Friday 17 January 2020

The functionalist theory of health inequality

It took me a long time to realize that the implicit theory underlying a lot of work on health inequality was the classic American idea of Structural-Functionalism, developed by people like Talcott Parsons and Robert Merton. This was dozy of me, as decades ago Gordon Marshall had pointed out that the Registrar-General's Social Class schema used in research on health inequality in UK was based on, as he saw it, outdated functionalist and eugenic notions.
When the national statistics office for England & Wales adopted a new measure of social class for the 2001 Census and all other official statistics from then onward, I did notice that people had trouble using it. There seemed to be a constant attempt to drag the meaning of the measure away from "employment relations and conditions", which was its theoretical basis, back toward something like "manual/ non-manual". I have already written about this all over the place, including in previous blogs. So I won't bind on about it too much more here.

But recent exhaustive international comparative research has given the idea new legs. It turns out that over the last 30-40 years, Italy and Spain have stubbornly retained the smallest differences in mortality and life expectancy between those in the most and the least advantaged social circumstances, whether these were measured by income, education or social class. I well remember the total shock 25 years ago when this was first discovered. Italy & Spain don't have the lowest income inequality for example, or the most egalitarian welfare states. In fact, health inequality in most studies is higher in the egalitarianNordic nations. For many years the standard explanation was that the smoking epidemic was delayed in these Mediterranean nations: smoking was slow to become concentrated among people with lower income and less advantaged occupations.
However, as the years rolled by, it began to seem less likely that the narrower health gaps in the Mediterranean nations could be purely due to smoking. So an alternative explanation began to emerge.
According to this idea, the size of the differences in health & life expectancy between more & less socially advantaged groups might be due to the ways in which their home nations allocate people into these groups. Accroding the the Functionalist theory, societies like the Norway & Sweden are more meritocratic. Education is available to everyone up to an advanced level. This helps to make sure that the fittest & most able people are channeled into those jobs that are most essential for the "functioning" of society, like senior management, judges, military and political leaders.  Regardless of origin family, the fittest and most intelligent people will be channelled through the schools and universities into these important positions. In order to motivate the fittest people to aspire to these destinations, salaries & status are high. As fitness for high position is only partly determined by genetic inheritance from the parents, this process is important to make sure that "good functioning" is ensured. A society cannot just rely on allocating the sons (and it would be sons) of the powerful into powerful positions themselves. There will have to be a turnover such that the less fit sons of more advantaged families in one generation are filtered out by the education system and replaced by the fitter sons of the less advantaged. So the less fit fall down the social ladder and contribute to worse health in the less advantaged social groups, and vice versa. Michael Young wrote about this many decades ago in his book "The Rise of the Meritocracy", depicting an eventual dystopia in which society was divided into extremes of health, intelligence, and income.
There is some evidence in favour of this idea

 https://academic.oup.com/eurpub/article/23/6/1010/439677

In addition, there were large increases in health inequality in England and Wales duriing the 1950s-1980s, a time when the numbers of middle class jobs increased enormously, with an associated increase in social mobility (although this mobility took place during the work career, not through the educaiton system). One might argue that the increase in mortality among older working men in unskilled manual jobs (which was the main source of the rising inequality) resulted from an unfit group being left behind.

https://tinyurl.com/u4vazyg

On the other hand, extensive sociological research has documented a pretty hefty role for the social class, income and education level of the parents in determining those of the children, even after taking coognitive variables ("intelligence") into account. If anything, the expansion of higher education in the UK, for example, has mainly benefited middle class children. Almost 100% of middle class children now go to University and get degrees, which must therefore cover a wide spectrum of the ability range.

So there is a certain amlunt of evidence out there that can be used to test this idea further. But a lot remains to be done.