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.%c. Sc?. .W& Vol. 3 I. so 3. pp. 285-290. 1990 Printed in Great Bntain. All rights reserved
HEALTH
AND SOCIAL INEQUITIES GEOFFREY
Department
of Social Administration,
University
IN IRELAND
Coon
College,
Belfield.
Dublin
4, Republic
of Ireland
Abstract-This paper attempts to discuss the shape of inequalities in health in the Republic of Ireland by focusing on social class, gender and regional inequalities in health outcomes as shown in annual publications of vital statistics and in various research studies. The Republic of Ireland has a demographic profile of rapid population increase, unique in Europe. While the birth rate is the highest in Europe. the infant mortality rate is relatively low. yet the perinatal mortality rate is relatively high. Attempts are made to analyse social class variations in mortality and morbidity rates but, except for psychiatric care, Irish data on health by social class are scarce. There exist more data on gender inequalities which pinpoint the particular vulnerability of Irish women to ischaemic heart disease and certain types of cancer. Regional analysis of vital statistics reveals the vulnerability of people in urban areas (compared to rural areas) to cancer of the trachea. bronchus and lung, cirrhosis of the liver. tuberculosis of the respiratory system. pneumonia, and bronchitis, emphysema and asthma. In comparison to several European countries. Irish standardized mortality rates were the worst for urban women dying from lung cancer. and for urban men and women, Irish standardized mortality rates were the worst for non-rheumatic heart disease and respiratory tuberculosis. Various studies of morbidity of the elderly clearly reveal the hidden clinical iceberg of symptoms which are not presented to the health care system. Unfortunately, there is relatively little evidence of the health situation of disabled people, the travelling community or the long term unemployed. The article concludes with some suggested reforms to improve an evaluation of the performance of the Irish health care system. Ke! irords-health,
social.
inequities,
Ireland
INTRODUCTION
This paper attempts to discuss the shape of inequalities in health in the Republic of Ireland. The principle focus is on social class, gender and regional inequalities in health outcomes as revealed in annual publications of vital statistics and in various research studies. Unlike many European countries, Irish vital statistics have ignored social class classifications. so the analysis of the Irish material is inevitably less comprehensive than for those countries. Despite these data deficiencies, Ireland makes a fascinating country to compare with her European neighbours. After a brief discussion of basic demographic features of Ireland, there is an analysis of various research studies which focus on social class inequalities in health, in particular respiratory disease and psychiatric illness, with also some discussion on ischaemic heart disease and cancer. There follow sections on gender and regional inequalities in health before a brief review of health care situations of various target groups like the elderly, travellers and the unemployed. DEMOGRAPHIC
PROFILE
The Republic of Ireland has an unusual demographic profile. Total population has increased from 3 million in 1971 to over 3.5 million in 1986. This large increase in population contrasts strongly with most other European countries where the population is relatively static or declining. Although the Irish birth rate has been declining rapidly from 22 per 1000 population in 1980 to an estimated 17 per 1000 285
population in 1986, this birth rate still represents the highest in Europe [I]. After a very long period of high net emigration, the period of significant net immigration of the 1960s and 1970s has now terminated with the resumption of net emigration. The calculation of the size of this exodus is the subject of considerable controversy. The net interaction between past and present birth, death and migration rates has produced a demographic profile unique to Europe. Ireland thus possesses a young population: half the nation are aged under 25 years. This structure poses exciting prospects for the potentiality of health education and promotion. The principal causes of death in Ireland are cardiovascular disease, cancer and respiratory disease. This mortality record thus resembles those of other developed countries. While death rates from neoplasms are among the lowest for the European community among Irish men and women, the death rate from lung cancer among Irish women is the highest. Death rates from respiratory diseases for both men and women are (with the United Kingdom) the highest in Ireland of the whole European community. Of the 33,000 deaths which occur in Ireland each year, 17,321 deaths in 1986 were due to smoking-related illnesses and about 5000 deaths were attributed directly to smoking [2].
SOCIAL CLASS INEQUALITIES
Ireland’s infant mortality rate of 9 per 1000 live births for 1984 has decreased rapidly in recent years and is close to the lowest rate in the European
286
GEOFFREY
community. and so compares well with fellow member states. Perinatal mortality on the other hand, at 13.8 per 1000 live births in 1984, puts Ireland in the upper echelon in comparison with her European partners [I]. Despite the difficulties of making international comparisons of the causes of death in general and infant deaths and perinatal deaths in particular because of different medical certification and vital registration procedures, Kirke’s comparisons of perinatal mortality and infant mortality between Ireland, England and Wales and Sweden are illuminating and disturbing [3]. The death rate from congenital malformations in 1974 was substantially higher for Ireland than the other two countries. The trend in developed countries is prenatal diagnosis of pregnancies at high risk of certain congenital malformations such as neural tube defects and Down’s syndrome and the termination of those affected. Given that amniocentesis followed by selective abortion will not become standard procedure of Irish obstetric practice in the foreseeable future. the present differences between Ireland and other countries in perinatal and morbidity rates resulting from neural tube defects and Down’s syndrome are likely to become even more marked in the future. In comparing Swedish and Irish infant mortality, the largest differences in the rates of death were for diseases of the respiratory system, accidents and infective and parasitic diseases. All these causes of death are known to be particularly influenced by adverse social conditions. Of all the complex set of factors which help to explain variation in infant mortality and in perinatal mortality, a key influence is low birth weight. Factors such as maternal age, parity and social class are believed to affect mortality largely through effects on birth weight and gestational maturity. Ireland lacks a well developed set of perinatal statistics but, when the Department of Health Birth Notification system is established, comprehensive data will be available on population birth weight distribution. Only then will there be clear Irish evidence of the assumed direct relationship between low birth weight and social class. Given the high incidence of respiratory morbidity and mortality in Ireland, a study conducted by Shelley, Dean, Daley and Hickey on factors related to respiratory symptoms among 720 men is of great interest because their data were analysed by social class (41. Their study focused on the respiratory symptoms of cough, phlegm, breathlessness and wheeze. Social class was a significant factor in the number reporting cough, phlegm, wheeze and the presence of any one symptom. Neither breathlessness nor the presence of all four symptoms was, however, significantly associated with social class. The percentage of men with breathlessness, wheeze or all four symptoms increased from class I to V. The presence of any one symptom increased from 17.5% in class I to 48.5% in class IV and 48.3% in class V. The fact that the respondent was a current smoker was a highly significant factor for the presence of respiratory symptoms. The research team found that smoking habits appeared more closely associated with respiratory symptoms than area of residence, age or social class.
