© International Epidemiological Association 2003
Printed in Great Britain
International Journal of Epidemiology 2003;32:332–335
DOI: 10.1093/ije/dyg176
EDITORIAL
Seeing social position: visualizing class
in life and death
Mary Shaw,1 Helena Tunstall2 and George Davey Smith1
There is a ‘magician’ Derren Brown who has recently been
featuring on British television (www.derrenbrown.co.uk). One
of his tricks is to stop a passer-by in the street and then, by using
his apparently ‘psychic powers’, to guess their occupation. This
produces an amusingly amazed reaction from the member of
the public, but what Brown does is really a more extreme version of what we do many times a day—gauging social position
from visual cues. When we look at an individual we quickly
process visual information that denotes where they fit in the
social world, and we do this predominantly without conscious
thought.
Visual indicators of class and wealth have played an important part in the historical development of the understanding of
the relationship between class and health. Accounts of poverty
and ill health in the 19th century frequently included descriptions
of the physical effects of poverty upon the body. Death rates in
British cities increased during the first half of the 19th century1
and to contemporary commentators it was clear that the burden
of ill health was concentrated on the poorest urban residents
and that this was evidenced by their abject physical condition.2–4
In Frederick Engels’ The Condition of the Working Class in England
in 1844 a Dr Hawkins is quoted as saying that visitors to
Manchester were struck by ‘the lowness of stature, the leanness
and the paleness which presents itself so commonly to the eye’
and in London Engels had seen ‘pale, lank, narrow chested,
hollow eyed ghosts’ with ‘languid, flabby faces, incapable of the
slightest energetic expression’.2
The physical effects of the living conditions of the poor had
their effects from early life: contemporary commentators pointed
out that; the female factory operatives worked when pregnant
until the hour of delivery (because otherwise they lost their
wages) and their offspring were feeble. The appearance of these
children showed their circumstances and neglect, which left
‘ineradicable traces which brings the enfeeblement of the whole
race of workers with it’.2 These characteristics—reflected in the
short, scrawny, pale, and physically degenerate factory worker
—were considered to be produced by long working hours, hot,
damp, dusty, and overcrowded working environments, repetitive
arduous work, physical abuse from overseers, poor food, lack
of sleep, and inadequate exposure to sunlight.2–5 The resultant
poor constitution increased susceptibility to disease and death.
While there were some improvements in social conditions
and standards of living from the mid 19th century onwards,6
1 Department of Social Medicine, University of Bristol, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR, UK.
2 School of Geographical Sciences, University of Bristol, Bristol, UK.
during the economic depression of the 1930s there was a
resurgence of popular and academic interest in the effects of
poverty on health. Again a particular focus was on the physical
condition of the poor. In their well-known book Poverty and
Public Health M’Gonigle and Kirby detailed shorter stature,
lower weight, greater dental decay, greater prevalence of rickets
and other bone diseases, worse posture, and greater prevalence
of squint among the inadequately nourished children from poor
households.7,8 The social medicine movement of the period was
concerned with social physiology; as John Ryle stated ‘The
comparison of social class with social class in respect of height,
weight, the routine clinical examination of systems, radiographic
appearances, the common disabilities, and of mental and physical
function tests ... should have much to teach us.’9
It is clear therefore that discussions of poverty and health
over the 19th century and the first half of the 20th century were
much concerned with the effects of social disadvantage on the
physique and constitution of the poor. However, the explosion
of research into inequalities which followed the 1980 publication of the Black Report has largely been disinterested in
macroscopic physiology10–12 and the visual manifestations of
class. Why has the recent inequalities in health literature paid
so little attention to the visual evidence of the relationship
between social position and health?
One possible explanation is that as material conditions of
living have improved in an absolute sense the direct effects
of living conditions upon the body have become less clearly
apparent. However, as some class-associated forms of ill health
have disappeared, for example rickets, others have replaced
them, like obesity—we continue to ‘see’ class. A second possible
explanation is that approaches to social class differences in
health which emphasize the physical characteristics of the poor
have become associated with hereditarian thinking and with
eugenics. An example of this type of hereditarian research is
work by Lee Ellis which postulates a fundamental genetic determination of socioeconomic differences in height, birthweight,
and brain size, in addition to intelligence, parental investment,
work motivation, drug use, altruism, and thus health.13 Thirdly,
a major concern of recent work on health inequalities has been
the assertion that socioeconomic differentials in major causes of
death, such as coronary heart disease, are not simplistically
explicable in terms of differences in behavioural patterns, such
as smoking, drinking, and exercise.14 Emphasis upon visual
manifestations of class differences may appear to support arguments which focus upon cultural differences in class-related
behaviour, class ‘lifestyles’, and the moral criticism of the
disadvantaged.
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VISUALIZING CLASS IN LIFE AND DEATH
The decline of interest in the visual manifestations of class
differences in epidemiological investigations of socioeconomic
variations in health coincided with an increasing interest in
these visual signifiers in academic sociology and cultural studies.
Much of this work has concentrated on the aesthetics of consumption. During the 1980s the classic work of the French
social theorist Pierre Bourdieu15 described how the system
of social class is manifested through consumption, aesthetics, and
education, via a system of ‘distinction’. Bourdieu argued that
this struggle for social distinction was a fundamental element of
all social life.
