Monday, 28 December 2015

An example of qualitative work?

I promised to give an example of what I thought might be one approach to doing qualitative research on health inequality in an unfamiliar culture.
This came from merely a conversation I once had with someone from Hong Kong who insisted there was no such thing as social class there. Social class is a property of the industrial structure, and I don't know anything about industrial structure in Hong Kong so I could not argue with this. So if one wanted to do research on health inequality there, how to proceed?
I decided to try asking about social status. Using my understanding of caste systems (from undergraduate days) I zeroed in on some questions about co-mensality and intermarriage. I started with intermarriage and did not (as it turned out) have to go any further.
"Lets say you had a daughter and she told you she had fallen in love and wanted to marry", I proposed to my friend. "What sort of guy would you be hoping she would want to marry?"
"Well", he replied, "of course he would need to be Chinese" (my friend is Chinese).
I said "OK, but would there be anything else about the potential husband that you and your wife would really prefer?"
My friend thought for a few minutes. At last he said
"Oh! You mean colour! Yes, of course, I understand".
So here we have an example of a discovery about a social status hierarchy. I had previously had no idea whatever that, within the Chinese community in Hong Kong (which I had realised was of high status and pretty endogamous), there were additional gradations of colour.
But if I had not already had a lot of ideas at the back of my mind, ideas that arise from reading theories about social inequality of different types, I would not have (1) been aware of the difference between class and status (2) had any idea of how to ask questions that might elicit relevant responses for the discovery of status systems.
I later discovered, partly by talking to experts and partly by reading additional literature, that within the African-American population there is well known to be a so called "pigmentocracy" in which those of darker skin colour have a lower status. This can be shown to even have associations with health. That indicates to me that the colour hierarchy is a very profound and stable phenomenon that "gets under the skin".
Since becoming aware of this phenomenon I have learned about its effects on the lives of several friends. This is anecdotal stuff of course. But if I had not been taught about the criteria for caste membership, I would never have even begun to realise that "pigmentocracy" existed at all, certainly not in Hong Kong.
The point being that without asking questions informed by social theory, a basic feature of social inequality might have been totally missed by qualitative work.

Tuesday, 15 December 2015

Are health inequalities less marked during "youth"?

Someone tweeted me a question about the famous (some years ago) "Health Equalization in Youth" hypothesis and I said it would take more than 140 characters to reply. So here it is in a few more characters

For a start it is called "Health Equalization" because health inequalities are very marked in the perinatal (not neonatal) period and in infancy. But between around 14 and 18 (depending on what paper you are reading,sometimes it goes higher) years of age it seems that health inequality is indeed lower than after around age 30. It does depend on how you measure health, however. Social class differences in average height, for example, are just as great in "youth" as earlier or later in the life course (or they were last time I looked). Class differences in, for example, louse infestation are also large. It is in mortality that we really see the smaller health gap.

Well, not many people, thank goodness, die during adolescence (this is changing now, but it was true in the 1980s and 1990s). At this time, cancers were one of the more common (not common really, just more common than heart disease which was the biggest killer in the adult population) causes of death in adolescents and cancers do not generally have a big social gradient. Apart from lung cancer, and this is unknown in young people. Leukaemia, for example, did not at this time have much of one as far as I remember.

The importance of the idea, however, was in the light some authors thought it shone on how health inequality in adulthood emerges. If, they argued, inequality in health according to the social class of one's parents was low in adolescence, but inequality according to one's own occupational class then emerged strongly by age 35 or so, maybe this tells us something about it. Perhaps it is that there are unhealthy adolescents scattered through the population at random, regardless of their parents social class. During youth, the deaths of these unhealthy adolescents will not, therefore, show a health gradient. What causes inequality in mortality later on in the life course is that the unhealthy ones (who were going to die anyway) could only get the lousiest, worst paid and most hazardous jobs? So although it looks like low pay and job hazards cause early mortality, actually it is poor health which causes both early mortality and having a lousy job. I know this sounds ridiculous, but that is what the argument was and why it got so much air-time.

I remember talking at a meeting to some people from a support group for people with chronic kidney disease. One the the conference speakers had put this idea forward. The people with kidney disease were very amused. They asked if anyone had the slightest idea what it was like, and how silly the idea was that people like them would be selected into things like mining, building work and ship building. They were looking forward to telling all their friends about the ludicrous academics who thought building workers have high mortality because they already suffered as children from diseases like kidney failure.

One thing you have to remember, especially in today's economic environment, is that the statistics on mortality that were being used did not include people with permanent disability who had no stable occupations at all. You could only be included in the statistics on health inequality if you had an occupation which defined your social class. So people who had chronic illness from childhood that prevented them from working were excluded altogether. And this was also in the days before people with chronic illnesses were being forced into various types of low paid work. So in fact, people in hard jobs were selected at the beginning of their working lives for good health. This has been called the "healthy worker effect". But that is another story.

As it was, at the time, there were quite a few people, including policy-makers, who for quite some time believed that health inequality was due to this process whereby sick people were recruited into tough jobs. It was called "direct selection".

The most important papers were written by Patrick West & colleagues:

West, P.  Health inequalities in the early years: Is there equalisation in youth? Soc Sci Med 1997 (44(6)) pp 833-858

West, P. Macintyre, S. Annandale, E. Hunt, K.  Social-class and health in youth - findings from the west of scotland 20-07 study. Soc Sci Med 1990 (30(6)) pp 665-673

and David Blane & colleagues:

Blane, D. Bartley, M. Smith, G D. Filakti, H. Bethune, A. Harding, S.
 Social patterning of medical mortality in youth and early adulthood. Soc Sci Med  1994 (39(3)) pp 361-366