Unprecedented growth, but for whose benefit?
Many studies52 confirm Wilkinson's view that changes in income relationships have profound effects on the health and life expectancy of those experiencing them, with the winners becoming healthier and living longer and the losers doing the reverse. In The Growth Illusion, Richard Douthwaite53 reported the adverse health effects associated with economic growth in Britain:
Elsie Pamuk, who investigated changes in Britain in the mortality rates of men in 143 occupations that could be consistently identified for the span from 1921 to 1971 found that mortality rates for occupations in social class V (such as labourers), tended to improve more rapidly than those for social class I (doctors, accountants, lawyers) in the period up to 1951, when war, economic depression and government policies pushed relative incomes in favour of the less well-off.
After 1951, however, there was a concentration of national income around the middle of the distribution - both the richest and the poorest 10% lost in relative terms to the middle group although their actual incomes increased. Pamuk's study showed that when the various classes' incomes ceased to converge, the difference between mortality rates ceased to converge as well. This was largely because the absolute death rate of class I people continued to fall while the Class V death rate behaved erratically, even worsening from time to time.
Later work54 has shown that the mortality gap between the classes continued to widen until 1991 at least. Douthwaite also reported that Pamuk found that wives' mortality rates moved in parallel with those of their husbands. 'Another study, published by the British Department of Health and Social Security55 in 1984, showed that children were affected too: the difference in height between eight-year-old children from the five social classes which had been converging until 1950 remained on a plateau until the end of the 1970s and then began moving apart' he wrote.
How the British income gap has widened since 1960
Anna Lee, chairperson of Combat Poverty Agency in 2000 stated the situation quite clearly ' Poor people get sick more often and die younger than the well-off.... The greater the scale of income difference, the bigger the gap in inequality, the more life expectancy drops'56 .
'You will know of those who are poor in the midst of riches, which is the worst of poverties'
F. The problems with Irish statistics
Anyone wishing to investigate whether the recent changes in relative incomes have affected Irish health faces enormous problems mainly due to a lack of data. Irish health data is grossly inadequate. This is admitted officially. In relation to children, the Chief Medical Office wrote in The Health of our Children, a report published in 2002:57 'The description and analysis of the health determinants, health status and service utilization pattern among children given in the report are necessarily limited due to the lack of comprehensive data.'
Nor is the adult situation any better. The following year Dr. Kiely wrote: 'There is increasing interest in the scale and nature of inequalities in health in Ireland. But the discussion is hampered by the lack of quality information. While a substantial amount of data on the Irish health service is collected, drawing inferences on inequalities is not straightforward, primarily because of weaknesses in the data collection systems used.'
The Institute of Public Health agrees. 'The poor quality of occupational data on death records on the island, particularly among people outside the working years and amongst females, severely limits our ability to explore the relationship between socio-economic circumstances and mortality. The absence of other data items such as ethnicity and country of origin imposes further limitations' it stated58 in 2002 in its publication Inequalities in Mortality.
When data is collected by the health system, no link is usually made between the patient's income, the health problem and the treatment outcome. Only the patient's occupation is recorded so that he or she can be assigned to a socio-economic group. The latter can, of course, be used by researchers as a proxy for a person's income but this may lead to erroneous conclusions. For example, those who are unemployed are categorized according to their previous employment and occupations traditionally associated with low pay, such as hotel work, hairdressing and farm labouring do not have a separate entry in the occupational statistics classification.
Nevertheless, even the limited data shows a marked discrepancy in health status between the socio-economic groups. Inequalities in Mortality examined mortality data between 1989 and 1998. It found that mortality from all causes in the occupational classes associated with lower rates of pay was 100-200% higher than the rate in the occupational classes associated with higher pay. For circulatory diseases it was 120% higher, for respiratory diseases it was over 200% higher, for injuries and poisoning, it was 150% higher and for cancers it was 100% higher. The overall all-cause mortality rate in the Republic was 6% higher than the North. Unfortunately, this study amalgamated data for the years 1989-1998, making it impossible to distinguish trends during this period of massive economic change and to ascertain if there was a link with income. There are no plans to repeat this analysis using data from the most recent census59 .
Even the results in Inequalities in Mortality may be underestimating the problem. A 2001 study by the Department of Community Health at Trinity College, Dublin60 found that the socio-economic group with the highest mortality rates was 'unknown'. It accounted for 14% of all deaths in 1981, rising to 24% in 1996. This category had a higher standardized mortality ratio for all-cause mortality, ischaemic heart disease, cancer, injuries and poisoning than every other socio-economic category. Over a third of people who were admitted to a psychiatric hospital had a classification of 'unknown' socio-economic group. The authors state that this could reflect either a lessening of standards in data coding and collection, or a genuine increase in the number of people in very poor health whose socio-economic group could not be identified.