Coax Amongst non-smokers. there was no significant difference in symptom prevalence between social classes. There was, however, a significant difference by social class in the number of current smokers who reported cough, wheeze or the presence of one symptom. Among smokers who complained of cough. there were fewer than would be expected among social class II and more than would be expected in social class IV. Of those who reported wheeze, there were more than expected in social class V and fewer than expected among smokers in social class I. There were significantly more smokers with any one symptom in social class IV and significantly less than expected in social class I. There was no significant difference in the number of cigarettes smoked per day by cigarette smokers in each social class. Neither was there a significant difference in the ratio of current to non-current smokers in the different social classes. Nevertheless. the percentage of current smokers increased from 32.5% in social class I to 47.6% in social class IV and 41.4% in social class V. Although the excess of current smokers in social class IV and V may have contributed to the increased prevalence of respiratory symptoms in these groups, social class remained as a risk factor when current smokers only were considered. Given the dearth of analysis of social class inequalities in health in Ireland, a study by Mulcahy, Hickey, Daly and Graham which takes level of education as a proxy for social class and compares level of education, coronary risk factors and cardiovascular disease among 1560 Irish men in 19781979 is of considerable interest [S]. Men were separated into three educational groups. Group 1 were those who experienced primary education only: 537 men. Group 2 were those who experienced both primary and secondary education and finished their education with secondary education: 821 men. While Group 3 were those who finished their educational experiencies with some form of higher education: 202 men. The risk factors showed a gradient for cigarette smoking. diastolic blood pressure, relative weight and plasma cholesterol corrected for age with Group I possessing the highest risk factors and Group 3 the least. Crude morbidity levels for Group 1 were almost four times that of Group 3, with Group 2 holding an intermediate position. Logistic function analysis was employed to determine if the observed gradient in morbidity prevalence could be explained by the distribution of risk factors in the educational groups. Although the morbidity gradient was reduced in comparison to crude morbidity, a significant gradient was still apparent. Thus, irrespective of educational group differences in risk factors, there remains a strong independent effect of education itself on morbidity. The men in Group 1 had more than double the morbidity of the men in Group 3 even when differences in risk factors were taken into account. On the basis of the authors’ logistic function analysis, the independent effect of education on cardiovascular disease is as strong as the effect of smoking, blood pressure, weight and cholesterol combined. Educational status is. of course, merely one dimension of social class, but the fact that people of different educational attainment have markedly-
Health
and social inequities
different risk factor profiles has important implications in the promotion of a preventive approach to cardiovascular disorders and in the role and thrust of health education programmes. Considerable controversy surrounds the contention that Ireland has high rates of patients deemed schizophrenic in comparison to other countries, given the wide cultural variation in behaviour which is labelled schizophrenic. In 1980, there were 27,098 admissions to psychiatric hospitals and psychiatric units of general hospitals [6]. Almost one-quarter of these admissions were for schizophrenia, just over one-quarter were for alcoholism or alcoholic psychosis, while just over one-fifth were for manic depressive psychosis. Psychiatric care records are the only area of the health services in Ireland in which there are data available for the social class of the patients. The Medical Social Research Board in Ireland published data which shows a strong relationship between psychiatric admission rates and social class [7]. The unskilled manual rate of 1621.6 per 100,000 was dominated by admissions for schizophrenia, alcoholism and manic depressive psychosis. The unskilled manual rate was twice the national average. In descending order the next highest admission rates were other non-manual (1057.7 per lOO,OOO),other agricultural (975.1), and intermediate non-manual (950.3). A detailed examination of admissions to psychiatric care in three rural counties and to one Dublin psychiatric hospital by Walsh and O’Hare confirmed the marked social class gradient [8]. In the rural areas, the highest rates of admission to psychiatric care-inpatient and outpatient-was for unskilled manual groups in which the male rate was 28 times those of the higher professional groups in 1974, and the female equivalent was 10 times higher. Other groups with high rates included agricultural workers and farmers. For the same year, the highest one day prevalence rate for the Dublin psychiatric hospital was for the higher professional group. In this case, male rates were only one and a half times those of the unskilled manual group with female rates almost double. By 1982, the data revealed that the same pattern for the three rural areas was maintained with the highest rates of admission to psychiatric care for the unskilled manual groups and the lowest rates for the higher professional group; but the disparity was not as marked. The Dublin psychiatric hospital data had changed markedly by 1982 to show the same characteristics as the rural areas, with the highest rates for the unskilled manual group. The lowest rate, however, was for the employers and managers group. The data also revealed a significant difference in the time period of care. Those in the professional, employers, managers and skilled groups were more likely to have short lived episodes of care compared with the unskilled groups who had a tendency to remain in long term care.
GENDER
INEQUALITIES
In moving from analysing and explaining social class inequalities in health to focusing on gender inequalities in health, Dean and Kelson’s research reveals some significant health hazards for both Irish men and Irish women [9]. As part of a group
in Ireland
287
research project, the authors analysed mortality statistics on an EEC basis. In order to make comparisons between countries, standardized mortality ratios were computed using for reference the populations and deaths for the combined study countries for the years 1969-1978. The all-EEC countries standardized mortality rate was 100. Male and female standardized mortality rates were calculated individually using separate gender specific reference populations. As part of this analysis included a social class dimension, the compounding of social class and gender inequalities can reveal particularly vulnerable health target groups. Dean and Kelson’s research focused on mortality patterns for six common cancers and ischaemic heart disease and found that Irish men and women had the highest standardized mortality ratios for colon cancer deaths for all EEC countries. In Ireland the standardized mortality ratio for cancer of the colon and cancer of the rectum was higher in semi-skilled male workers (SMR = 249 and 153) than in skilled workers (SMR = 137 and 81). The standardized mortality rate for death from thyroid cancer was lower for Irish men and higher for Irish women than the mean for all EEC countries, but thyroid cancer deaths are rare in Ireland so the Irish standardized mortality rates should be treated with caution, and this applies to deaths from cancer of the prostate also. Cancer of the cervix and of the uterus are of great interest because high standardized mortality ratios for cervical cancer deaths tend to be accompanied by low standardized mortality ratios for uterus cancer and vice-versa, suggesting that diagnostic transference between the two categories may be taking place. If the two categories of cancer of the cervix and cancer of the uterus are combined, the lowest risk in the EEC was in Ireland with an SMR of 74. The highest female standardized mortality ratio in the EEC for ischaemic heart disease was in Irish women, with a standardized mortality rate of 230, the next highest being in women in England and Wales with a standardized mortality ratio of 170. In men, ischaemic heart disease was highest in England and Wales, standardized mortality rate of 162, with Ireland coming a close second with a standardized mortality rate of 160. Again, there was a clear social class gradient with a higher standardized mortality rate among the semi-skilled (SMR = 164) than among skilled manual workers (SMR = 117). In reaching for explanation for some of these disturbing Irish standardized mortality ratios, considerable weight is to be placed on occupation, diet and personal behaviour patterns. Thus, the very high ratios for cancer of the colon may be related to the Irish diet which is high in animal fat and relatively low in protein. With the standardized mortality rates combined for cancer of the cervix and the uterus, the very low rates may be related to the relatively late age of first sexual intercourse and relatively low number of sexual partners. Certainly these factors have been most pertinent in explaining cancer of the cervix. If Ireland in the past has been characterized as a country with a relatively strict code with regard to sexual mores, it also has the highest proportion of unmarried women with marriage occurring later than the average in the EEC.
