In the Begining of Disparities

The International Origins of Disparities
Over the past decade, a rapidly expanding body of scientific evidence has been put forth documenting differences in health status among US racial and ethnic groups. Evidence has also mounted suggesting that these differences may be related to both medical and nonmedical determinants. Internationally, however, neither the evidence nor the realization of a link between nonmedical sociobehavioral factors and health outcomes is new. The earliest reported observation of a hypothesized association between socioenvironmental risk factors and health outcomes occurred in Italy over three centuries ago when Bernardino Ramazzini detailed an unusually high frequency of breast cancer in Catholic nuns. Not long thereafter, in 1775, British surgeon Sir Percival Pott reported a cluster of scrotal cancer cases among British chimney sweeps.


By the mid 19th century, large-scale epidemiologic evidence began to corroborate these early observations. In 1840, Edwin Chadwick, British civil servant and statistician, demonstrated mortality differentials between the social classes living in Liverpool, England. Chadwick asserted that these differences were likely due to poverty and lifestyle factors common to the poorer working classes. German physician Rudolph Virchow went a step further when, in 1849, he asserted that because diseases of the populace are traceable to defects in society, the focus of medicine should shift from changing the individual to that of changing the society. Finally, in France, French physician Louis Villerme recommended improving school and working conditions as social interventions that would reduce class differences in mortality. Thus, in Europe, by the beginning of the 20th century, the existence of class variations in morbidity and mortality were clearly evident in the scientific literature.

Throughout the 20th century the study of social class differences in health status continued across Europe, especially in Britain were epidemiologists began using decennial census data to evaluate national mortality trends. The insights gained from these analyses enabled them to construct an occupational social class grading system that correlated inversely with infant mortality. It also was the basis of the claim made by the Registrar General of Britain that at least 40% of British infant mortality was entirely preventable if the social conditions of poor infants could be elevated to that of upper-class infants.

Two British researchers, Titmuss and Logan, evaluated regional class–based mortality trends and documented that the disparity in infant mortality rates between upper- and lower-class infants continued to increase from 1910 to 1950. This data, along with the Depression and World War II, encouraged the British government, in 1942, to respond by instituting the welfare state and promoting several policy initiatives designed to address the “five giants of Want, Disease, Ignorance, Squalor and Idleness”. Despite this government investment, however, problems attributable to social inequalities and inadequate access to health care persisted. In fact, by the mid 1970s, some 30 years later, the evidence seemed to indicate that the problems were still increasing and that the health of British citizens was slipping behind that of other industrialized nations. Thus, in 1977, the British government formed the Research Working Group on Inequalities in Health and selected Sir Douglas Black as its chair. The committee’s report, issued three years later in 1980, became known as the Black Report, and it represents the first attempt by a national government to systematically study, understand, and explain health inequalities. In summary, the health improvement recommendations of the report emphasized the need to improve the physical and the social environment in which the poor and lower classes lived.

My next blog will discuss the origins of Healthcare Disparities in the US. Portions of this post were taken from the article eHealth Solutions for Healthcare Disparities published in the Journal of Medical Internet Research in 2005  by MC Gibbons.