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Studies in Poverty, Inequality and Social Exclusionx
Objective: To investigate the association between social circumstances in childhood and mortality from various causes of death in adulthood.
Design: Prospective observational study.
Setting: 27 workplaces in the west of Scotland.
Participants: 5,645 men aged 35-64 years at the time of examination.
Main outcome measure: Death from various causes.
Results: Men whose fathers had manual occupations when they were children were more likely as adults to have manual jobs and be living in deprived areas. Gradients in mortality from coronary heart disease, stroke, lung cancer, stomach cancer, and respiratory disease were seen (all p<0.05), generally increasing from men whose fathers had professional and managerial occupations (social classes I and II) to those whose fathers had semiskilled and unskilled manual occupations (social classes IV and V). Relative rates of mortality adjusted for age for men with fathers in manual versus non-manual occupations were 1.52 (95% CI: 1.24-1.87) for coronary heart disease, 1.83 (1.13-2.94) for stroke, 1.65 (1.12-2.43) for lung cancer, 2.06 (0.93-4.57) for stomach cancer, and 2.01 (1.17-3.48) for respiratory disease. Mortality from other cancers and accidental and violent death showed no association with fathers’ social class. Adjustment for adult socioeconomic circumstances and risk factors did not alter results for mortality from stroke and stomach cancer, attenuated the increased risk of coronary heart disease and respiratory disease, and essentially eliminated the association with lung cancer.
Conclusions: Adverse socioeconomic circumstances in childhood have a specific influence on mortality from stroke and stomach cancer in adulthood, which is not due to the continuity of social disadvantage throughout life. Deprivation in childhood influences risk of mortality from coronary heart disease and respiratory disease in adulthood, although an additive influence of adulthood circumstances is seen in these cases. Mortality from lung cancer, other cancers, and accidents and violence is predominantly influenced by risk factors that are related to social circumstances in adulthood.
Mortality relates to voting patterns within areas: mortality is higher the greater the proportion of the electorate who vote Labour or abstain and the converse is the case with regard to the percentage of the electorate who vote Conservative.1 This reflects the socioeconomic characteristics of individuals who vote for these parties, with Labour being identified with the working class and the Conservatives with the middle class. In the 1997 Election, Labour was returned to office after 18 years in opposition. The government has released targets for reducing health inequalities and made it clear that such a reduction is a principal policy aim.2 These targets may be difficult to meet for two reasons. Firstly, factors influencing inequalities in adult health act from an early age onwards and may not respond rapidly to social change;3 secondly, there has as yet been no reduction in social inequality (as indexed by income inequality) under the Labour government.4 Here we use premature mortality as an indicator of which population groups have fared best under the present government.
The mortality data are from the Office for National Statistics’ digital records of all deaths in England and Wales and the equivalent records from the General Register Office for Scotland.1 The full postcode of the usual residence of the deceased was used to assign each death to one of the 641 parliamentary constituencies to reflect where the deceased usually lived. The death data were provided for single years. Standardised mortality ratios (SMRs) and directly age-standardised mortality for the age range 0-64 years were calculated using rates for England and Wales.
Indices of deprivation based on the characteristics of areas of residence are widely used in epidemiology and public health, and have a number of possible applications. First, they may be used when data describing an individual’s socioeconomic circumstances have not been, or cannot be, collected directly.1 Second, they may inform the distribution of health service resources, for primary care, community health services and hospital services.2 Third, in ecological studies examining the effects of local environmental conditions on health they allow investigators to control for possible socioeconomic confounding.3 Lastly, they can be used when the main analytic interest lies in the effects of characteristics of place of residence on health.3,5
Since the particular socioeconomic and demographic characteristics of areas which are related to ill health could differ for different diseases, we have compared how two indices – the Townsend deprivation index and a measure developed by Congdon which has been referred to as an anomie index4,5 – relate to cause-specific mortality. The first of these indices was developed as a measure of deprivation; the second as a measure of social fragmentation, based on Durkheim’s theoretical concept of social integration. Since Durkheim’s concept of social integration differs from his notion of anomie, we refer to the Congdon measure as an index of social fragmentation.7 Mortality data from 1981-92 for 633 parliamentary consistencies of Britain (as defined in 1991) were used. The Townsend deprivation score was based on 1981 and 1991 Census data regarding unemployment, car ownership, overcrowded housing and housing tenure.
In Chapter Nine we presented data on the association between voting patterns and mortality in England and Wales during the 1983, 1987, and 1992 British General Elections.1 There was a strong negative association between voting Conservative and mortality and a strong positive association between voting Labour and mortality; there was a weaker negative association between voting Liberal Democrat and mortality and a weaker positive association between abstention and mortality. The 1997 General Election, in which a Labour government was elected with a large majority, was interpreted as reflecting a breakdown of traditional voting loyalties.2,3 We analysed the results of the 1997 General Election in England and Wales with the exception of two seats: Tatton, in which an independent candidate stood against a Conservative alleged to have taken money in return for asking questions in Parliament, and West Bromich West, where the speaker of the House of Commons was unopposed. We used mortality data for 1990-92; these are the most recent data from the 1991 Census for which estimates of the population at risk of death were available. In Table 1 we have added our findings for the 1997 Election to the results from previous elections.
The relation between childhood socioeconomic position and adult cardiovascular mortality is examined in 3,750 individuals whose families took part in the Carnegie survey of family diet and health in England and Scotland between 1937 and 1939. The trend in coronary heart disease mortality across social position groups was not statistically significant at conventional levels (p=0.12), while a strong linear trend was seen for stroke mortality (p=0.01). Adjustment for the Townsend deprivation index of area of residence during adult life did not materially alter these findings, indicating that the effects of socioeconomic influences upon particular cardiovascular diseases differ according to the age at which they are experienced.