What a difference one's income makes.
The standard of data compilation and publication has certainly fallen in one key area - the perinatal statistics. It has been established that, in general, the incidence of low birth-weight is higher in babies born to poorer mothers than in babies born to more affluent ones. Consequently, one of the first effects of an increase in inequality could be a rise in the number of low birth-weight babies. Unfortunately information on birth-weights is not published promptly. The 1999 figures were only published in 2002 and the figures for 1993-1998 have not been compiled at all, although the data was collected. This has made it very difficult to follow trends during the high-growth period.
This matters because research by Professor David Barker,61 an epidemiologist at Southampton University, has shown that underweight babies are much more likely to develop heart disease, high blood pressure, diabetes and kidney and liver problems in later life. This may be because their bodies diverted the poor supply of nutrients their mothers provided in the womb away from their vital organs to ensure that their brains, at least, developed fairly well. Some workers think, however, that their brains could be permanently locked in 'fight or flight' mode. If true, this could partially explain the high incidence of crime and behavioural problems among deprived groups.
From the national point of view, the birth of an underweight baby is a double tragedy. It is bad for the community, who will have to shoulder the expense of providing medical (and possibly custodial) care for the new individual for a lot of his or her life. It is worse, however, much worse, for the family and the baby concerned, as it will have to put up with chronic illnesses and never develop its full potential.
In 1998, research by the Southern Health Board62 found that the high infant mortality figures for Cork City were caused by low birth-weight, congenital abnormalities and infant death syndrome. It associated these with the high levels of social deprivation in the city. The report found that despite 'significant overall improvements in infant mortality in the SHB area, infants born into the lower socio-economic area (Cork City) continue to experience higher relative risks of mortality in comparison with those born in the higher socio-economic areas'.
In the absence of official national low birth-weight statistics from 1994-1998, I compared the birth-weights of babies born to mothers who were confined in public wards (as a proxy for mothers on lower incomes) and who tend to have a higher proportion of babies with low birth-weight, with the birth-weights of babies born to mothers who were confined in private wards in a large Irish maternity hospital over the years 1995 to 2000. One fifth of the babies born to women in the public wards weighed less than 3kg, in 1995, and this remained the same in 2000, while the percentage of low birthweight babies in the private wards had fallen from 14.8% to 10.6%. In other words, economic growth and the reduction in absolute poverty did nothing to reduce the number of low birthweight babies being born to the poorer section of the population.
This result was confirmed by the publication in 2002 of the 1999 perinatal statistics, which showed that the proportion of babies born in 1999 with low birth-weight was significantly higher than in the early 1990s. Furthermore, the perinatal mortality figures for babies from poorer homes had worsened seriously since that time. In 1993, the perinatal mortality rates for single babies born to fathers who were classified as being manual unskilled workers and unemployed were 6.2 and 7.9 per thousand respectively. By 1999, the corresponding figures were 10.7 and 11.4. The figures for babies with fathers classified as higher professionals had improved, however, falling from 5.0 in 1993 to 3.5 in 1999. So the gap I had been trying to measure in one Dublin hospital had clearly widened in the country overall. Again, economic growth was clearly not benefiting everyone equally.
More underweight babies
|Table 6 shows that the percentage of babies born with low birth-weights increased by 20% between 1993 and 1999. The increase appears to have been concentrated in babies born to parents on lower incomes.|
Figure 11 shows that the decline in infant mortality after 1990 stopped during the high growth years and may have resumed since. The ESRI data suggests that the plateau may have been due to the fact that the survival rate of children born into affluent families continued to improve while the death rate in poor families worsened, the two trends canceling each other out.
The 2003 edition of the report Better Health for Everyone from the Department of Health states that the infant mortality rate in Ireland is second highest in the EU-15 at 6.2, the EU-15 average being 5.2. Only Greece is worse. However, the reasons for infant mortality are complex and the report suggests that 'variations in practice relating to the registration of deaths' might be responsible. The same report states that the Irish perinatal mortality rate at 10.00 is the highest in the EU-15, the average being 7.7. Part of the difference here however, could be due to the fact that abortion is not carried out in Ireland on babies with serious congenital malformations who may then die after they are born.
