89. (OPCS 1978, op. cit, p.167). Compared with 1959-63 the mortality ratios of several manual occupations (including the 3 listed above) deteriorated, relative to the ratio for all men. (Registrar General’s Decennial Supplement, 1971, op cit, Table 3A(i)).

Trends in Mortality by Age

47, The trends during the life-span have been shown for both sexes. Inequalities are largest during the first year of life especially after the end of the first month. After some diminution in the differential between the classes during childhood it widens again and reaches a second smaller, peak in early adulthood. The differential narrows in late middle age for women and not only men (Table 3.4) and appears to remain small among the elderly. These trends with age apply whether we take the difference between classes V and I or IV and I (Table 3.13). However we must emphasise that although the relative difference between classes V and I and IV and I diminishes in middle and old age the absolute difference in numbers of deaths increases. For example, at 60-64 that additional numbers of deaths of men per million population in class V than in class I was 10,622, compared with 868 per million at 20-24 (OPCS, 1978, op.cit., p37)

Table 3.13 Male mortality rates at different ages in occupational class IV and V as a percentage of those in class I

Class IV as per cent class I Class V as per cent class I
1959-63 1970-72 1959-63 1970-72
Stillbirths 148 199
Perinatal (still births, and less than 1 week) 145 195
Early neonatal (less than 1 week) 143 192
Late neonatal (1-3 weeks) 164 249
Post neonatal (1-11 months) 211 421
Total infant mortality (under 1 year) 162 255
1-4 years 153 212
5-9 years 160 246
10-14 years 141 200
Total 1-14 151 219
15-19 148 197 161
20-24 184 254 236
25-34 145 176 246 297
35-44 151 163 263 235
45-54 137 163 209 209
55-64 130 137 171 157

3.48. The structure of inequality in mortality rates during the life-span does not appear to have changed much in recent decades. Table 3.13 shows that although the ratio of class V deaths to class I deaths diminished for some age-groups during the 1960s it increased for others, and the ratio of class IV deaths to class I deaths increased in all age-groups. If we combine classes IV and V then between 1959-63 and 1970-72 their mortality worsened, relative to classes I and II, for each ten-year age-group between 25 and 65. It should also be noted that class III also slipped back (Table 3-4). These trends for adults, as those quoted earlier for infants, are very serious, and need to be carefully analysed and explained.

Morbidity

3.49 As pointed out earlier it is difficult to trace morbidity data by class for any span of years. The General Household Survey has now been running since 1971 but it is still too early to distinguish reliable trends in health from that source. Two examples are given below. Table 3.14 shows that absence from work because of sickness or injury is sharply related to class but that the precise rates are liable to fluctuation from year to year. The average number of days lost through illness or accident among unskilled manual men was 41/2 times that among professional men in 1971 and 1972 (the data are not given for 1977).

Table 3.14 Working males absent from work due to illness or injury (England and Wales 1971)

Socio-economic group Absent from work due to illness or injury in a two week reference period – rate per 100 Average number of work days lost per person per year
1971 1972 1977 (rates given only to nearest 10) 1971 1972
Professional 37 21 20 3.9 3.1
Employers and managers 37 39 20 7.2 6.2
Intermediate and junior non-manual 44 48 50 7.6 6.0
Skilled manual 57 56 60 9.3 9.4
Semi-skilled manual 56 68 70 11.5 10.5
Unskilled manual 88 99 60 18.4 17.6
All groups 52 54 40 9.1 8.4

3.50 Table 3.15 also shows a class gradient during the 1970s for restricted activity (acute sickness), long-standing (chronic) illness and GP consultations but the rates are even more uneven fromyear to year and in some years, for some age-groups, there is no perceptible gradient. The figures illustrate the problems of drawing conclusions about trends in self-reported sickness, for some major sex/age-groups if not for the population as a whole, during a short span of years.

