Health and Social Change

An International Comparison in Time and Space

Summary

Health and Social Change will analyze the relationship between social change and health by presenting case studies of that relationship from 12 nations. The project, a collaboration between the PHOENIX network in the European Union and the Milbank Memorial Fund, was established during the spring of 2002 and will finish its first phase within two years.

For each case study, institutions and scholars will examine periods of social transition in their own nation. They will survey the literature, statistics, and current research and will analyze factors like socio-economics and demographics that have improved or undermined that nation's health. The report as a whole will compare the case studies and draw conclusions from them. One of its objectives is to develop research models and analytical tools that will allow more precise methods of comparison during a later stage of the project. A second objective is to formulate generalizations and theories based upon the studies. The discussion of the conclusions will be a stepping-stone for future research. The report should help us understand the relationship between the social determinants of health and policymaking.

Results will be evaluated in a dialogue between the project's participants and its audience, which will include academicians, decision makers, administrators of welfare and health systems, the media, and the general public. We will seek users for IT-supported international courses for masters and doctoral students through international programs for education and educational exchange such as the Socrates program within the EU. A model course will be tested in a collaboration between the University of Linköping in Sweden and the University of the Western Cape in South Africa.

At present, case histories will cover Austria, China, the Czech Republic, Finland, France, Latvia, Peru, Portugal, Russia, South Africa, Sweden, the United Kingdom, and the United States of America. Requests for information regarding possibilities to join the project may be directed to PHOENIX through its forum, Health and Social Change, accessible at http://phoenixtn.net or to the coordinator of the project:

homepage: http://www.tema.liu.se/people/jasun/

Background

Health is a basic component of human welfare. Serious health problems cause individual suffering and create psychological and material burdens for families and societies. Conversely, good health helps individuals to fulfil their goals in life and contributes to the wealth of an entire society. For both humanitarian and economic reasons, most welfare societies invest about one-tenth of their budgets in curing disease and caring for the sick. They spend less than that to promote health and prevent disease. One reason for this imbalance between prevention and cure is the complex relationship between social factors and health, which often makes it difficult to evaluate, or even estimate, the costs and benefits of public health policies. Yet policymaking and institutional structures greatly influence the wellbeing of populations and individuals, especially during periods of rapid social change.

Traditionally, economic development has been studied as a factor affecting public health. Economists have recently demonstrated that a healthy population, with low mortality among children and adults and a reasonably high birthrate, will in the long run contain enough middle-aged adults to promote economic growth. Health is therefore both a dependent and an independent factor relative to the wealth of individuals and nations.

Swedish demographic data, which cover the last 250 years, illustrate the point. During the first half of the 19th century, reduced infant and child mortality and the consequent growth of these age groups were at first accompanied by low rates of economic growth. Higher rates followed when these children reached their economically productive ages. The positive trend was further strengthened when modern family planning reduced the number of dependant children per family and, later, when a growing proportion of women entered the labor market. Economic growth can of course be attributed to a number of factors. But the recently diminishing growth in Sweden, and in the rest of the industrialized world, may result in part from the reduced proportion of the population at work. After the baby boom in the 1940s, birth rates have declined dramatically in Europe. The result is the current reduction in the size of the workforce relative to the population as a whole, a tendency that will be even more significant during coming decades. Furthermore, older people tend to leave -or be dismissed from- active work at an earlier age than before.

For future productivity and wealth, both industrialized and less-developed countries need to protect the health of their populations and reduce illness and mortality. History proves that longer life spans have resulted mainly from public interventions that lessened health risks. Numerous studies show that infant and child mortality has been dramatically cut by campaigns for breast-feeding, better childcare, personal and public hygiene, and mass vaccinations against smallpox. These are just a few of the factors that affected industrialized nations during the 19th century and developing countries during the 20th. The decline in adult mortality usually began later.

Historical analysis becomes more complex when national, regional, and local patterns are studied. Culture and politics influence the timing and speed of improvements in health, and socioeconomic conditions affect disparate social groups differently. Social and cultural factors can reflect conscious or unconscious human behavior and interventions. Gender -the culturally and socially constructed distinctions between female and male resources, rights, and duties- causes striking differences in adult mortality, especially when marital status is taken into account. In the western world, differences between the sexes that cannot be explained by biology have usually resulted in higher mortality among men during the last two centuries. This excess mortality is particularly high among urban men who are unmarried, divorced, or widowed. Yet gender patterns are highly variable, depending on time, space, age, and social status.

Every society needs institutions for safety, welfare, and health, whether the institutions are more formal, less formal, private, or public. At certain stages in history, traditional institutions, norms, and rules have proved inadequate in the face of profound social changes. The Gemeinschaft model of an ancièn regime agrarian, preindustrial society became inadequate in early 19th-century Europe, given increased geographical and social mobility, urbanization, and the emergence of a landless proletariat. In some countries, this transitional period was accompanied by stagnant, or even increased, mortality rates, especially among unmarried men in urban areas.