No improvement in proportion of babies dying at birth
Other data problems
Here's a round-up of some of the other statistical difficulties I came across in the course of this research:
- The National Disease Surveillance Centre is concentrating on infectious diseases which caused only 0.6% of deaths in 1999, the last year for which such information is available. They do not collect information on income.
- Ireland does not have national registers for asthma, diabetes, depression, arthritis, and most other common disorders despite the fact that they account for a high proportion of all healthcare activity. This means that we can neither assess the incidence of these diseases nor examine an association with income.
- The Irish National Cancer Registry does not record income.
- HIPE (Hospital In-Patient Enquiry), which reports activity in Irish hospitals, does not note socio-economic status or income.
- Data on prescriptions is only analyzed for medical cardholders, whose income is extremely low. This prevents investigations into the differences in health status between people on low incomes with medical cards and those on higher incomes who don't.
- Although farmers are one of the groups worst affected by relative poverty, those compiling the report Inequalities in Mortality were unable to analyze their mortality figures because of inadequacies in the data.
- Although the height of British schoolchildren was found to track their socioeconomic circumstances, it is not possible to follow height trends of Irish schoolchildren because, although they were being measured regularly by the schools medical service, measuring methods do not appear to be standardized and accurate socio-economic details are not recorded. As a former schools doctor, I was particularly interested in following this issue up and wrote to the Department of Health to ask if the data had been analyzed in any way. I received no reply.
- No income records are kept on people who are eligible for the long-term illness card scheme.
- The Census Office changed the way it assigned the living to socio-economic groups in 1996 without a corresponding change being made in the death classifications. This highlights the need for a coordinated approach to addressing the issue of monitoring trends in health.
In summary, although income inequality plays a significant role in determining illness and mortality, the relevant data is not collected routinely.
G. What the available statistics do show
There are no long-run, consistent time-series showing trends in the nation's overall health in a way that can be related to trends in the distribution of income. There are however two Irish studies on the issue. One is a study63 from the European Foundation for the Improvement of Living and Working Conditions, which relates self-assessed health in Ireland to income. This was published in 2002 and compares the proportion of the poorest fifth of the population saying they were experiencing bad health with that of the richest fifth. The results were shocking. Those in the lowest fifth (quintile) in Ireland were over eight times more likely to say that they had bad or very bad health compared to those in the top quintile, far higher than any other EU country. The Irish figure of 8.3 compares with 4 in Denmark, 2.6 in France and 1.6 in Germany. The next worst figures after Ireland were from Greece at 5.7. Furthermore, a recent study from the Irish Institute of Public Health64 found that people on the lowest incomes are 52% less likely to be very satisfied with their health compared with people on the highest incomes.
If people feel badly about themselves they may think of suicide and the rate at which suicide is increasing among young Irish men is the fastest in the world65 . It trebled in adolescents in the past decade66 to become the most common cause of death among 15-24 year olds. Since 1997, all deaths by suicide have been consistently higher than the number of deaths from road traffic accidents67 . Ireland has the second highest young male suicide rate in the world68 and is the only EU country where youth suicide continues to rise.69 Concern has been expressed that suicide may still be under reported.70 The national chairperson of the mental health association GROW, Jean Hasset, stated in the organization's annual report for 2001 that high suicide rates 'did not represent the full extent of the despair that is rampant among Ireland's men and women and were little more than a record of those who had succeeded'71 . Rates of suicide in young women doubled in past ten years, and violence and aggression in young women were cited as possible reasons.72
The experience of being a young Irish person in 2002 is one of 'personal loneliness, lack of purpose and engagement' according to a draft report from the National Economic and Social Forum.73 In a youth poll, carried out by The Irish Times and published74 in September 2003, it was found that 55% of those aged 15-24 knew somebody in their age group who had committed or attempt to commit suicide. It is a sobering reflection on our society that each health board has its own 'suicide resource officer'.
In 2000, the first ever large-scale Irish epidemiological study to examine rates of psychiatric illness among young people75 , found one fifth of adolescents to be at risk of developing psychiatric disorders. Another report, 'The male perspective - Young men's outlook on life study' released in January 2004 by the Mid Western Health Board, and referred to earlier, found that half of those surveyed had contemplated suicide at one time, and 4% had actually planned it.
The National Suicide Research Foundation has developed a parasuicide (attempted suicide) registry, the first of its kind in the world. Parasuicide rates among teenage girls aged between 15 and 19 have outstripped all other age specific rates among men and women, making them the most vulnerable group76 . The registry's second report, for 2002 but issued in 2004, found that the incidence had increased from 2001, but also reported that not all hospitals participated in this survey. The peak rate of parasuicide was in girls aged 15-19, at 626 per 100,000. This figure indicates that 1 in every 160 girls in this age group presented to hospital after a suicide attempt. The highest rate was at age 17, when 1 in every 140 girls presented to hospital after an attempt. The peak rate for men appeared to be in the 20-24 age group, at 407 per 100,000.