GEOFFREYCook
288
The unacceptably high rates of mortality for both men and women in Ireland from ischaemic heart disease may again be related to diet and personal habits. Ireland has the highest consumption of animal fats in the EEC, and this situation is greatly exacerbated by cigarette consumption which is the highest per capita in the EEC. The scope for a really effective health promotion campaign is therefore higher in Ireland than in any other EEC country. The real problem for a successful campaign to change Irish dietary habits and personal consumption patterns would be the employment effects on the farming and tobacco industries in Ireland, and the associated loss of revenue to the government. In this way, the Irish government has a financial interest in the status quo rather than facing the employment and revenue consequences of a very successful Irish health promotion campaign. For psychiatric illness, Walsh and O’Hare’s research shows that female incidence rates for both the three rural counties’ psychiatric services and the Dublin psychiatric hospital significantly exceeded male incidence rates in the 1974 registers, but by 1982, these differences had largely disappeared [8]. For women, the most common incidence of diagnosis in both registers was depression which greatly exceeded the next most common diagnosis of neuroses. These two diagnoses accounted for about 55% of the incidence of reported female psychiatric illness. Male incidence rates were generally highest for alcohol abuse and depressive illnesses. While for all diagnoses incidence rates fell for both registers between 1974 and 1982, this was most evident for neuroses, schizophrenia and for organic psychoses in the three rural counties. When Walsh and O’Hare compared the data from the Irish registers with five similar British registers for one year prevalence of psychiatric illness, they discovered that the combined three rural counties emerged as the only register with higher male than female rates. All the other registers except one had a female excess of approximately one-third. While the three county rates for women were similar to the British registers, the male rate was an average 40% higher than the British register rates. A detailed review of the statistics of the Irish case registers reveals that the very large proportion of long stay inpatients in the three rural counties sets them apart from the English registers and the register of the Dublin psychiatric hospital. Many of these patients have been labelled schizophrenic and have been incarcerated for many years. They represent one of the biggest challenges to the future direction of Irish health care policy in terms of a visible transfer of resources to community care. REGIONAL INEQUALITIES
Several illnesses in Ireland show a marked contrast between regions and. in particular, between urban and rural prevalences. In a study analysing the Hospital Inpatient Enquiry data which covers most but not all Irish hospitals, Ward. Healy and Dean showed five conditions for which reported prevalences among men in Dublin County Borough were greater than 150% of that in rural districts in 1970-1972 [IO]. In all five cases, Dublin prevalence rates exceeded those
in the remaining urban districts, with rural rates lower still. The five in descending order of excess of Dublin rates over rural rates were cancer of the trachea, bronchus and lung 202%, cirrhosis of the liver 192%. tuberculosis of the respiratory system 161%. pneumonia 158%. and bronchitis, emphysema and asthma 157%. Four out of these five illnesses are respiratory and significantly exacerbated, if not caused. by chronic cigarette consumption. Cirrhosis of the liver on the other hand is directly linked to high alcohol consumption. According to Ward. Healy and Dean, adult males smoked 30% more cigarettes in the Dublin area than in rural areas, and alcohol consumption was 48% higher per capita in urban than in rural households in 1973. There was a significant difference between the genders. Among women in the Hospital Inpatient Enquiry no excess of Dublin over rural rates of prevalence exceeded 150%. Pneumonia was the highest at 145% Dublin excess over rural prevalence, benign and unspecified neoplasms 143%. cancer of the trachea, bronchus and lung 141%, and bronchitis, emphysema and asthma 129%. Again. the significant feature of these data is that most of these diseases are respiratory, and in 1971, adult females in the Dublin area smoked 90% more cigarettes than rural women. As part of a European study, Dean analysed five respiratory illnesses (lung cancer, influenza, pneumonia, bronchitis, emphysema and asthma and respiratory tuberculosis) and ischaemic heart disease in Ireland, Scotland, England and Wales, France, West Germany, Italy, Belgium, Denmark and the Netherlands, and obtained urban/rural differentiation for Ireland, England and Wales, France, Denmark and the Netherlands [I I]. This analysis underscores the particular vulnerability of both Irish men and women to respiratory disease and urban Irish women to certain illnesses. With the standardized mortality ratio for all EEC at 100, the most disturbing statistic by far was the SMR for bronchitis, emphysema and asthma for Irish urban women at 345 (the rural rate was 266). For men, the rates were also the highest for all men in the EEC with an urban SMR of 249 and rural 170. Influenza and pneumonia standardized mortality rates were also very high for both men and women in both urban and rural areas, but this high level of mortality is shared by England and Wales in both urban and rural areas. While the SMR for lung cancer for men in Irish urban areas was exceeded by men in urban areas in England and Wales and in the Netherlands, Dean’s analysis clearly reveals the significant vulnerability of Irish urban women with an SMR for lung cancer of 256, greatly in excess of urban women in other EEC countries. Urban women in England and Wales are the next most vulnerable with an SMR of 226. For the five countries for which Dean had data, non-rheumatic heart disease and respiratory tuberculosis also produced higher standardized mortality ratios in Ireland than elsewhere, and among both urban men and women the SMRs were the greatest. Ireland is divided into eight health board areas and so it is possible to go beyond a straightforward urban/rural division and specify areas of higher mortality. While the crude birth rate was 19 per 1000 in 1983 and was the highest in the EEC, the highest
Health
and social inequities
birth rate was in the north-eastern area (20.6) and the lowest in the western area (18.0) [I]. The infant mortality rate of 9.8 per 1000 live births in 1983 showed a regional variation between 8.0 per 1000 in the western region to 10.9 per 1000 in the southern region. The highest death rate from diseases of the circulatory system in 1983 was 608.7 per 100,000 in the western area and the lowest was 338.2 per 100,000 in the eastern area (around Dublin). By region, the cancer death rates varied from 214.2 per 100,000 in the north-western region to 167.5 per 100,000 in the eastern region. Motor vehicle deaths were the highest in the Midlands in 1983 (23.8 per 100,000 people) and lowest in the southern region (12 per 100,000 people). THE ELDERLY
Reviewing the research work on various target groups’ morbidity and mortality in Ireland, more analysis has been done on the elderly than on other target groups. Martin and Doyle conducted one of the largest surveys of people aged over 65 in a city health centre and in a suburban health centre [12]. They focused on morbidity patterns and living conditions among 586 patients and found that the commonest disorders were rheumatic disease (31%), psychiatric illness (26%) and cardio-respiratory conditions (26%). Martin and Doyle divided the sample of elderly people into three groups. Group 1 contained those with normal mobility who possessed no incapacitating illness. Group 2 consisted of those whose movement was restricted or who were housebound. Illness was present but patients were able to cope. The third group consisted of those who were bedfast; 39% of the sample were found to be in social classes IV and V, the majority of them living on an income of less than f30 per week in 1981. Not only were they found to be socially isolated and financially disadvantaged, but this group of elderly people in social class IV and V were found to have a high incidence of illness. 21% of this group of elderly in social classes IV and V were classified as being in Group 2, and 4% of them were classified as Group 3. This low social class group had a high proportion of some form of long term treatment (65%) and this was substantially higher and their compliance with treatment poor compared with the rest of the sample. This research study also discovered that the elderly in social class IV and V lived mainly in substandard housing and were more likely to live alone than the rest of the elderly sample. This picture of chronic deprivation and morbidity amongst the elderly was endorsed by Walsh in his sample survey of a much smaller number of elderly aged over 65 (105 people) in North Dublin [l3]. The elderly in this sample were subjected to a wide range of tests to make an assessment of vision, mental impairment, anaemia, general medical problems and entitlement to benefits. Some of Walsh’s findings reveal a staggering level of morbidity amongst the elderly and show a huge clinical iceberg of symptoms not touched by the traditional medical system. Of the sample of 105 elderly, 55 were judged to have satisfactory vision with current spectacles and 10 were deemed to have normal vision without spectacles. Seven people had known visual impairment but a very high number-