During the second half of the 19th century, industrialization offered more jobs and higher real wages. But before the newly industrial societies became stable, other health risks arose. Deplorably unsanitary conditions, indoors and out, spread infections in overcrowded living quarters, particularly among children of both sexes and among girls and women. At the height of migration from the countryside to the cities, unmarried men who lived in cramped apartments frequented the pubs; deaths that were directly or indirectly caused by excessive alcohol consumption rose significantly. Within a few decades, however, more stable families, improved hygiene, and -later on- the welfare state lessened mortality for all age groups and lengthened life expectancy.

One historical case and two contemporary cases illustrate the relationship between social change and health in three nations: Sweden, Russia, and South Africa. During the past 10 to 20 years, mortality crises have developed in the former socialist countries of eastern and central Europe, especially in Russia. Life expectancy has fallen, mostly among men who are unmarried, uneducated, or unemployed, particularly those in impoverished regions and urban areas. These crises are usually attributed to the combination of rapid changes in society: political and social disintegration; a weak government; deterioration of welfare and health care systems; rapid privatization of the economy, which created unemployment; increased migration and rootlessness; a weak civil society, including less stable families and social networks; alcoholism; and crime. These factors, and their effects on health, have been called «social stress».

Social stress also marks many developing countries, notably African nations. Even in South Africa, the most affluent country south of the Sahara, cultural and epidemiological factors combine in ways that seem to be unhealthy for both sexes. Political democracy following the abandonment of apartheid has not immediately produced a stable society and prosperity for all. Shantytowns are growing in the suburbs of big cities as poor people migrate from the countryside. They endure difficult social and hygienic conditions, extremely high unemployment, crime, and drug abuse. The opening of South Africa's borders to the global economy has led to de-industrialization and unemployment in many sectors. Morbidity and mortality from infectious diseases have remained high, or have even increased, with the advent of HIV and AIDS. The health care system is often least developed in areas with the most urgent needs.

According to some South African studies, HIV and AIDS are more common among young and middle-aged women than among men in the same age groups, partly because of women's higher physiological risk of being infected by the virus. These studies need to be scrutinized for possible bias in the reporting systems. In any case, the risk of infection is exacerbated because popular misconceptions do not acknowledge that HIV is sexually transmitted. The misconceptions are an obstacle to educational campaigns. Culturally defined gender roles also make it difficult for many women to stand up for their right to voluntary and safe sex. People suffering from AIDS are vulnerable to other diseases, like tuberculosis, as well. Contrary to the European cases referred to above, where the excess mortality is found mainly among middle-aged men, both male and female mortality in Africa is rising due to the dramatic epidemiological situation. Education, free contraceptives, and medicine are urgently needed in order to halt and minimize the effects of AIDS and related mortal diseases in Africa. But it is hard to see how this vicious circle of disease and premature death, weakness and waste of human capital, demographic instability, disruption of the civil society, increased poverty, and, in the end, new threats to the health of large sectors of the population can be broken unless the socioeconomic situation is improved, unemployment is reduced, and institutions for education, welfare, and health care get substantially larger resources, especially at the community level.

Some social changes are obvious, such as the decline and fall of socialist states in eastern and central Europe and the de-colonization, majority rule, and economic globalization of large parts of the world during the last decades of the 20th century. The effects of these «revolutionary» transitions upon health can be seen almost immediately. The effects of slower «evolutionary» changes are harder to see and harder to separate from other factors during the same time periods. When the western world was transformed from a predominantly agrarian to an industrial society, the process could not immediately be assessed by contemporary observers. In early 19th-century Sweden, social instability adversely affected the health and survival of the most vulnerable parts of the population, although change eventually led to increased prosperity and longevity. The latter trend was slower and evolutionary, with many interacting factors that are hard to evaluate one by one.

The analysis of the relationship between social transitions and health must include the role of institutions in a specific socioeconomic, cultural, and political context. The depth and speed of change affect its impact, and various segments of the population are affected differently. Slow changes may allow both formal and informal institutions to adapt to new circumstances before health is undermined. Contemporary Russia and South Africa differ from each other and from early 19th-century Sweden. But while firm conclusions cannot be based only upon these three examples, certain observations and hypotheses concerning the connection between social transitions and health are worth testing further. Our project will attempt to evaluate them. Those three nations provide strong evidence that:

• Transitions that are fundamental and rapid have immediate, profound effects on the health of large parts of the population.

• Changes in the labor market and social security systems put a heavy burden on people's occupational flexibility, social adaptability, and ability to find economic safety for themselves and their families.

• Old rules, norms, and institutions no longer function as efficiently as they did before, at least not for all groups.

• If social and geographical mobility increases, some people benefit while others lose out.

• «Social capital»-material, educational and cultural-is one factor that determines who will become short-term or long-term winners and losers.