Table 3.15 rates of long standing and acute illness and consultations per 1000 of occupational classes IV and V, as a per cent class I (1971-76) Britain

Sex/class/health indicator 1971 1972 1973 1974 1975 1976
Males Class IV
long-standing illness 158 163 157 160 157
acute sickness 126 133 110 134 102 80
(percent of class II) 120 120 125 119 124 99
GP consultations 133 132 125 146 129 91
Males class V
long-standing illness 196 213 218 197 196
acute sickness 155 181 129 150 85 102
(percent of class II) 148 163 146 134 103 127
GP consultations 143 175 164 147 121 125
Females Class IV
long-standing illness 274 214 182 197 176
acute sickness 105 128 115 115 134 95
(percent of class II) 111 134 110 123 128 130
GP consultations 180 150 110 123 114
Females class V
long-standing illness 320 276 204 253 246
acute sickness 107 141 113 122 128 94
(percent of class II) 114 146 109 131 122 129
GP consultations 117 150 120 107 102

INEQUALITIES AND DISTRIBUTION

3.51. When examining indicators of health for different occupational or socioeconomic classes for a span of years any changes that may be taking place in the relative size of particular classes may be as important as any changes in the inequality between classes in assessing trends in the overall health of the population. Some commentators have pointed out that while inequalities in health between the unskilled manual class and other classes may not have diminished, or may even have increased that class has become smaller and therefore there has still been an “improvement” in the distribution of health. This change has been regarded as compensation for the lack of any closing of the gap between classes.

3.52. Two comments should be made. The first is that changes in occupational classification have caused commentators to believe that the reduction of class V since 1931 has been greater than it has. This is shown by the adjusted and unadjusted figures in Table 3.16. Since 1961, for example, the fall in proportion of men in class V has been small and in absolute numbers has not fallen at all.

3.53. The second is that relatively poor health experience applies to other manual classes and especially class IV and that though this class too has fallen in proportion to population it continues to make up, together with class V, more than a quarter of the economically active male population, Mortality indicators for class IV, relative to other classes, have shown some deterioration between the early 1960s and early 1970s and, as discussed above, it would be wrong to confine discussion of health inequalities to class V.

Table 3.16 Percentage of economically active men in different occupational social classes 1931, 1951, 1961, 1966, 1971 (England and Wales)

Occupational class
1931
1951
1961 1966 1971
I 1.8 2.2 2.7 3.2 4.0 4.5 5.0
II 12.0 12.8 12.8 14.3 14.9 15.7 18.2
III 47.8 48.9 51.5 53.4 51.6 50.3 50.5
IV 25.5 18.2 23.3 16.2 20.5 20.6 18.0
V 12.9 17.8 9.7 12.9 8.9 8.8 8.4
Total 100 100 100 100 100 100 100
Number (Thousands)
13,247
14,067
14,649 15,686 15,668

Percentage have been weighted to allow for changes in classification between 1931 and 1961 censuses. The second column for 1931 and 1951 are based on the classification at those times.

CONCLUSION

3.54. Our review of trends in inequalities of health has produced some disturbing conclusions.

3.55. As explained earlier in the chapter trends are not easy to trace, either because of inconsistencies in the categorization of data or changes in occupational classification. Our conclusions make allowances for these. problems. We have also had the opportunity of comparing trends in infant mortality with trends in mortality of people at later ages. Analyses in the literature have tended to concentrate attention either on infant mortality or mortality of males of economically active age rather than on the population of both sexes of different age.

3.56. Perhaps the most important general finding in the chapter is the lack of improvement, and indeed in some respects deterioration, of the health experience not merely of occupational class V but also class IV in health relative to occupational class I, as judged by mortality indicators during the 1960s and early 1970s. The more specific conclusions underlying this finding, are as follows. (These conclusions apply to England and Wales. Scottish experience has been rather similar, though certain differences are noted in the text).

i. Mortality rates of males are higher at every age than of females and in recent decades the difference between the sexes has become relatively greater.

ii. For men of economically active age there was greater inequality of mortality between occupational classes I and V both in 1970-72 and 1959-63 than in 1949-53.