A 2003 report by the South Eastern Health Board, An Overview of Suicide, notes that parasuicide is a growing phenomenon among adolescents, reflecting their feeling of helplessness and hopelessness in coping with life stresses, their impulsiveness in relationship breakdown, and the vulnerability of those with poor education, low incomes or no employment. 'The increase of affluence and material well-being has been met with a parallel increase in societal pressures that some young children cannot cope with' Paul Gilligan, the chief executive of the ISPCA77 , said when commenting on the shocking statistic that 201 children aged between 10 and 14 were treated in Irish hospitals for attempted suicide in 2002. Over €4.5 million will be spent in 2004 to try to reduce the suicide and attempted suicide rates.78 Unfortunately, these and other mental health services will tend to be concentrated in areas of highest affluence, not in areas of greatest need79 .
Male suicide increases during economic growth spurt
Alcohol and drug use
Many people deal with stress by turning to drink or drugs. And they did. 'Against the backdrop of the fastest growing economy in Europe, Ireland has had the highest increase in alcohol consumption among EU countries,' a government report80 stated. 'Between 1989 and 1999, alcohol consumption per capita in Ireland increased by 41%, while ten of the European Union member states showed a decrease and three other countries showed a modest increase during the same period.' Ireland's consumption continued to increase in 2000 and ranked second after Luxembourg for alcohol consumption with a rate of 11 litres of pure alcohol per head of population or 14.2 litres per adult. The EU average for 2000 was 9.1 litres per head. The same report noted that while alcohol consumption per adult had been gradually rising over the previous 40 years 'since 1995, there has been a dramatic increase in consumption'. Irish alcohol consumption was below the EU average until 1996, when it began its rapid ascent81 .
Big increase in Irish alcohol consumption
Hospitals came under pressure as a result. A pilot study undertaken in the Mater Hospital in Dublin found that one in four attendances was alcohol related.82 'The health service is creaking and groaning and is collapsing under the weight of our new lifestyle. The nation is richer than it has ever been and yet the health service is under severe pressure because of this lifestyle' an Accident and Emergency consultant in Cork University Hospital told a conference on alcohol in November 2003.
Alcohol abuse is also a problem with older people. One in five Irish people are now drinking in a manner that is either harmful or hazardous to their health and Dr. Ann Hope, National Alcohol Policy Advisor at the Department of Health and Children, has stated that suicide, cirrhosis, crisis pregnancies, and sexually-transmitted disease have risen dramatically with the increase in the consumption of alcohol.
Drinking rises in step with increasing incomes
According to a 2003 report comparing drinking patterns in Ireland with six other European countries,83 half of all Irish men now binge-drink at least once a week, the highest in the countries surveyed, and 16% of Irish women do too, which was also higher than the other European countries studied. 12.4% of Irish men said that their alcohol consumption affected their ability to do their job, again the highest of all countries surveyed. 11.5% of men had 'got into a fight', three times the EU average, 9.6% said that friendships had been harmed and 6.3% had been in an accident as a result of drinking, both figures again the highest percentage. Alcohol is a factor in a quarter of visits to casualty in Irish hospitals, thirty percent of road accidents and forty percent of fatal accidents. It is also associated with one in three cases of marital breakdown and public order offences. The economic cost of 'alcohol harm' has been estimated at €2.3 billion84 .
Big increase in alcohol-related offences.
The Interim Report on Alcohol85 highlighted the link between alcohol and street violence. 'Of particular concern is the increase in intoxication in public places among teenagers which has risen by 370% since 1996,' it said, adding that in the five-year period between 1996-2000, assaults and public order offences by adults increased by 97%. The Garda Commissioner highlighted the link between alcohol and the rise in street violence.
Changes in the behaviour of Irish schoolchildren in the 15-16 year old age group between 1995 and 1999 were examined by ESPAD, the European School Survey Project on Alcohol and Other Drugs (See figure 16). The study covered alcohol, tobacco and drug use by schoolchildren in 26 European countries. It found that there had been a marked deterioration in behaviour patterns between the two years among Irish participants and that Ireland ranked among the highest of all participating countries in relation to alcohol and illicit drug use. The proportion of Irish participants who reported using alcohol ten or more times in the previous 30 days had increased. This was particularly true for the girls, whose rate had almost doubled. The number of Irish students of both sexes who reported having been drunk on three or more occasions in the previous 30 days rose from 15 per cent to 24 per cent, ranking Ireland joint second with the UK for this indicator.