in Ireland
289
33 people-had uncorrected and uninvestigated sight impairment. The visual impairment suffered ranged from pure refractive errors to severe glaucomas and cataracts. The mental status assessment raised equally perturbing results. While 78 of the elderly were deemed to have a normal mental state, 25 were judged to have a mental impairment and only three of these had been previously recognized. Ten were assessed as possessing a mild mental impairment, eight a moderate mental impairment, six a severe mental impairment and one a profound impairment. Only one of the six with severe and one of the eight with moderate impairment were previously recognized as such by the patient’s general practitioner. All ten cases of the mildly impaired elderly were viewed by the general practitioners as normal elderly people. Three men were found to be anaemic, all bachelors living alone, two of them in deplorable conditions. Walsh also found a high proportion of hypertension amongst the sample of elderly, both newly discovered hypertension and previously treated but uncontrolled hypertension. The sample also discovered significant numbers of congestive heart failure, osteo-arthritis and chronic bronchitis, all newly discovered or previously treated but uncontrolled. A very high proportion (41 out of 105) were in need of some form of chiropody, and a significant number of the sample (16 out of 105) had severe dental disease for which the patients needed urgent treatment. There were also several undiagnosed cases of depression, severe anxiety, diabetes and various carcinomas. In six cases of moderate to severe hearing impairment and wax in both ears, four were cured by having their ears washed out. These cases of treatable deafness illustrate that deafness is widely accepted by doctor and old person alike as a symptom of old age not needing further investigation. A comparison between Walsh’s results and British studies of unreported illness provides a useful framework of reference for discussion of the clinical iceberg of prevalent but unreported illness. In comparison with Williamson’s study in Edinburgh in 1964 [14], Thomas’s study in Bristol in 1968 [15], Lowther’s study in Edinburgh in 1970 [16], and Williams’ study in Bolton in 1972 [l7], Walsh’s Dublin study revealed a high amount of unreported visual impairment. The detection and treatment of visual impairment amongst the elderly is revealed by Walsh’s study to be an Achilles heel of the Irish health system, with an urgent need for a reformed ophthalmology service. The high level of mental impairment amongst the elderly was endorsed by Williamson’s 1964 Edinburgh study [14]. The high level of unreported and uncontrolled hypertension (15% of the sample in comparison with the British studies which reported undiscovered and unreported hypertension between 5 and 12% of the appropriate samples) is underscored by the high systolic and diastolic levels which Walsh took before the subjects were categorized as hypertensive. Walsh’s study as a whole raises fundamental questions about the objectives, efficiency and delivery of Ireland’s health care system for elderly people. This requires a rethinking of the role and operation of the general practitioner service and public health nursing service on the frontline of the primary care system. Walsh’s
GEOFFREY
290
study also focused on the particular inadequacies of eye. dental and chiropody services for the elderly and a simplification of delivery and much more appropriate targeting of resources to the designated high risk target groups. OTHER TARGET GROUPS
Apart from the elderly. there are very few research studies on the morbidity patterns and health care situations of various target groups. Great concern has been expressed with the life styles and social impact of the travelling people. and a special Commission of Enquiry produced a report but with very little evidence on the health situation of the travellers [IS]. Casual observation suggested that very few travellers reached old age and many lived in very unsatisfactory and insanitary situations. Thus, the Department of Health in Ireland has established a special research team to investigate the health profile of the travelling community. The results of this study are awaited with great interest, and it will be surprising if the research does not reveal profound health disadvantages of the travellers’ life styles. Very little research work has been conducted on single parents’ health situation or on the health situation of single people generally in comparison to married people or cohabitees. Neither has there been a study comparing the health situation of families with various numbers of children. Given the larger size of Irish families in comparison with other countries, such a study could have a great deal of policy relevance. Perhaps the greatest deficit of research studies into various target groups is the lack of research into the health situation of the unemployed. In comparison to many other countries where there have been major research studies into the health impact of unemployment, Ireland has avoided such a study. Yet the situation of the unemployed is of great pertinence. Ireland has had the highest rate of registered unemployment in the EEC for many years, with a current rate of approx. Zoo/u. Two-fifths of this group, or 100,000 people have been unemployed for more than a year. A research study on the health impact of short term and long term unemployment in Ireland should be of the utmost urgency.
CooK
A discussion of the nature of the transmission process of profound disadvantage in health would be premature in the absence of much more comprehensive morbidity statistics and the widespread utilization of social class criteria in the collection of vital statistics. The adoption in Ireland of the equivalent of the British General Household Survey on a regular basis would provide the data framework for the development of plausible hypotheses about the nature and transmission of profound and significant disadvantage in health care outcomes. Existing Irish health care data are based on inputs and outputs of the health care system. Recent cutbacks of health care expenditure have focused on obtaining similar outputs from reduced inputs and in changing the eligibility system for health care. Of far greater pertinence to both the taxpayer and consumer of health care services is the impact of retrenchment in health care expenditure on health outcomes between social classes and between regions and genders. Such data on health outcomes would provide a bedrock for the more effective evaluation of existing health care strategies and the more effective targeting of medical care resources on health states. REFERENCES
I. Statistical information
relevant to the Health Services, Department of Health. 1986. 2. Health--the wider dimension. A consultative statement on health policy. Department of Health. 1986. P. Perinatal mortality in Ireland and selected countries: variations in underlying factors. Irish med. J. 221-225. 1981. 4. Shelley E.. Dean G., Daly L. and Hickey N. Factors related to respiratory symptoms in Irish men.
3. Kirke
Irish med. J. 240-247.
1980.
5. Mulcahy
R., Hickey N., Daly L. and Graham 1. Levels of education, coronary risk factors and cardiovascular disease. Irish med. J. 316-318. 1984. 6. Tussing D. Irish medical care resources: an economic analysis, p. 72. Economic and Social Research Institute, Dublin, 1985. 7. Medico Social Research Board. Activities of Irish psychiatric hospitals and units 1980. Dublin, 1981. 8. O’Hare A. and Walsh D. The three county and St Loman‘s psychiatric case registers 1974 and- 1982. Med.
Sot. Res. 1987.
9. Dean G. and Kelson M. The reported
COSCLUSION
This review of social class, regional and gender inequalities in health outcomes in Ireland has revealed significant and sometimes profound disadvantages. Severe social class gradients in mortality patterns have been revealed with respect to cardiovascular diseases. respiratory diseases and several types of cancer. These data have been reinforced by more patchy but no less significant morbidity data, which have revealed acute social class differences in health care outcomes. Particularly vulnerable groups include the long term unemployed. the disabled and the travelling community. but studies of the health care outcomes of such groups are either non-existent or have only recently commenced.
mortality pattern in the countries of the EEC for six common cancers and ischaemic heart disease. Irish med. J. 98-100, 1984. IO. Ward J. B.. Healy C. and Dean G. Urban and rural mortality in the Republic of Ireland. Irish med. J. 1978. disease and heart attacks among Il. Dean G. Respiratory rural workers in Ireland and other countries of the European Economic Community. Irish med. J. 338-341. 1982.
12. Martin J. and Doyle V. Survey of the elderly in an urban general
practice.
Iris/z med. J. 358-361,
1984. unrecognised treatable illness in an Irish elderly population. lrish med. J. 62-67, 1980. Williamson J. er a/. Lancer 1, I I 17-l 120. 1964. Thomas P. Br. med. J. 3, 275-277, 1970. Lowther C. er al. Br. med. J. 3, 275-277. 1970. Williams E. Br. med. J. 2, 445-448. 1972. Commission q/ Ihe Trarelling People. Stationery Office, Dublin, 1983.