The potential reduction in mortality that could be achieved through reductions in smoking behaviour has often been calculated on the assumption that smokers would reduce their mortality rate to that of the ex-smokers in the population if they quit, or would have the mortality rates of lifetime non-smokers if they had never started smoking.1-3 In a recent contribution to this journal, Sterling and Weinkam4 have pointed out that since smoking is strongly related to occupation and to socioeconomic position, these assumptions do not hold. The smoking group within a population will over-represent the working class, whose mortality exceeds that of the middle classes independently of smoking. Thus a more appropriate comparison would be between the mortality rates of smokers, ex-smokers and non-smokers within the same socioeconomic groups.
In this chapter we demonstrate the effects of making such appropriate comparisons when predicting the benefits of non-smoking. We use data from the Whitehall Study of London civil servants, in which both occupational grade and smoking have been shown to be strongly associated with mortality rates.5,6 The extent of confounding due to the relationship between smoking and employment grade is examined.
Death in Hollywood brings to mind the page-turning pleasures of Kenneth Anger’s classic tales of a contemporary Babylon.1,2 The mixture of drugs, drink, sex, violence, monstrous egos, gangsterism, speed and madness is often most starkly revealed in the premature deaths of (sometimes has-been) stars. The suicides can be particularly indicative of the roller coaster nature of fame. Albert Dekker, who wrote sections of the poor reviews from his last film in crimson lipstick on his body before hanging himself; Lou Tellegen, stabbing himself with gold scissors engraved with his name, surrounded by film posters, photographs and newspaper cuttings from his days of triumph; or Peg Enwistle who jumped to her death from one of the giant letters of the Hollywood sign (setting off a spate of copycat leaps into oblivion). Among the better known are (probably) Marilyn Monroe, or her Oscar-winning co-star in All About Eve, George Sanders, whose note read “Dear World: I am leaving you because I am bored. I am leaving you with your worries in this sweet cesspool”. To these can be added the long list of those for whom the road to excess lead to premature demise, from the stars of the silent screen such as Wally Reid (morphine), John Gilbert (drink), Alma Rubens (heroin), Olive Thomas (barbiturates), Marie Prevost (drink), Barbara La Marr (everything), through to more recent times, with Oscar-winner and heroin enthusiast Bobby Driscoll, found dead in a New York tenement, or River Phoenix collapsing after his last speedball outside Johnny Depp’s Viper Room club in Los Angeles.
Recently there has been a shift in the focus of investigations of the causes of chronic disease from health-related behaviours and risk factors acting during adulthood to experiences occurring during early life: in childhood, infancy and during intra-uterine development. The work of the Medical Research Council (MRC) Environmental Epidemiology Unit in Southampton, under the direction of Professor David Barker, has been largely instrumental in this. The unit’s work has occasioned an editorial in the British Medical Journal claiming that the ‘early life experience’ paradigm is a strong candidate for the replacement of the ‘lifestyle paradigm’ of chronic disease aetiology.1
The speed with which the findings of this research programme have entered policy discussions is noteworthy. The first publication2 of the now extensive series3 from Barker’s team appeared only in 1986, but by 1989 the annual report of the Chief Medical Officer was already noting “the importance of health in childhood as a determinant of subsequent health in adult life”,4 while in 1992 the Department of Health strategy document The health of the nation made reference to the “increasing evidence to suggest that there is a relationship between growth and development starting from before birth and during childhood, and risk in later life of CHD (coronary heart disease)”.5
Study objectives: In the UK, studies of socioeconomic differentials in mortality have generally relied upon occupational social class as the index of socioeconomic position, while in the US, measures based on education have been widely used. These two measures have different characteristics; for example, social class can change throughout adult life, while education is unlikely to alter after early adulthood. Therefore, different interpretations can be given to the mortality differentials that are seen. The objective of this analysis is to demonstrate the profile of mortality differentials, and the factors underlying these differentials, which are associated with the two socioeconomic measures.
Design: Prospective observational study.
Setting: 27 work places in the west of Scotland.
Participants: 5,749 men aged 35-64 who completed questionnaires and were examined between 1970 and 1973.
Findings: At baseline, similar gradients between socioeconomic position and blood pressure, height, lung function, and smoking behaviour were seen, regardless of whether the education or social class measure was used. Manual social class and early termination of full-time education were associated with higher blood pressure, shorter height, poorer lung function, and a higher prevalence of smoking. Within education strata, the graded association between smoking and social class remains strong, whereas within social class groups the relation between education and smoking is attenuated. Over 21 years of follow-up, 1,639 of the men died. Mortality from all-causes and from three broad cause of death groups (cardiovascular disease, malignant disease, and other causes) showed similar associations with social class and education. For all-cause of death groups, men in manual social classes and men who terminated full-time education at an early age had higher death rates. Cardiovascular disease was the cause of death group most strongly associated with education, while the noncardiovascular noncancer category was the cause of death group most strongly associated with adulthood social class. The graded association between social class and all-cause mortality remains strong and significant within education strata, whereas within social class strata the relation between education and mortality is less clear.
Conclusions: As a single indicator of socioeconomic position, occupational social class in adulthood is a better discriminator of socioeconomic differentials in mortality and smoking behaviour than is education. This argues against interpretations that see cultural rather than material resources as being the key determinants of socioeconomic differentials in health. The stronger association of education with death from cardiovascular causes than with other causes of death may reflect the function of education as an index of socioeconomic circumstances in early life, which appear to have a particular influence on the risk of cardiovascular disease.