Encyclopedia of Public Health | Urban Social Disparities

It is a truism of epidemiology that disease is not uniformly distributed across society—that some social groups or geographical areas experience higher disease rates, while other social groups or areas experience lower disease rates. Thus, some epidemiologists have investigated the relationship between social class or socioeconomic position and health or disease. These studies show that disease and mortality rates are higher in those urban areas or social classes where the incumbents are the least educated, and where household income is lowest, jobs are insecure, and where there is little wealth or political power. Similarly, disease and mortality rates are lower in those areas and social classes where the incumbents are the most educated, and where household income is highest, jobs are secure, and where wealth and political power are concentrated.

SOCIAL CLASS DEFINED

Richard Scase (following the trail blazed by Karl Marx) writes that social classes in the industrial era are inherent to capitalism—that differential control over the means of production (factories, restaurants, computers, software systems) produces different social classes. Thus the concept of "class" is important for understanding urban (or rural) social disparities in health and disease in capitalist societies. Dennis Gilbert (following both Karl Marx and Max Weber) defines a social class as a large group of families or households that are "approximately equal in rank to each other but clearly differentiated from other families" along the dimensions of occupational autonomy and security, education, income, wealth, and political power.

Gilbert in 1998 maintained that six classes adequately describe the American class structure: a capitalist class (1% of households), an upper middle class (14%), a middle class (30%), a working (or lower middle) class (30%), the working poor (13%), and an underclass (12%).

• Capitalist households are composed of investors, heirs, and executives; their incomes average around $1.5 million per year (in 1995); and their main source of income is property, stocks, or other investments. Capitalists-to-be usually graduate from selective universities.
• Upper-middle-class households are composed of upper managers, professionals, and medium-sized business owners; their incomes average $80,000 per year, and their main source of income is from one (or two) salaries. Upper-middle-class professionals often have postgraduate credentials.
• Middle-class households are composed of lower managers, semi-professionals, and nonretail sales workers; their incomes average $45,000 per year; and some middle-class incumbents may not be college graduates.
• Lower-middle-class households are composed of operatives, low-paid craftsmen, clerical workers, and retail sales workers; their incomes average $30,000 per year; and they are typically high school graduates.
• Working poor households are composed of service workers, laborers, low-paid operatives, and clerical workers; incomes average $20,000; and many incumbents are not high school graduates.
• Underclass households are composed of unemployed or part-time workers; many incumbents depend on government assistance; their incomes average $10,000 per year; and many are not high school graduates.

Because wealth, job autonomy and security, and political power are hard to measure, epidemiologists have generally relied upon occupation, income, or education to characterize the class position of the people in their studies. However, relying on education or occupation as the only measure of social class may underestimate the true relationship between social class and disease. Social epidemiologists also argue that more attention should be paid to measuring the socioeconomic characteristics of neighborhoods and communities where people live. The reasoning behind this assertion is the hypothesis that the social environment (absence of safe parks for walking or exercise, for example) may have additional impacts on health that would be missed if the focus of measurement were household characteristics exclusively.

HOW SOCIAL CLASS AFFECTS HEALTH

The social class distribution in a community or urban area appears to affect both the general level of health as well as specific disease rates through a variety of mechanisms. One hypothesis is that the general susceptibility to disease is higher in the disadvantaged classes because of chronic exposure to stressful life events. The presumed biological mechanisms involve several aspects of the neuroendocrine system that adversely impact host resistance. Another hypothesis is that social class affects life chances from birth through old age—that is, disadvantaged circumstances early in life can set the stage for late onset chronic disease. Starting tobacco smoking and engaging in sedentary behaviors as a teenager from a disadvantaged lower-middle-class household, followed by the development of ischemic heart disease in middle age, would be an example of this life course phenomenon. Another mechanism through which social class can affect health is via differential access to high quality primary and specialty medical care.

EVERETT E. LOGUE

(SEE ALSO: Social Class; Social Determinants; Urban Health; Urban Sprawl)