13. Walsh B. Previously 14. 15. 16. 17. 18.
.%c. Sc?. .W& Vol. 3 I. so 3. pp. 285-290. 1990 Printed in Great Bntain. All rights reserved
HEALTH
AND SOCIAL INEQUITIES GEOFFREY
Department
of Social Administration,
University
IN IRELAND
Coon
College,
Belfield.
Dublin
4, Republic
of Ireland
Abstract-This paper attempts to discuss the shape of inequalities in health in the Republic of Ireland by focusing on social class, gender and regional inequalities in health outcomes as shown in annual publications of vital statistics and in various research studies. The Republic of Ireland has a demographic profile of rapid population increase, unique in Europe. While the birth rate is the highest in Europe. the infant mortality rate is relatively low. yet the perinatal mortality rate is relatively high. Attempts are made to analyse social class variations in mortality and morbidity rates but, except for psychiatric care, Irish data on health by social class are scarce. There exist more data on gender inequalities which pinpoint the particular vulnerability of Irish women to ischaemic heart disease and certain types of cancer. Regional analysis of vital statistics reveals the vulnerability of people in urban areas (compared to rural areas) to cancer of the trachea. bronchus and lung, cirrhosis of the liver. tuberculosis of the respiratory system. pneumonia, and bronchitis, emphysema and asthma. In comparison to several European countries. Irish standardized mortality rates were the worst for urban women dying from lung cancer. and for urban men and women, Irish standardized mortality rates were the worst for non-rheumatic heart disease and respiratory tuberculosis. Various studies of morbidity of the elderly clearly reveal the hidden clinical iceberg of symptoms which are not presented to the health care system. Unfortunately, there is relatively little evidence of the health situation of disabled people, the travelling community or the long term unemployed. The article concludes with some suggested reforms to improve an evaluation of the performance of the Irish health care system. Ke! irords-health,
social.
inequities,
Ireland
INTRODUCTION
This paper attempts to discuss the shape of inequalities in health in the Republic of Ireland. The principle focus is on social class, gender and regional inequalities in health outcomes as revealed in annual publications of vital statistics and in various research studies. Unlike many European countries, Irish vital statistics have ignored social class classifications. so the analysis of the Irish material is inevitably less comprehensive than for those countries. Despite these data deficiencies, Ireland makes a fascinating country to compare with her European neighbours. After a brief discussion of basic demographic features of Ireland, there is an analysis of various research studies which focus on social class inequalities in health, in particular respiratory disease and psychiatric illness, with also some discussion on ischaemic heart disease and cancer. There follow sections on gender and regional inequalities in health before a brief review of health care situations of various target groups like the elderly, travellers and the unemployed. DEMOGRAPHIC
PROFILE
The Republic of Ireland has an unusual demographic profile. Total population has increased from 3 million in 1971 to over 3.5 million in 1986. This large increase in population contrasts strongly with most other European countries where the population is relatively static or declining. Although the Irish birth rate has been declining rapidly from 22 per 1000 population in 1980 to an estimated 17 per 1000 285
population in 1986, this birth rate still represents the highest in Europe [I]. After a very long period of high net emigration, the period of significant net immigration of the 1960s and 1970s has now terminated with the resumption of net emigration. The calculation of the size of this exodus is the subject of considerable controversy. The net interaction between past and present birth, death and migration rates has produced a demographic profile unique to Europe. Ireland thus possesses a young population: half the nation are aged under 25 years. This structure poses exciting prospects for the potentiality of health education and promotion. The principal causes of death in Ireland are cardiovascular disease, cancer and respiratory disease. This mortality record thus resembles those of other developed countries. While death rates from neoplasms are among the lowest for the European community among Irish men and women, the death rate from lung cancer among Irish women is the highest. Death rates from respiratory diseases for both men and women are (with the United Kingdom) the highest in Ireland of the whole European community. Of the 33,000 deaths which occur in Ireland each year, 17,321 deaths in 1986 were due to smoking-related illnesses and about 5000 deaths were attributed directly to smoking [2].
SOCIAL CLASS INEQUALITIES
Ireland’s infant mortality rate of 9 per 1000 live births for 1984 has decreased rapidly in recent years and is close to the lowest rate in the European
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community. and so compares well with fellow member states. Perinatal mortality on the other hand, at 13.8 per 1000 live births in 1984, puts Ireland in the upper echelon in comparison with her European partners [I]. Despite the difficulties of making international comparisons of the causes of death in general and infant deaths and perinatal deaths in particular because of different medical certification and vital registration procedures, Kirke’s comparisons of perinatal mortality and infant mortality between Ireland, England and Wales and Sweden are illuminating and disturbing [3]. The death rate from congenital malformations in 1974 was substantially higher for Ireland than the other two countries. The trend in developed countries is prenatal diagnosis of pregnancies at high risk of certain congenital malformations such as neural tube defects and Down’s syndrome and the termination of those affected. Given that amniocentesis followed by selective abortion will not become standard procedure of Irish obstetric practice in the foreseeable future. the present differences between Ireland and other countries in perinatal and morbidity rates resulting from neural tube defects and Down’s syndrome are likely to become even more marked in the future. In comparing Swedish and Irish infant mortality, the largest differences in the rates of death were for diseases of the respiratory system, accidents and infective and parasitic diseases. All these causes of death are known to be particularly influenced by adverse social conditions. Of all the complex set of factors which help to explain variation in infant mortality and in perinatal mortality, a key influence is low birth weight. Factors such as maternal age, parity and social class are believed to affect mortality largely through effects on birth weight and gestational maturity. Ireland lacks a well developed set of perinatal statistics but, when the Department of Health Birth Notification system is established, comprehensive data will be available on population birth weight distribution. Only then will there be clear Irish evidence of the assumed direct relationship between low birth weight and social class. Given the high incidence of respiratory morbidity and mortality in Ireland, a study conducted by Shelley, Dean, Daley and Hickey on factors related to respiratory symptoms among 720 men is of great interest because their data were analysed by social class (41. Their study focused on the respiratory symptoms of cough, phlegm, breathlessness and wheeze. Social class was a significant factor in the number reporting cough, phlegm, wheeze and the presence of any one symptom. Neither breathlessness nor the presence of all four symptoms was, however, significantly associated with social class. The percentage of men with breathlessness, wheeze or all four symptoms increased from class I to V. The presence of any one symptom increased from 17.5% in class I to 48.5% in class IV and 48.3% in class V. The fact that the respondent was a current smoker was a highly significant factor for the presence of respiratory symptoms. The research team found that smoking habits appeared more closely associated with respiratory symptoms than area of residence, age or social class.
