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Life & Death on the Social Ladder


Last October I went for a walk in Sighthill Cemetery on the outskirts of Glas-gow. Glasgow is a gloomy Victorian city of silent monuments in green squares and heavy stone buildings with streaks of damp trailing from their windows like tears. It was a time of year when one is very aware of Scotland’s winter darkness closing in. Even at mid-day, in bright sunshine, a reddish haze hung in the air around the weathered, lichen-stained graves.

The oldest burials at Sighthill date from the 1840s, when it was surrounded by open hilly countryside. Today this grassy slope with its obelisks and pillars and swaying trees lies on the edge of one of the city’s main eastbound arterial roads. It is surrounded by derelict industrial sites and overlooks the gray tower blocks, barbed wire, and broken glass of the Sighthill housing project.

Built in the 1960s as an experiment in social housing for the working class, the Sighthill estate is now, like similar projects in New York or Chicago, a ghetto for the socially excluded. On the ground floor of the buildings are the boarded-up premises of shops that closed long ago. Thousands of people live in these buildings, but when I was there the streets were nearly deserted. Paper trash blew here and there; a stray dog rummaged in a pile of garbage in the central courtyard. A heavyset woman in a pink tracksuit, ponytail swinging down her back, pushed a stroller with a tiny child inside. For many of the children growing up here, Sighthill graveyard will be the only countryside they will ever know.

The Industrial Revolution sprang from northern towns like this, but the slow decline of manufacturing in Britain left a long shadow on the region. Most of Britain’s old northern industrial cities, such as Manchester, Sheffield, Leeds, and Liverpool, have high-rise slums like Sighthill, where as many as a third of workers may be unemployed, and two thirds of children leave school without passing their final exams. However, nothing about these places is so alarming as their death rates.

Life expectancy in places like Sighthill can be as much as ten years less than it is in well-to-do neighborhoods in the southern shires, such as Hampshire, Essex, and Hertfordshire. If Britain were divided into two nations, one containing the richer regions and the other the poorer ones, there would be nearly 80,000 more deaths every year in the poorer nation, equivalent to twice the number of deaths from lung cancer. This is what epidemiologists would ordinarily call a plague, and it is killing more people in Britain every year than AIDS ever has. Yet we barely even know it is there.

The difficulty in recognizing this hidden epidemic is partly due to the protean nature of the afflictions of poverty in modern industrialized countries like Britain. Compared to the rich, the poor in Britain are more prone to about eighty different causes of death, including stroke, diabetes, heart disease, cancers of the lung, bowel, and stomach, emphysema, and asthma, as well as infant death, accidents, and mental illnesses such as depression and senile dementia.

I had come to Glasgow to visit Sally Macintyre, a social scientist who has studied health in Scotland for twenty years. She is part of a growing number of people who are concerned about early death among the poor in industrialized countries, where obvious health hazards such as inadequate sanitation, malnutrition, and infectious diseases, which kill millions in the developing world, are relatively unimportant. Unlike such traditional diseases of poverty as malaria and cholera, which can kill in days, Macintyre sees the poverty of the industrialized world as a sort of chronic disease that slowly eats away at the body throughout life.

As we sat in Macintyre’s office, she told me how she thought people age, as though they are obeying the signals of an internal, biological clock that seems to run much faster for the urban poor.

I used to do research in an obstetric clinic in a poor neighborhood,” she told me, “and I’d see these women who looked about forty to me. The obstetrician would ask them if they had any of their own teeth and they’d say no. These women were really only twenty and they were having their first child, but they had the faces of old people.

If you go to poor areas of Glasgow, or any big city, what you see is that people look older. At any given chronological age, life is speeded up if you’re poor in all sorts of ways. You leave school earlier, you have children earlier, your children leave home earlier, your organs wear out earlier, and you grow old before your time. In some sense you can read off social class from people’s bodies.”

Macintyre has seen how health is a luxury many people cannot afford. If you come from a place like Sighthill, for example, you are likely to end up going to a bad school, which prepares you mainly for tedious unskilled jobs or unemployment. When you are sick, you are more likely to see a doctor who would probably much rather be working elsewhere. Smoking and television are among the few affordable forms of recreation.