iii. For economically active men the mortality rates of occupational class III and combined classes IV and V for age-groups aver 35 either deteriorated or showed little or no improvement between 1959-63 and 1970-72. Relative to the mortality rates of occupational classes I and II they worsened.

iv. For women aged 15-64 the standardised mortality ratios of combined classes IV and V deteriorated. For married and single women in class IV (the most numerous class) they deteriorated at all ages.

v. Although deaths per thousand live births in England and Wales have diminished among all classes the relative excess in combined classes IV and V over I and II increased between 1959-63 and 1970-72.

vi. During period of less than a decade maternal mortality fell by more than a third. Although that of class I fell less sharply than other classes inequality between the more numerous class II and classes IV and V remained about the same.

vii. Among children between 1 and 4 years of age, there has been a small reduction in the class differential (especially for girls), for children aged 5 to 9 little or no change, but for children aged 10 to 14 an increase in the differential. For boys aged 1-14, mortality ratios for classes IV and V in 1970-72 were both higher than for classes I and II for 23 of 38 causes of death compared with only one cause (asthma) where the ratios were lower. For girls the corresponding figures were 22 and 0 respectively. There is evidence that as rates of child death from a specific condition decline to very low levels class gradients do disappear. The gradual elimination of death from rheumatic heart disease over the post war period provides evidence of this (Morris, 1959).

CHAPTER 3 – References

ADELSTEIN, A.M., and WHITE, G.C., “Causes of Children’s Deaths Analysed by Social Class (1959-63)”, in Child Health: A Collection of Studies. London, HMSO, 1976.

BRENNER, M.H., “Foetal, Infant and Maternal Mortality daring Periods of Economic Instability”, International Journal of Health Services, Vol 3, 1973.

BRENNER, M.H., “Influence of the Social Environment and Psycho pathology: The Historical Perspective”, in Barrett, J.E., et al (eda), Stress and Mental Disorders t New York, Raven Press, 1979.

Fit for the Future The Report Of the Committee on Child Health Services ( Court Report), Cmnd, 6684 London, HMSO, 1977

FOX, A.J., and ADELSTEIN, A.M., “Occupational Mortality: Work or Way of Life?” Journal of Epidemiology and Community Health, vol 32,No 2, June, 1978.

HIGGINS, I.T.T., et al. “Population Studies of Chronic Respiratory Disease; A Comparison of Miners, Foundry Workers and others in Staveley, Derbyshire”, British Journal of Industrial Medicine. Vol 16, 1959.

McKEOWN, T., The Role of Medicine. London, The Nuffield Provincial Hospitals Trust, 1976.

McLAUGHLIN, A.I.G., “Chronic Bronchitis and Occupation”, British Medical Journal. Vol 1, 1966.

Medical Research Council, “Chronic Bronchitis and Occupation”, British Medical Journal, Vol 1, 1966

MORRIS, J.N., “Health and Social Class” The Lancet February 7th, 1959.

MORRIS, J.N., “Social Inequalities Undiminished”, The Lancet, January 13th» 1979.

MORRIS, J.N., Uses of Epidemiology. Churchill Livingstone, Edinburgh, 1975 (3rd ed).,

MORRIS, J.N., and HEADY, J.A. “Social and biological factors in infant mort V mortality in relation to the father’s occupation 1911-1950 The Lancet 1 (1955) 554.

OPCS. Occupational Mortality. Decennial Supplement. 1970-72. England and Wales. London, HMSO, 1978.

Registrar General’s Decennial Supplement. England and Wales. 1961: Occupational Mortality Tables. London, HMSO, 1971•

Scottish Home and Health Department, Towards an Integrated Child Health Service Edinburgh, HMSO, 1973.

Social and Biological Factors in Infant Mortality. 1975-76. Occasional Paper No 12, OPCS, 1978.

TOWNSEND, P. “Inequality and the Health Services11, The Lancet. 15 June, 1974

3 Comments

  1. fatima says:

    good

  2. fatima says:

    good explenations of the black report

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