Coax Amongst non-smokers. there was no significant difference in symptom prevalence between social classes. There was, however, a significant difference by social class in the number of current smokers who reported cough, wheeze or the presence of one symptom. Among smokers who complained of cough. there were fewer than would be expected among social class II and more than would be expected in social class IV. Of those who reported wheeze, there were more than expected in social class V and fewer than expected among smokers in social class I. There were significantly more smokers with any one symptom in social class IV and significantly less than expected in social class I. There was no significant difference in the number of cigarettes smoked per day by cigarette smokers in each social class. Neither was there a significant difference in the ratio of current to non-current smokers in the different social classes. Nevertheless. the percentage of current smokers increased from 32.5% in social class I to 47.6% in social class IV and 41.4% in social class V. Although the excess of current smokers in social class IV and V may have contributed to the increased prevalence of respiratory symptoms in these groups, social class remained as a risk factor when current smokers only were considered. Given the dearth of analysis of social class inequalities in health in Ireland, a study by Mulcahy, Hickey, Daly and Graham which takes level of education as a proxy for social class and compares level of education, coronary risk factors and cardiovascular disease among 1560 Irish men in 19781979 is of considerable interest [S]. Men were separated into three educational groups. Group 1 were those who experienced primary education only: 537 men. Group 2 were those who experienced both primary and secondary education and finished their education with secondary education: 821 men. While Group 3 were those who finished their educational experiencies with some form of higher education: 202 men. The risk factors showed a gradient for cigarette smoking. diastolic blood pressure, relative weight and plasma cholesterol corrected for age with Group I possessing the highest risk factors and Group 3 the least. Crude morbidity levels for Group 1 were almost four times that of Group 3, with Group 2 holding an intermediate position. Logistic function analysis was employed to determine if the observed gradient in morbidity prevalence could be explained by the distribution of risk factors in the educational groups. Although the morbidity gradient was reduced in comparison to crude morbidity, a significant gradient was still apparent. Thus, irrespective of educational group differences in risk factors, there remains a strong independent effect of education itself on morbidity. The men in Group 1 had more than double the morbidity of the men in Group 3 even when differences in risk factors were taken into account. On the basis of the authors’ logistic function analysis, the independent effect of education on cardiovascular disease is as strong as the effect of smoking, blood pressure, weight and cholesterol combined. Educational status is. of course, merely one dimension of social class, but the fact that people of different educational attainment have markedly-
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different risk factor profiles has important implications in the promotion of a preventive approach to cardiovascular disorders and in the role and thrust of health education programmes. Considerable controversy surrounds the contention that Ireland has high rates of patients deemed schizophrenic in comparison to other countries, given the wide cultural variation in behaviour which is labelled schizophrenic. In 1980, there were 27,098 admissions to psychiatric hospitals and psychiatric units of general hospitals [6]. Almost one-quarter of these admissions were for schizophrenia, just over one-quarter were for alcoholism or alcoholic psychosis, while just over one-fifth were for manic depressive psychosis. Psychiatric care records are the only area of the health services in Ireland in which there are data available for the social class of the patients. The Medical Social Research Board in Ireland published data which shows a strong relationship between psychiatric admission rates and social class [7]. The unskilled manual rate of 1621.6 per 100,000 was dominated by admissions for schizophrenia, alcoholism and manic depressive psychosis. The unskilled manual rate was twice the national average. In descending order the next highest admission rates were other non-manual (1057.7 per lOO,OOO),other agricultural (975.1), and intermediate non-manual (950.3). A detailed examination of admissions to psychiatric care in three rural counties and to one Dublin psychiatric hospital by Walsh and O’Hare confirmed the marked social class gradient [8]. In the rural areas, the highest rates of admission to psychiatric care-inpatient and outpatient-was for unskilled manual groups in which the male rate was 28 times those of the higher professional groups in 1974, and the female equivalent was 10 times higher. Other groups with high rates included agricultural workers and farmers. For the same year, the highest one day prevalence rate for the Dublin psychiatric hospital was for the higher professional group. In this case, male rates were only one and a half times those of the unskilled manual group with female rates almost double. By 1982, the data revealed that the same pattern for the three rural areas was maintained with the highest rates of admission to psychiatric care for the unskilled manual groups and the lowest rates for the higher professional group; but the disparity was not as marked. The Dublin psychiatric hospital data had changed markedly by 1982 to show the same characteristics as the rural areas, with the highest rates for the unskilled manual group. The lowest rate, however, was for the employers and managers group. The data also revealed a significant difference in the time period of care. Those in the professional, employers, managers and skilled groups were more likely to have short lived episodes of care compared with the unskilled groups who had a tendency to remain in long term care.
GENDER
INEQUALITIES
In moving from analysing and explaining social class inequalities in health to focusing on gender inequalities in health, Dean and Kelson’s research reveals some significant health hazards for both Irish men and Irish women [9]. As part of a group
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research project, the authors analysed mortality statistics on an EEC basis. In order to make comparisons between countries, standardized mortality ratios were computed using for reference the populations and deaths for the combined study countries for the years 1969-1978. The all-EEC countries standardized mortality rate was 100. Male and female standardized mortality rates were calculated individually using separate gender specific reference populations. As part of this analysis included a social class dimension, the compounding of social class and gender inequalities can reveal particularly vulnerable health target groups. Dean and Kelson’s research focused on mortality patterns for six common cancers and ischaemic heart disease and found that Irish men and women had the highest standardized mortality ratios for colon cancer deaths for all EEC countries. In Ireland the standardized mortality ratio for cancer of the colon and cancer of the rectum was higher in semi-skilled male workers (SMR = 249 and 153) than in skilled workers (SMR = 137 and 81). The standardized mortality rate for death from thyroid cancer was lower for Irish men and higher for Irish women than the mean for all EEC countries, but thyroid cancer deaths are rare in Ireland so the Irish standardized mortality rates should be treated with caution, and this applies to deaths from cancer of the prostate also. Cancer of the cervix and of the uterus are of great interest because high standardized mortality ratios for cervical cancer deaths tend to be accompanied by low standardized mortality ratios for uterus cancer and vice-versa, suggesting that diagnostic transference between the two categories may be taking place. If the two categories of cancer of the cervix and cancer of the uterus are combined, the lowest risk in the EEC was in Ireland with an SMR of 74. The highest female standardized mortality ratio in the EEC for ischaemic heart disease was in Irish women, with a standardized mortality rate of 230, the next highest being in women in England and Wales with a standardized mortality ratio of 170. In men, ischaemic heart disease was highest in England and Wales, standardized mortality rate of 162, with Ireland coming a close second with a standardized mortality rate of 160. Again, there was a clear social class gradient with a higher standardized mortality rate among the semi-skilled (SMR = 164) than among skilled manual workers (SMR = 117). In reaching for explanation for some of these disturbing Irish standardized mortality ratios, considerable weight is to be placed on occupation, diet and personal behaviour patterns. Thus, the very high ratios for cancer of the colon may be related to the Irish diet which is high in animal fat and relatively low in protein. With the standardized mortality rates combined for cancer of the cervix and the uterus, the very low rates may be related to the relatively late age of first sexual intercourse and relatively low number of sexual partners. Certainly these factors have been most pertinent in explaining cancer of the cervix. If Ireland in the past has been characterized as a country with a relatively strict code with regard to sexual mores, it also has the highest proportion of unmarried women with marriage occurring later than the average in the EEC.