Schoolchildren become heavy drinkers and illegal drug users
There is no sign that the situation has improved since 1999. A survey86 of 2,297 post-primary students in 2003 found that 39% had used drugs, an increase of 10% on a 1998 study. It was also noted that the number of teenagers who had used inhalants had increased by almost 8% to 21.3% in the four years since 1998, with 6.8% having used inhalants in the previous month, compared with 2.7% in 1998. Another survey, this time of 1,200 secondary school teachers in 2003, found that a third of teachers had taught in classes where students were under the influence of alcohol or drugs87 . Furthermore, a 2003 report from the Drug Treatment Centre Board found that rates of opiate, cannabis, benzodiazepines, cannabis and ecstasy use remained high, and cocaine abuse was increasing88 .
A survey89 of 2,297 post primary students carried out in the Mid West region in 2002 found that rates of smoking and drinking had increased since a similar survey four years previously. It found that over a fifth of 14-year-olds reported that they had been 'binge drinking' or had consumed five consecutive drinks in the 30 days before the survey, and 44% of 16-year-olds had been drunk in the month before the survey. And the stark reality of the alcohol problem among young people was illustrated by an analysis of patients admitted to Mayo General Hospital in 200090 . Of all admissions under the age of 16, 30% had been found in the open, comatose and alone.
Obesity and diabetes increasing
Besides alcohol and drugs, stressed, anxious people also comfort themselves by eating. This may be a contributory factor in the rise in obesity. Recent research has shown that people who are struggling socially tend to have low self-esteem which in turn is reflected in their diet and tendency to obesity91 . Since 1990, the prevalence of obesity in Ireland has increased by 250% in men and by 125% in women. In 2002, 14% of men were obese, up from 11% in 1998, and 12% of women were obese in 2002, up from 9% in 199892 . At present, one in eight Irish people is obese and every second person is overweight93 'There has been an alarming increase in both diabetes and obesity in the past ten years' according to Professor John Nolan of Trinity College, Dublin, a consultant endocrinologist, speaking at the launch of a new study on obesity. An international study carried out in 13 countries found that Ireland had one of the highest proportions of overweight teenagers94 . An all-Ireland survey, undertaken in 2001 and 2002, found that of 18,000 children, one in three 4 year olds were overweight95 .
'Obesity-related type 2 diabetes is presenting at younger ages than in the past, and is now seen in young teenagers in Ireland96 (Type 2 diabetes is usually more common in obese people over the age of 40). Ireland was one of the first countries to report type 2 diabetes in young people97 . In 2003 Professor Nolan98 , stated that 'Ireland will drown in diabetes' if the current trend continues, warning that obesity-related conditions such as polycystic ovary syndrome would reach epidemic proportions. He had seen a doubling of the number of patients referred to him in the previous three years.
The medical director of the VHI (Voluntary Health Insurance) is also alarmed. In 200399 she described childhood obesity as a time bomb and said that obesity was storing up problems for future health care provision. Indeed, the Irish environment has been called 'obesegenic' by a principal investigator in an international study on childhood obesity100 referring to the fact that 'most families had two cars and used a remote control for their TV.'
Obesity is an important risk factor for heart disease, blood pressure, stroke, diabetes, and increases the risk of cancers of the breast, bowel, womb, ovary and prostate. Mortality as a result of cardiovascular disease is almost 50% higher in obese patients than in those of average weight, and is 90% higher in these with morbid obesity, which is defined as a Body Mass Index greater than 40. If the Body Mass Index is greater than 30, there is also an increased risk of diabetes, if it is over 40, there is a 90% chance. (The Body Mass Index takes into account an adult's weight and height to gauge total body fat, and thus whether they are obese.)
A 2003 study showed that the average Irish schoolchild eats 50% less fresh fruit and vegetables than he or she did five years ago and that they spend 15 hours a week watching television.101 The Central Statistics Office reported that the proportion of primary school children walking to school declined from 47% in 1981 to 26% in 2002 even though most children lived near their schools. The proportion of children being driven increased from 19.7% in 1981 to 50.3% in 2002, with most of the increase occurring since 1991102 . Obesity is causing pressure on health services and a special clinic treating children with diabetes stopped taking new referrals because it was unable to cope with the numbers attending103 .
