Tuesday, January 31, 2023

I have just finished reading George Eliot’s wonderful novel “Middlemarch.” Whenever I read a book or see a movie from the Victorian era, I am reminded about the great emphasis that existed on social class in the U.K. I think of “Peaky Blinders,” “The English Game,” the Dickens novels or other novels by Eliot. And while the U.S. also certainly has class differences, the ones in Great Britain somehow seem more dramatic and insurmountable.

It is not easy to give a clear-cut definition of social class, though it does seem to have an intuitive je ne sais quoi that most people appreciate. It is most obviously tied in with wealth and occupation, but certainly with who your family is. In most definitions, it constitutes some sort of social hierarchy that is composed of an amalgam of wealth, income, occupation, education, race and ethnicity, and family status in society. In Great Britain, the schools you go to and the resultant accents you acquire can distinguish a gentleman from the working class.

It may not surprise you to learn that in the U.K., the death certificate until quite recently had a box or field for social class. In the older social class systems, you had to be of noble birth or a baronet to be in the top tiers of the social class table. The classification scheme used after about 1930 relied primarily on occupation to define the five social classes—professional occupation; employers and managers; skilled occupations; semi-skilled occupations; and unskilled manual occupations. More recently, a seven-level schema for social class was devised in order to incorporate wealth as well as cultural interests and activities. These seven categories are Elite—the most privileged group through its wealth; Established middle class—second wealthiest and second highest cultural capital; Technical middle class—prosperous but low in cultural activity; New affluent workers—socially and culturally active with lower wealth; Traditional middle class—low wealth, low cultural capital, but owns his/her own house; Emergent service workers—relatively poor but high cultural capital; Precarious proletariat—poorest and low cultural and social capital.

While socioeconomic status (SES) has always been shown and known to correlate with mortality, social class, as defined by the older scale, has been shown to correlate with mortality as well, independently of SES. In other words, social class conveys some important relationship or characteristic in an individual that goes over and above pure financial status. A former colleague, Bruce Link, a social epidemiologist, once explained this to me in the context of tuberculosis. It was well recognized that there were large disparities in TB-related mortality between the upper and lower classes in the 19th and early 20th centuries. This could easily be explained by how TB was managed. It was known and understood that fresh air would help to combat the disease. Thus, those who could afford it would go to sanitaria or areas where they could have fresh air—Arizona, the Alps, rural parts of New England—where they would stay for months at a time. The poor were restricted to the congested, densely populated urban ghettos where TB during the Victorian era killed one in four.

In 1951, isoniazid, a cheap, effective antimicrobial, was first marketed for the treatment of TB. What happened to the disparity in TB mortality? Mortality decreased for both social classes, but the disparity remained. Link argues that we see that it is not money that drives social class differences but some other factor in how upper- and lower-class people deal with the health care system. Upper-class people availed themselves of the new antimicrobials to a greater and more effective degree than the lower classes did, even though both groups could afford the medication.

It should, therefore, not surprise us to find that social class differences also translate to cancer as well. Those who belong to upper classes tend to have lower rates of certain cancers that are associated with certain negative lifestyle behaviors, such as cigarette smoking. More importantly, survival tends to be better for those of the upper classes as well. This is true for many if not all types of cancer, and remains true in statistical analysis even after controlling for socioeconomic status. Thus, again it is clear that social class plays an important role in the interaction of the cancer patient with the health care system or the behavior of the patient with cancer. Being wealthy isn’t all there is to social determinism—how would the Beverly Hillbillies fare within our modern health care system? Or conversely, I often think that my parents, poor immigrant survivors in the late 1940s and early 1950s, if faced with a cancer crisis, would somehow have found the wherewithal to obtain the services of a high-quality provider rather than settling—that is the difference that class provides.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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