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The unacceptably high rates of mortality for both men and women in Ireland from ischaemic heart disease may again be related to diet and personal habits. Ireland has the highest consumption of animal fats in the EEC, and this situation is greatly exacerbated by cigarette consumption which is the highest per capita in the EEC. The scope for a really effective health promotion campaign is therefore higher in Ireland than in any other EEC country. The real problem for a successful campaign to change Irish dietary habits and personal consumption patterns would be the employment effects on the farming and tobacco industries in Ireland, and the associated loss of revenue to the government. In this way, the Irish government has a financial interest in the status quo rather than facing the employment and revenue consequences of a very successful Irish health promotion campaign. For psychiatric illness, Walsh and O’Hare’s research shows that female incidence rates for both the three rural counties’ psychiatric services and the Dublin psychiatric hospital significantly exceeded male incidence rates in the 1974 registers, but by 1982, these differences had largely disappeared [8]. For women, the most common incidence of diagnosis in both registers was depression which greatly exceeded the next most common diagnosis of neuroses. These two diagnoses accounted for about 55% of the incidence of reported female psychiatric illness. Male incidence rates were generally highest for alcohol abuse and depressive illnesses. While for all diagnoses incidence rates fell for both registers between 1974 and 1982, this was most evident for neuroses, schizophrenia and for organic psychoses in the three rural counties. When Walsh and O’Hare compared the data from the Irish registers with five similar British registers for one year prevalence of psychiatric illness, they discovered that the combined three rural counties emerged as the only register with higher male than female rates. All the other registers except one had a female excess of approximately one-third. While the three county rates for women were similar to the British registers, the male rate was an average 40% higher than the British register rates. A detailed review of the statistics of the Irish case registers reveals that the very large proportion of long stay inpatients in the three rural counties sets them apart from the English registers and the register of the Dublin psychiatric hospital. Many of these patients have been labelled schizophrenic and have been incarcerated for many years. They represent one of the biggest challenges to the future direction of Irish health care policy in terms of a visible transfer of resources to community care. REGIONAL INEQUALITIES
Several illnesses in Ireland show a marked contrast between regions and. in particular, between urban and rural prevalences. In a study analysing the Hospital Inpatient Enquiry data which covers most but not all Irish hospitals, Ward. Healy and Dean showed five conditions for which reported prevalences among men in Dublin County Borough were greater than 150% of that in rural districts in 1970-1972 [IO]. In all five cases, Dublin prevalence rates exceeded those
in the remaining urban districts, with rural rates lower still. The five in descending order of excess of Dublin rates over rural rates were cancer of the trachea, bronchus and lung 202%, cirrhosis of the liver 192%. tuberculosis of the respiratory system 161%. pneumonia 158%. and bronchitis, emphysema and asthma 157%. Four out of these five illnesses are respiratory and significantly exacerbated, if not caused. by chronic cigarette consumption. Cirrhosis of the liver on the other hand is directly linked to high alcohol consumption. According to Ward. Healy and Dean, adult males smoked 30% more cigarettes in the Dublin area than in rural areas, and alcohol consumption was 48% higher per capita in urban than in rural households in 1973. There was a significant difference between the genders. Among women in the Hospital Inpatient Enquiry no excess of Dublin over rural rates of prevalence exceeded 150%. Pneumonia was the highest at 145% Dublin excess over rural prevalence, benign and unspecified neoplasms 143%. cancer of the trachea, bronchus and lung 141%, and bronchitis, emphysema and asthma 129%. Again. the significant feature of these data is that most of these diseases are respiratory, and in 1971, adult females in the Dublin area smoked 90% more cigarettes than rural women. As part of a European study, Dean analysed five respiratory illnesses (lung cancer, influenza, pneumonia, bronchitis, emphysema and asthma and respiratory tuberculosis) and ischaemic heart disease in Ireland, Scotland, England and Wales, France, West Germany, Italy, Belgium, Denmark and the Netherlands, and obtained urban/rural differentiation for Ireland, England and Wales, France, Denmark and the Netherlands [I I]. This analysis underscores the particular vulnerability of both Irish men and women to respiratory disease and urban Irish women to certain illnesses. With the standardized mortality ratio for all EEC at 100, the most disturbing statistic by far was the SMR for bronchitis, emphysema and asthma for Irish urban women at 345 (the rural rate was 266). For men, the rates were also the highest for all men in the EEC with an urban SMR of 249 and rural 170. Influenza and pneumonia standardized mortality rates were also very high for both men and women in both urban and rural areas, but this high level of mortality is shared by England and Wales in both urban and rural areas. While the SMR for lung cancer for men in Irish urban areas was exceeded by men in urban areas in England and Wales and in the Netherlands, Dean’s analysis clearly reveals the significant vulnerability of Irish urban women with an SMR for lung cancer of 256, greatly in excess of urban women in other EEC countries. Urban women in England and Wales are the next most vulnerable with an SMR of 226. For the five countries for which Dean had data, non-rheumatic heart disease and respiratory tuberculosis also produced higher standardized mortality ratios in Ireland than elsewhere, and among both urban men and women the SMRs were the greatest. Ireland is divided into eight health board areas and so it is possible to go beyond a straightforward urban/rural division and specify areas of higher mortality. While the crude birth rate was 19 per 1000 in 1983 and was the highest in the EEC, the highest
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birth rate was in the north-eastern area (20.6) and the lowest in the western area (18.0) [I]. The infant mortality rate of 9.8 per 1000 live births in 1983 showed a regional variation between 8.0 per 1000 in the western region to 10.9 per 1000 in the southern region. The highest death rate from diseases of the circulatory system in 1983 was 608.7 per 100,000 in the western area and the lowest was 338.2 per 100,000 in the eastern area (around Dublin). By region, the cancer death rates varied from 214.2 per 100,000 in the north-western region to 167.5 per 100,000 in the eastern region. Motor vehicle deaths were the highest in the Midlands in 1983 (23.8 per 100,000 people) and lowest in the southern region (12 per 100,000 people). THE ELDERLY
Reviewing the research work on various target groups’ morbidity and mortality in Ireland, more analysis has been done on the elderly than on other target groups. Martin and Doyle conducted one of the largest surveys of people aged over 65 in a city health centre and in a suburban health centre [12]. They focused on morbidity patterns and living conditions among 586 patients and found that the commonest disorders were rheumatic disease (31%), psychiatric illness (26%) and cardio-respiratory conditions (26%). Martin and Doyle divided the sample of elderly people into three groups. Group 1 contained those with normal mobility who possessed no incapacitating illness. Group 2 consisted of those whose movement was restricted or who were housebound. Illness was present but patients were able to cope. The third group consisted of those who were bedfast; 39% of the sample were found to be in social classes IV and V, the majority of them living on an income of less than f30 per week in 1981. Not only were they found to be socially isolated and financially disadvantaged, but this group of elderly people in social class IV and V were found to have a high incidence of illness. 21% of this group of elderly in social classes IV and V were classified as being in Group 2, and 4% of them were classified as Group 3. This low social class group had a high proportion of some form of long term treatment (65%) and this was substantially higher and their compliance with treatment poor compared with the rest of the sample. This research study also discovered that the elderly in social class IV and V lived mainly in substandard housing and were more likely to live alone than the rest of the elderly sample. This picture of chronic deprivation and morbidity amongst the elderly was endorsed by Walsh in his sample survey of a much smaller number of elderly aged over 65 (105 people) in North Dublin [l3]. The elderly in this sample were subjected to a wide range of tests to make an assessment of vision, mental impairment, anaemia, general medical problems and entitlement to benefits. Some of Walsh’s findings reveal a staggering level of morbidity amongst the elderly and show a huge clinical iceberg of symptoms not touched by the traditional medical system. Of the sample of 105 elderly, 55 were judged to have satisfactory vision with current spectacles and 10 were deemed to have normal vision without spectacles. Seven people had known visual impairment but a very high number-