In a nationwide survey of general practitioners104 68% indicated that their workload had increased due to the surge in obesity. Studies in countries where the prevalence of obesity is similar to Ireland indicate that its direct costs are between 2% and 6% of the national health care budget. Despite this drain on resources and the fact that a 2003 survey105 showed that 44% of young people knew somebody with an eating disorder, no research has been carried out to date in Ireland on the incidence of these complaints106 . A task force has been established by the Minster for Health to examine the country's obesity problem107 .
It will be interesting to see if the task force reaches the same conclusion as Lord Haskins, food advisor to the British government, who stated at a conference on food in Dublin in 2004 that obesity 108 ' is not an ignorance issue, it is a despair issue.... If you could solve the problem of poverty, you would solve 80% of diet problems. The 20% of middle-class people who eat too much can be left to sort it out for themselves'.
H. Other signs that health deteriorated
More prescriptions issued to people on low incomes
The only data available on the number of prescriptions written in Ireland refers to people whose income is low enough for them to have been able to obtain a medical card. It is astonishing that no record is kept of prescriptions issued to non-medical card holders. However, as can be seen from the three graphs below, although the number of people covered by the medical card system in the years 1985-2001 declined as incomes rose, the total number of prescriptions issued went up, as did the number of items per prescription. This could indicate that the health of those on lower incomes had declined. The recent report from the Institute of Public Health on inequalities found that people on lowest incomes are 52% less likely to be very satisfied with their health.
The poor get sicker
A report109 in 2002 found that medical card holders had higher incidences of cardiovascular disease, stroke, hypertension, asthma, osteoarthritis, skin cancer and all other cancers, underactive thyroid, kidney stones, osteoporosis, gallstones, duodenal and gastric ulcers, and diabetes. A further report110 found that 52.9% of medical card holders suffered from one or more health conditions, in contrast to 22.7% of private insurance holders. It is interesting to note that only 13.9% of medical cardholders said that their health was excellent, in contrast to 36.2% of those who had private insurance. In another study, 90% of those without medical cards reported both better health and quality of life whereas the corresponding figures for medical card holders were only 70% and 60% respectively. Professor Cecily Kelleher, one of the authors, commented that the difference was due to medical card status and was not related to whether their sample lived in an urban or a rural area.111
In 2002, €50 million were spent on anti-depressants and mood stabilizers, up a staggering €42 million since 1993. Department of Health figures indicated that more than one in six medical card holders was taking anti-depressants112 .
More people with longstanding illnesses
The number of people carrying a long-term illness card rose steadily between 1992-2001; from 14.2 per 1000 in 1992, to 17.7 in 1996 and to 22.9 in 2001. This card has been issued since 1991 to those with illnesses such as diabetes, epilepsy and spina bifida. (The full list comprises hydrocephalus, phenylketonuria, muscular dystrophy, parkinsonism, acute leukaemia, multiple sclerosis, diabetes insipidus, diabetes mellitus, cerebral palsy, haemophilia, cystic fibrosis, phenylketonuria, mental handicap and mental illness.)
More cancers in men
The 2003 report of the National Cancer Registry states that allowing for the effects of population change and ageing, the overall true risk of developing cancer is increasing by 0.6% per annum for men but is not increasing for women 113 .
The only major instances of improved health I could find to set against the catalogue of decline we have just reviewed was in mortality from two great causes of death in Ireland, cancer and heart disease, but the statistical information is not adequate to allow us to say whether the gains were shared equally by all sections of society. As a result, I can definitely say as a public health doctor that the health of some sections of the Irish population deteriorated seriously during the high growth years. Moreover, I think that the deterioration is likely to accelerate in future because the full effects of prolonged stress and the recent changes in lifestyle have not yet become apparent.
I also believe that the shifts in relative income brought about by economic growth were largely responsible for the deterioration. The evidence is convincing and could become absolutely conclusive if proper statistics were kept. I will comment more widely at the end of the next section.
A. Did growth improve the social environment?
'The concept of social capital ... couldn't be simpler. Do you trust people? How many clubs, societies or social groups are you a member of? If your child gets sick, do you have support to call on? Basically how much social contact do you have in your life? These social ties, according to research, will help you live longer and are probably worth money to the economy' a submission from Cork County Council included in a 2003 National Economic and Social Forum (NESF) report114 states. Unfortunately, however, besides damaging physical and mental health, the increase in income inequality during the high-growth period appears to have depleted social capital by diminishing people's sense of belonging and their feelings of community and reducing the cohesiveness of society as a result.