• Welfare and health also depend on gender, age, and social class.

Sweden and Eastern Europe show that middle-aged males are especially vulnerable, if life expectancy is used as the measure; the vulnerability is caused by gender roles, not biology. Cultural and gender factors within a particular epidemiological setting can also cause serious health problems and mortality among females. The impact of change upon health and welfare is always filtered through formal and informal institutions. Public institutions, for example, can distribute and redistribute material resources, welfare, and social capital like education. But informal institutions -such as voluntary associations, social networks in the workplace or among neighbours, the family, and other primary groups- and the way civil society functions are as essential for social stability and security as public institutions are.

This introductory discussion about the impact of social change on health does not cover a number of other, equally important, matters. It does illustrate the need for a better understanding of what is general or typical and what is determined by the specific context of a given society. Such an understanding is necessary for both affluent and developing societies. In the industrialized world, the growing number of patients with psychosocial diagnoses, long periods of sick leave and rehabilitation, and early retirements for medical reasons burden the welfare society and diminish economic productivity, which is, in turn, the basis for good social service. Human welfare for decades to come will depend on today's investments in health care, insurance, and pensions, whether in public systems, private systems, or a mixture of both types. Investment in the health of middle-aged people today protects their productivity and lets them work longer and save more money before they retire. It can also enhance their material wealth and physical health in old age, lessening their need for expensive health care after retirement.

In developing nations, the gigantic waste of lives due to HIV and other infectious diseases must be halted if sustainable growth and prosperity are to be achieved. Greater understanding of the cultural and social mechanisms related to welfare and health is also essential in view of increasing international migration into new cultural systems, another fundamental form of transition. Otherwise, migrants cannot be integrated into their new societies and be treated equitably.

The failure of old institutions to solve new problems has given rise to the argument that the collective society should keep its hands off politics and rely on «the invisible hand» and the free market. Lassies-fair and Manchester liberalism were the two most common terms used in order to classify the advocates of such beliefs in early 19th-century Europe. Today a similar message is heard in the form of a more or less radical critique of the welfare state. The distribution of health -and of illness and death- is, however, strongly correlated with the distribution of material and social security, whether by a free market or by collective interventions.

Health and Social Change. A Comparative Project

This discussion of the relationship between social change and health in one historical case and two contemporary cases is merely a starting point. An unbiased analysis of evidence should be based upon observations of a larger set of cases. To that end, the PHOENIX network and the Milbank Memorial Fund are collaborating on this project. The first stage of the project will take two years, starting in the spring of 2002. This stage will rely mainly on literature, statistics, and research in order to:

• survey socioeconomics, demographics, and health during periods of social transition in 12 nations;

• analyze factors that have improved or undermined public health in each case; and

Special attention will be paid to these factors: economics, social structure, cultural patterns, political systems, civil society, family structure, and formal and informal institutions for welfare and health. A dialogue among the national teams of participants will permit critical analyzes, exclusions, amendments, additions of variables, hypotheses, and theories. Attempts will be made to produce evidence from the various cases that is comparable, within the limits of available data and current research in each nation. Quantitative data will be particularly important in order to evaluate economies, social structures, and demographic patterns. Some other factors will have to be presented on a nominative scale or «holistically», for instance by the use of Max Weber's method, where «ideal types» represent models of particular combinations of social processes.

One objective of the first, short-term stage of the project, which will be completed by the end of the year 2003, will be to develop research models and analytical tools to permit more precise methods of comparison during a later stage. The second goal is to develop generalizations and theories based upon the cases. These results will be discussed in the conclusions, which will be a stepping stone for future research. According to this plan, a second stage can begin in 2004, when specific questions have been identified for further funding, research and comparative analysis.

Dissemination of Results

The project's results, and their usefulness in permitting a better understanding of the relationship between the social determinants of health and future policymaking will be evaluated in a dialogue between the project's participants and its audience, including scholars, decision makers, administrators of welfare and health systems, and the media. The results will also be disseminated by integrating the project's research activities and results with academic education. We will seek resources and markets for IT-supported international courses for masters and doctoral students through Socrates and other international programs for education and educational exchange. The project's results will inform the students about social and cultural conditions outside their own nations. A model for such courses will be tested in collaboration between the University of Linköping in Sweden and the University of the Western Cape in South Africa. The PHOENIX network and the Milbank Memorial Fund will be valuable partners and channels for a dialogue among academicians, decision makers, and the general public.

Timetable

A workshop with representatives of the participating countries will be held in connection with the PHOENIX seminar in Évora, Portugal, 23rd of September 2002. This workshop is at present closed for new participants, but information about its results will be posted on the PHOENIXTN homepage and there may be a possibility to accept new participants after this workshop. A second workshop is planned to take place in June 2003 in order to discuss the report's conclusions. Final manuscripts from the participating national teams, including preliminary conclusions, will be ready by the end of 2003.