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33 people-had uncorrected and uninvestigated sight impairment. The visual impairment suffered ranged from pure refractive errors to severe glaucomas and cataracts. The mental status assessment raised equally perturbing results. While 78 of the elderly were deemed to have a normal mental state, 25 were judged to have a mental impairment and only three of these had been previously recognized. Ten were assessed as possessing a mild mental impairment, eight a moderate mental impairment, six a severe mental impairment and one a profound impairment. Only one of the six with severe and one of the eight with moderate impairment were previously recognized as such by the patient’s general practitioner. All ten cases of the mildly impaired elderly were viewed by the general practitioners as normal elderly people. Three men were found to be anaemic, all bachelors living alone, two of them in deplorable conditions. Walsh also found a high proportion of hypertension amongst the sample of elderly, both newly discovered hypertension and previously treated but uncontrolled hypertension. The sample also discovered significant numbers of congestive heart failure, osteo-arthritis and chronic bronchitis, all newly discovered or previously treated but uncontrolled. A very high proportion (41 out of 105) were in need of some form of chiropody, and a significant number of the sample (16 out of 105) had severe dental disease for which the patients needed urgent treatment. There were also several undiagnosed cases of depression, severe anxiety, diabetes and various carcinomas. In six cases of moderate to severe hearing impairment and wax in both ears, four were cured by having their ears washed out. These cases of treatable deafness illustrate that deafness is widely accepted by doctor and old person alike as a symptom of old age not needing further investigation. A comparison between Walsh’s results and British studies of unreported illness provides a useful framework of reference for discussion of the clinical iceberg of prevalent but unreported illness. In comparison with Williamson’s study in Edinburgh in 1964 [14], Thomas’s study in Bristol in 1968 [15], Lowther’s study in Edinburgh in 1970 [16], and Williams’ study in Bolton in 1972 [l7], Walsh’s Dublin study revealed a high amount of unreported visual impairment. The detection and treatment of visual impairment amongst the elderly is revealed by Walsh’s study to be an Achilles heel of the Irish health system, with an urgent need for a reformed ophthalmology service. The high level of mental impairment amongst the elderly was endorsed by Williamson’s 1964 Edinburgh study [14]. The high level of unreported and uncontrolled hypertension (15% of the sample in comparison with the British studies which reported undiscovered and unreported hypertension between 5 and 12% of the appropriate samples) is underscored by the high systolic and diastolic levels which Walsh took before the subjects were categorized as hypertensive. Walsh’s study as a whole raises fundamental questions about the objectives, efficiency and delivery of Ireland’s health care system for elderly people. This requires a rethinking of the role and operation of the general practitioner service and public health nursing service on the frontline of the primary care system. Walsh’s
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study also focused on the particular inadequacies of eye. dental and chiropody services for the elderly and a simplification of delivery and much more appropriate targeting of resources to the designated high risk target groups. OTHER TARGET GROUPS
Apart from the elderly. there are very few research studies on the morbidity patterns and health care situations of various target groups. Great concern has been expressed with the life styles and social impact of the travelling people. and a special Commission of Enquiry produced a report but with very little evidence on the health situation of the travellers [IS]. Casual observation suggested that very few travellers reached old age and many lived in very unsatisfactory and insanitary situations. Thus, the Department of Health in Ireland has established a special research team to investigate the health profile of the travelling community. The results of this study are awaited with great interest, and it will be surprising if the research does not reveal profound health disadvantages of the travellers’ life styles. Very little research work has been conducted on single parents’ health situation or on the health situation of single people generally in comparison to married people or cohabitees. Neither has there been a study comparing the health situation of families with various numbers of children. Given the larger size of Irish families in comparison with other countries, such a study could have a great deal of policy relevance. Perhaps the greatest deficit of research studies into various target groups is the lack of research into the health situation of the unemployed. In comparison to many other countries where there have been major research studies into the health impact of unemployment, Ireland has avoided such a study. Yet the situation of the unemployed is of great pertinence. Ireland has had the highest rate of registered unemployment in the EEC for many years, with a current rate of approx. Zoo/u. Two-fifths of this group, or 100,000 people have been unemployed for more than a year. A research study on the health impact of short term and long term unemployment in Ireland should be of the utmost urgency.
CooK
A discussion of the nature of the transmission process of profound disadvantage in health would be premature in the absence of much more comprehensive morbidity statistics and the widespread utilization of social class criteria in the collection of vital statistics. The adoption in Ireland of the equivalent of the British General Household Survey on a regular basis would provide the data framework for the development of plausible hypotheses about the nature and transmission of profound and significant disadvantage in health care outcomes. Existing Irish health care data are based on inputs and outputs of the health care system. Recent cutbacks of health care expenditure have focused on obtaining similar outputs from reduced inputs and in changing the eligibility system for health care. Of far greater pertinence to both the taxpayer and consumer of health care services is the impact of retrenchment in health care expenditure on health outcomes between social classes and between regions and genders. Such data on health outcomes would provide a bedrock for the more effective evaluation of existing health care strategies and the more effective targeting of medical care resources on health states. REFERENCES
I. Statistical information
relevant to the Health Services, Department of Health. 1986. 2. Health--the wider dimension. A consultative statement on health policy. Department of Health. 1986. P. Perinatal mortality in Ireland and selected countries: variations in underlying factors. Irish med. J. 221-225. 1981. 4. Shelley E.. Dean G., Daly L. and Hickey N. Factors related to respiratory symptoms in Irish men.
3. Kirke
Irish med. J. 240-247.
1980.
5. Mulcahy
R., Hickey N., Daly L. and Graham 1. Levels of education, coronary risk factors and cardiovascular disease. Irish med. J. 316-318. 1984. 6. Tussing D. Irish medical care resources: an economic analysis, p. 72. Economic and Social Research Institute, Dublin, 1985. 7. Medico Social Research Board. Activities of Irish psychiatric hospitals and units 1980. Dublin, 1981. 8. O’Hare A. and Walsh D. The three county and St Loman‘s psychiatric case registers 1974 and- 1982. Med.
Sot. Res. 1987.
9. Dean G. and Kelson M. The reported
COSCLUSION
This review of social class, regional and gender inequalities in health outcomes in Ireland has revealed significant and sometimes profound disadvantages. Severe social class gradients in mortality patterns have been revealed with respect to cardiovascular diseases. respiratory diseases and several types of cancer. These data have been reinforced by more patchy but no less significant morbidity data, which have revealed acute social class differences in health care outcomes. Particularly vulnerable groups include the long term unemployed. the disabled and the travelling community. but studies of the health care outcomes of such groups are either non-existent or have only recently commenced.
mortality pattern in the countries of the EEC for six common cancers and ischaemic heart disease. Irish med. J. 98-100, 1984. IO. Ward J. B.. Healy C. and Dean G. Urban and rural mortality in the Republic of Ireland. Irish med. J. 1978. disease and heart attacks among Il. Dean G. Respiratory rural workers in Ireland and other countries of the European Economic Community. Irish med. J. 338-341. 1982.
12. Martin J. and Doyle V. Survey of the elderly in an urban general
practice.
Iris/z med. J. 358-361,
1984. unrecognised treatable illness in an Irish elderly population. lrish med. J. 62-67, 1980. Williamson J. er a/. Lancer 1, I I 17-l 120. 1964. Thomas P. Br. med. J. 3, 275-277, 1970. Lowther C. er al. Br. med. J. 3, 275-277. 1970. Williams E. Br. med. J. 2, 445-448. 1972. Commission q/ Ihe Trarelling People. Stationery Office, Dublin, 1983.
13. Walsh B. Previously 14. 15. 16. 17. 18.