While the meaning attributed to visual signs of social
distinction vary across time and place, in any setting there is
symbolic meaning attached to visual codes, and these convey
information about status and socioeconomic position. The
visual codes of clothing and fashion mirror the social structure,
allowing us to send messages to others as to how we expect to
be received and providing useful clues as to where to place people
in the social hierarchy. The Aztec civilization used headdresses
made from the feathers of eagles to denote the status of brave
and esteemed warriors.16 In contrast, in Britain in the 19th and
early 20th centuries hats were an indispensable part of any
man’s wardrobe, but the type of hat—be it top hot, bowler, or
peaked cap—indicated his position in the social structure of
industrial society; hats were used to claim and maintain
traditional social class boundaries.17 If examined, these markers
of social position would have been strongly associated with
health outcomes, as GB Shaw eloquently remarked:
‘… it is easy to prove that the wearing of tall hats and the
carrying of umbrellas enlarges the chest, prolongs life, and
confers comparative immunity from disease; for the statistics
show that the classes which use these articles are bigger,
healthier, and live longer than the class which never dreams
of possessing such things.’18
Figure 1 ‘Action’ toys have become more muscular
Photograph: Mary Shaw
333
Figure 2 Obelisks in a Glasgow graveyard
Instead, hats and other symbols of social status were indicators
of the material factors which really did have an influence on
health outcomes—working and living conditions. As material
living standards have risen in all socioeconomic groups (albeit
more in some than in others) markers of social class may appear
far less obvious and more complex. It has been argued since the
1930s that the visible signs of class in British society have lessened, but with hindsight these markers remained clearly apparent19 and they continue today. The visual markers of class have
not declined, rather, it is more the case that we have different,
proliferated, and more rapidly changing markers of social position
(such as the precise make and style of trainers deemed desirable
by one cultural group or the shade and fabric of a pashmina
for others). It is still the case that subtle signs of appearance are
read as markers of social position.
Physical characteristics, such as obesity, are also current
‘aesthetic’ markers of social class. In western contexts obesity
now indicates low social status and is commonly seen as a sign
of self-indulgence, lack of control, and lack of concern for
health.20 Children as young as three have been found to have
negative attitudes towards overweight people. There is even
evidence that the stigma of fat is so insidious that it also transfers to those associated, even by mere observed proximity, to
overweight people.21 The medical profession have also been
found to share with the wider public an ‘anti-fat’ bias, as demonstrated by negative moral stereotypes, even among those who
specialize in treating obesity.22 In other contexts, however, and
others times, excessive body fat has denoted high social status
and beauty.23 The aesthetic of the muscular body, on the other
hand, has recently shifted in most post-industrial nations as
manual labour and the association of muscularity with low
social status has declined; even the physique of male action toys
has become more muscular in the last 30 years.24
Height too continues as a physical marker associated with
social position and social mobility, with taller height being associated with higher social position, and the upwardly mobile being
on average taller than their less socially successful counterparts.25,26 Epidemiologically, the extent to which adult height
results from social position and better conditions in early life as
opposed to height contributing to a more advantaged adulthood
334
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
social position (through social mobility) is debated. However,
there is certainly evidence that height continues to affect the
way we respond to people; one psychological study has found
that tall people are perceived as of higher professional status,
tall men are seen as more socially attractive, and tall women as
more physically attractive than their shorter counterparts.27
Health-related behaviours are part and parcel of the system
of codes used to indicate social distinctions.28 Many foods hold
connotations of class; peasant stew has been superseded by
certain types of fast food as an indicator of low social status in
developed countries.29,30 Smoking too has become a marker of
low socioeconomic position in many of these countries, and in
some cases a badge of honour of working class identity in contexts where there is a palpable normative pressure to smoke.31
Discussion of the relationship between visual signifiers of class
and healthy and unhealthy ‘lifestyles’ may be uncomfortable
for those researchers who have focused on repudiating behavioural explanations of socioeconomic inequalities in health.
There has, however, been some recent interest in researching
the relationship between health and visual signifiers of socioeconomic position found in housing and living environments.
One such visual indicator that has recently entered healthrelated research is the ‘broken windows index’, which has been
used as an alternative or supplementary measure of socioeconomic circumstances within residential areas or localities. The
‘broken windows’ theory, originated by Wilson and Kelling,32,33
suggests that if the first broken window of a building is not
repaired then people will presume that no-one cares about
the building and more windows will be broken. The sense of
decay in the neighbourhood will increase and social disorder
will flourish. A number of studies have taken up this idea in an
epidemiological setting. For example, Galobardes and Morabia
have developed an indicator of the ‘social standing of the
habitat’ which assesses descriptors of the wider neighbourhood
as well as immediate streets and surroundings, and the external
and internal aspects of a building.34 In this project digital photography was used and buildings were classified as of high, medium,
or low social standing. Intriguingly, the authors found an association with hypertension, and that this highly visual measure
appeared to capture aspects of the socioeconomic environment
that were not revealed by the education or occupation of
the residents alone. Our visual culture thus not only relates to
how we see and classify individuals, but how we interpret the
appearance, and standing, of places as well.
Bringing together people and places, in death too visual cues
can communicate information about social position. An example
of this is the positive correlation between height of commemorative obelisks and the social standing of the deceased (and
their length of life), as exemplified in Glasgow graveyards of the
Victorian era. Those people who had greater wealth and superior
living conditions during their lives enjoyed greater longevity.
Moreover, these more affluent people also chose to (and could
afford to) continue to visually convey their social status in death
through taller memorials—every metre in height of the obelisk
translated to 1.42 years later age at death for men and 2.19 years
for women.35
Life and death are still marked by visual cues of social position.
Social position, social processes, and inequalities become
embodied36,37and our life chances continue to be related to
our accumulated social (dis)advantage. We do not need to be
magicians to see it, but epidemiologists do need to hone their
perception to the continued pervasiveness of socioeconomic
position on health. Many of the papers in this volume of the IJE
contribute to that understanding.38–47
Acknowledgements
Thanks to Debbie Lawlor for commenting on a draft of this
editorial.
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