More and more research shows that people living in unequal societies tend to have lower rates of involvement in community activities and lower levels of trust and that these reductions have inescapable psychosocial effects. Low levels of social capital have been found to be associated with relative deprivation and violent crime, including homicide (that is, murder and manslaughter), assault and robbery. In fact, Wilkinson115 writes that the association between unequal income distribution and both homicide and violent crime is even stronger than it is for mortality.
In a US study116 income inequality was found to be linked with decreased social capital when that was assessed according to the number of groups to which people belonged and their level of social trust as reflected by their responses to the question 'Do you think most people would take advantage of you if they got the chance?' There was also a strong correlation between income inequality, firearms offences and homicide. In another American study117 of over 32,000 men, it was found that strong social networks (as measured by membership of church or community groups, having fewer than six friends), led to lower mortality by reducing deaths from cardiovascular disease, accidents and suicide. This study also found that strong social networks were associated with a reduced incidence of stroke, and were also found to possibly prolong the survival of men with established coronary heart disease. Similar results were found in a study based on data from 39 US states, where it was found that income inequality led to increased mortality via lowered social capital118 .
While researching his book 'Bowling Alone'119 , Robert Putnam found that social capital had declined in the US, due to pressures of time and money, especially in two-income families; the distance traveled to work, and the time spent watching television. His review of the research into the effects of this decline led him to state that, statistically speaking, the evidence for the health consequences of social disconnectedness was as strong today as the link between smoking and cancer was at the time of the first Surgeon General's report on smoking. He writes that more than a dozen large studies over the past twenty years have shown that people who are socially disconnected are between two and five times more likely to die from all causes compared with individuals who have close ties with family, friends and the community. The more integrated a society is, he says, the less likely people are to die prematurely or to get heart attacks, strokes, cancer, and depression. It is therefore not surprising that the Irish study by Patricia Casey120 I mentioned earlier found that people who had difficulty in getting practical help from their neighbours were more likely to have depressive disorders. Furthermore, it has been found that people who have infrequent contact with their friends are 31% less likely to have to have excellent or very good mental health and 24% less likely to have a high general mental health score121 .
Social capital may improve our health by stimulating the immune system and buffering stress. As Robin Stott says122 'Health is as much a collective as an individual value, more dependent on networks than genes'.
(i) Democratic participation and social capital reduced
If one accepts the evidence that increased inequality damages social capital, the implications of the widening incomes gap in Ireland are profound. We can expect to find that, besides poorer health, violence has increased, that people have become more isolated and trust each other less. We might also find that a change Kawachi123 predicts has come about and that the lower levels of social trust have spilled over to create a lack of trust and confidence in government and that this has led to lower voter turnouts.
So what actually happened during the high growth years? The NESF survey did find that both interpersonal trust and levels of election turnout had declined during the 1990s and that only 25% of the survey's respondents agreed with the statement 'most people can be trusted'. Moreover, the 2004 Amarach study124 referred to earlier reported that the number of people who trusted institutions such as the Gardai, the legal system, the church, media, government, health service and supermarkets 'a great deal' to be honest and fair had fallen between 2001 and 2004. This can be seen in table 7.
Decline in the public's confidence in Irish institutions
% Trusting each
institution 'a great deal' to be honest and fair
% Trusting each
institution 'a great deal' to be honest and fair
|The Legal system||12%||5%||-58%|
|The health service||11%||7%||-37%|
|Table 7 shows the extent to which the public's confidence in Irish institutions deteriorated between 2001 and 2004.|
This lack of trust has an impact on health. The Institute of Public Health125 has reported that compared to those who trust most of their neighbours, people who do not trust most of their neighbours are 24% less likely to have excellent or very good general health and 20% less likely to have a very good quality of life.
Voter turnout in presidential, local, general and European elections certainly shows a downward trend and in 2002 was the lowest in the history of the state despite the polling stations being open for the longest time ever (15 hours) and government campaigns to encourage people to register to vote. The higher turnout in the 2004 elections may have been associated with three separate votes taking place on the same day. The Institute of Public Health's report126 'Inequalities in perceived Health', did not assess voting patterns; however, in the US, 90% of people in families with incomes over $75,000 tend to vote in presidential elections, but only half with incomes under $15,000. The result is that politicians become more interested in issues affecting the affluent, in turn narrowing the circle of social concern and political responsibility127 .