Food, particularly nutritious food, is often more expensive in poor neighborhoods. Sighthill, like many of the industrialized world’s public housing estates, is miles from the city itself. The only shop in walking distance is a huge discount warehouse selling mainly canned and frozen food. Grocers say it isn’t cost-effective to sell fruit and vegetables in poor neighborhoods. In some of Glasgow’s grimmer districts, one of Macintyre’s students told me, the nearest apple is a ten-dollar bus journey away.

During the Industrial Revolution, when Frederick Engels visited London and the great cities that awoke around the mines and textile mills in northern England, he was struck by the harshness of the workers’ lives. For most of them, the day began before sunrise with a long walk to a factory or a dark pit in the ground where the dank air was filled with particles of cotton or coal or metal filings that slowly poisoned the lungs and heart. Workers would return home late in the evening to crowded back-to-back tenements without air or light or plumbing. Disease seeped through the damp and rotting walls and half of all children died. A child born to a working-class family lived, on average, to the age of fifteen. A child born into a rich family survived, on average, more than twice as long.

In 1911, the Registrar General divided the British people into five social classes according to their occupations (or, for women, the occupations of their husbands). For example, doctors, lawyers, and other professionals were assigned to social class I, and unskilled laborers, such as cleaners and farm workers, were assigned to social class V. After the introduction of the National Health Service in 1948, which provided free health care to the entire population, it was expected that health inequalities among different social classes would gradually disappear.

British life expectancy has been increasing throughout the century by about two years every decade. Under the National Health Service, it continued to improve at about the same rate, or even a little more slowly. The enormous increases in life expectancy during this century are believed to have resulted less from such medical advances as vaccines and antibiotics than from basic public health measures including improved housing and nutrition, sanitation, cleaner water, and the social imperative to bathe, which emerged after World War I. This is not to say that safer childbirth and the free distribution of antibiotics and vaccines under the National Health Service after World War II were not important, but rather that other measures have been even more important.

However, while the National Health Service improved health overall in Britain, it failed to eliminate health inequalities. Just as the poor had been more prone to infectious diseases in Victorian slums, they were now more prone to such chronic diseases as stroke, heart disease, and many cancers. These chronic diseases have been this century’s real emerging plagues, and today they are the leading cause of death in Western countries.

In the 1970s, a British government committee found that while death rates for children in all social classes were going down, adult death rates showed a disturbing rise in inequality.1 For example, among adult men in higher social classes, such as doctors, lawyers, and managers, death rates declined between 1950 and 1970 by around 20 percent, but among bus conductors, cleaners, postmen, and other semiskilled or unskilled workers, death rates remained roughly constant. Since 1970, death rates have continued to decline much more quickly for men in higher social classes, so that in 1991 death rates in the poorest 10 percent of electoral wards in Britain were four times higher than they were in the richest 10 percent.

Something similar has been happening in the United States. Today male life expectancy in such generally poor urban areas as the Bronx or Washington, D.C., is ten to fifteen years lower than it is in richer districts such as Fairfax, Virginia, or Douglas, Colorado. A thirty-year-old black man living in Harlem is likely to die younger than a thirty-year-old male Bangladeshi, and he will most likely die of stroke, heart disease, cancer, or diabetes, not, as one might assume, from homicide or the complications of drug addiction.

Year by year, everyone in Western countries, except perhaps the very poor, can expect to live a little bit longer than he or she could the previous year. The underlying causes of these gains in life expectancy are much debated, but whatever they are, not everyone seems to be benefiting equally. During the 1960s, a group of epidemiologists in London made a disturbing discovery. Apparently these stark health differences are not just a problem for the poor. The life expectancy of most people seems to be exquisitely tuned by social status, even the life expectancy of middle-class people who don’t live in slums. Wherever you stand on the social ladder, your risk of early death is higher than it is for your social betters. In other words, the high rate of early death among the poor seems closely linked to the fact that they occupy the bottom of a very tall social ladder. All of us stand somewhere on this ladder, and the nearer we are to the bottom, the sicker we are likely to be and the younger we are likely to die.


Around dawn on weekday mornings, in the district of central London known as Whitehall, with its early morning tourists in their colorful leisure gear gazing at Big Ben and the royal guards in their sentry boxes and the statues of mounted heroes, a busy stream of dark-suited office workers heads for the white stone buildings that house the departments of government. These men (and some women) in the civil service are the nation’s neurons, making the government bureaucracies run.

  1. 1

    See The Black Report on Inequalities in Health, edited by Peter Townsend and Nick Davidson (London: Pelican, 1982).

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