In 2003, social capital was reported128 to be so low in some disadvantaged communities in Ireland that some families were unable to engage in any activities outside their homes because of low incomes, a lack of social supports and a fear of crime. The NESF study reported that half of those surveyed had not made a social visit in the previous four weeks excluding those to family members and other relatives. A startling 82.5% had not attended a public meeting, and only 5.5% had joined an action group of any kind in the previous year. Furthermore, the report added that surveys had shown that the number of people prepared to volunteer had declined from 38.2% in 1992 to 35.1% in 1994 and 33.3% in 1997/8. 'Increased work pressure, commuting and other factors are beginning to impinge on patterns of social contact and network support' it reported, echoing Putnam's US findings.
The extra traveling time to work was confirmed by the CSO's 2002 Statistical Report. Workers on average traveled 9.8 miles from home to work in 2001, up from 6.7 miles six years earlier while those living in rural areas traveled over twice as far as their counterparts had done twenty years before. Rural based workers traveled over twice as far to work in 2002 as they did in 1982. The time taken by the extra travel left less for social activities. Putnam found this too and reported an inverse relationship between the two time uses.
(ii) Membership of voluntary organizations declines
"The Irish have gone for a 'work hard, play hard' ethos, which leaves little place for altruism beyond the immediate family". Amarach report 2002
When a sample of Irish people was asked in 1989 what they would do if they had more money, 48% replied that they 'would help a good cause,' followed by 'enjoy myself more'. When the same question was asked in 2001, however, the order was reversed and only 25% said they would help a good cause while the proportion saying that they would enjoy themselves more had risen to 57%129 .
After I read in the NESF report that eighty percent of the population was not involved in local community groups or in any type of volunteering, I asked a sample of voluntary organizations if they had problems recruiting members. The results were disturbing. None reported an increase in membership in recent years.
- The Irish Girl Guides Association reported a 'dramatic drop' in membership and in the number of adult volunteers since 1990.
- The Scouting Association also reported a decline in membership since 1990.
- The Irish Red Cross said that it found it more difficult to recruit volunteers and that their numbers were down.
- Both the Lions and Rotary clubs reported a reduction in membership
- The St. Vincent de Paul society noted that the time commitment that members gave was less than in previous years.
- The Parent Teacher Association reported that both participation levels and membership numbers had decreased over the last five years.
Again, this reflects the US experience. According to Putnam, the American groups whose membership is rising most rapidly are those in which the only commitment is to pay a subscription and receive a newsletter. He notes that the bonds of loyalty in this situation are to symbols, leaders or ideals and not to other people. This also has significance for health; there is evidence130 that those who have not been actively involved in local organizations are 37% less likely to be very satisfied with their health and 20% less likely to have a very good quality of life.
(iii) Criminal offences increase
Recorded crime, apart from murder, fell between 1995 to 2000, as can be seen in Figure 18. This could have been because it became easier for potential offenders to fulfill their economic aspirations by getting a job in the legitimate economy. A British Home Office study found131 that when the economy grew and more jobs were created for relatively poorly-educated young men the number of offences grew at a slower pace, but when the economy slowed, the crime rate caught up with its long-term rising trend line. This might be the reason that the most recent garda reports shown that total offences in the ten 'headline offences' categories (homicide, assaults, sexual offences, arson, drug offences, theft, burglaries, robberies, fraud and 'other') went up by 18% in 2001 and by a further 22% in 2002132 , years in which the growth rate had slowed down. Certainly, homeless young men who could have obtained work at the height of the boom were finding it very difficult to do so as a result of the slowdown, Fr. Peter McVerry told a conference in Dundalk in March 2004.
While theft, drug dealing and burglary might be 'economic' offences, murder and manslaughter generally aren't and Wilkinson133 cites a study which found that income inequality accounted for 35% of the difference in homicide rates between the 46 US states for which there was data. A similar relationship seems to hold in Ireland as Irish murder rates increased very significantly in the high growth decade. They rose from 0.69 per 100,000 in 1994 to 1.08 in 2000 and 1.43 in 2001. In the latter year, 52 murders took place, a far cry from Ireland in 1949 when just one murder was recorded134 .
Dr. Ian O'Donnell, the author of a major report on murders in Ireland, Unlawful Killing, Past and Present states135 that 'contributory factors cited as possible explanations for the increase in the murder rates, include the rise in alcohol consumption, dissatisfaction among those left behind by the Celtic Tiger, demographic changes and the rise in gangland feuding'. He adds: 'An unequal society creates a context for violent crime.'
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|This paper is from
Growth:The Celtic Cancer,
the second Feasta Review. Copies of the Review can be ordered online from Green Books, priced at £9.95 plus postage and packaging.