David Blane, George Davey Smith,and Mel Bartley

Social selection: what does it contribute tosocial class differences in health?

Abstract Social selection, or the idea that an individual's health caninfluence their social mobility and, hence, their position in thesocial hierarchy, has been suggested as an important element inthe process which produces social class difference in health.The present paper examines this idea by drawing togetherevidence from a range of published research. EHrect selectionaccording to health is judged to have little effect on classgradients. The logically distinct idea of indirect selection can beseen most usefully as referring to the accumulation of advantageor disadvantage during life.

IntroAiction

The Black report (DHSS 1980) suggests social selection as one of fourprocess^ which might create social class differences in health. Socialselection, as originally conceivoi, accepts a causal relationship betweenhealth and social position but reverses the normal direction of causality.Social class differences in health are explained by a process of health-related social mobility in which the healthy are more likely to move upthe social hierarchy and those in poor health to move down.

The idea of sodal selection has a long lineage. Ogle (1885) u s ^ it dur-ing the late nineteenth century in his enquiry into the causes of differ-ences in occupational mortality rates. In the United States of America,work started on the idea before the 1939-45 war (Perrott and Collins1935; Lawrence 1948; Perrott & Sydenstriker 1955; Harkey 1976). InBritain, evidence in support of the idea came from Illsley (1955),Meadows (1961) and Goldberg and Morrison (1963). This body of workestablished that in Britain and the US the sick, and especially the long-term sick, were likely to be disadvantaged occupationally and penalisedfinancially. Other evidence points to the same conclusion. People with

Sociology of Health & Illness Vol. 15 No. 1 1993 ISSN 0141-9889

2 David Blane, George Davey Smith and Mel Bartley

disabilities, for example, are disadvantaged in the labour market, despitethe protection which Parliament intended to provide by means of theDisabled Persons (Employment) Act 1944 (Blaxter 1976; Blane et al1990). Similarly, for those in employment, the right to move to another,albeit lower grade, job when one's health fails is part of the industrialrelations agreements in certain industries (Blane 1985).

There is thus little doubt that illness can result in downward socialmobility and that, in consequence, those in good health are relativelymore likely to be upwardly mobile (IUsley 1986). The question thatremains concerns the size of the contribution which social selection makesto class gradients in health (Wilkinson 1986, 1987). Is it a minor phenom-enon or does it need to be central to attempts to understand the causes ofsocial class differences in health? The studies mentioned earlier did notanswer this question and were content to demonstrate that health couldinfiuence the direction of social mobility. Simple observation cautionsagainst confusing possibility with major effect, however. Rather than tak-ing lower status employment, those in poor health may join the long-termunemployed, register as chronic sick or opt for early retirement, and noneof these alternatives involve downward social mobility within theRegistrar General's scheme. Incapacity may also result in upward mobil-ity. The physical demands of white collar work are usually less than thosein manual occupations, and this may influence employment choices atlabour market entry or if health fails in mid-career (Ostlin 1988).Academic estimates of the importance of social selection vary. The Blackreport concludes that its contribution is small in comparison with materi-alist and, to a lesser extent, behavioural/cultural explanations, althoughthis is qualified by the suggestion that its importance may vary in the dif-ferent stages of the life cycle. Stem (1983), in contrast, has argued thathealth-related social mobility between the generations could accountentirely for social class differences in adult health. The purpose of thepresent paper is to pursue this question in the light of more recentresearch.

Much of the debate since the pubhcation of the Black report has con-cerned health during early life and its relationship to both social mobilityand health in later life. Health and early life, it is argued, may influencethe direction of social mobility as well as morbidity and mortality duringadulthood and thus, by a process of direct selection, produce the classdifferences observed in occupational mortality statistics. More recently,Wilkinson (1986) and West and his co-workers (1988, 1990, 1991,Macintyre & West 1991) have extended the idea to include indirect selec-tion, by which is meant social mobility due not to health but to factorssuch as education, height and childhood deprivation which act as predic-tors of both adult socioeconomic position and adult health. Althoughboth the direct and indirect versions of social selection share an emphasison social mobility, they are nevertheless logically distinct. Direct selection

Stocial selection 3

accepts a causal relationship between health and social position and seesthe direction of causality as flowing from health to social class. Indirectselection, in contrast, does not accept a causal relationship betweenhealth and social class and sees some third variable as responsible fortheir co-variation. Fartors which cause indirect selection, therefore, mustbe able to cause variation in both health and social position.

Social mobility is usually sub-divided into its intra- and inter-genera-tional forms. This distinction is useful for the period from labour marketentry onwards into adult life but for present purposes it suffers from aninability to deal adequately with childhood. This weakness is givensalience by the recent emphasis within the 'selection debate' on early lifeexperience. Class gradients in mortality occur in all age-groups, includingchildhood. If the contribution of selection to these gradients is to beexamined, a concept of social mobility is necessary which can be appliedto all age-groups, including childhood. The present paper, therefore, willpay less attention to the conventional distinction between intra- andinter-generational mobility and, instead, examine social mobility in rela-tion to four labour market-determined phases of the life cycle: childhood;labour market entry and early adulthood; middle age; and post-retire-ment. Structuring the argiunent in terms of labour force participation hasthe additional advantage of relating directly to the Registrar General'sclassification. Most data on health inequalities are expressed in terms ofthis classification, which relies upon occupation both to categorise 'class'and to assign individuals to classes. Relating directly to the RegistrarGeneral's scheme has the further advantage of identifying instances whereany social mobility is derived from outside the group which exhibits theclass gradient in mortality and in which selection explanations are there-fore difBcult to sustain. Childhood is one of these instances.

Cluldhood

The social class which is assigned to a child by the Registrar General'sclassification {OPCS 1986) depends on the occupation of their father, andany social mobility which the child experiences depends upon the fatherchanging social class. At first sight, therefore, it is difficult to see howselection could explain class differences in childhood health, because anysocial mobility that takes place does not depend upon the group in whichthe health variation occurs.

Selectionists have responded to this chaUenge in several ways. Oneaccount argues that the fathers of sick children may be disadvantaged inthe labour market, and hence more liable to downward mobility, becausetheir responsibilities as informal carers are incompatible with their respon-sibilities as employees. The National Survey of Health and Developmenthas examined the relationship between a father's social mobility and

4 David Bkne, George Davey Smith and Mel Bartley

serious illness among their children (Wadsworth 1986). A healthy child-hood, in the sense of not having suffered a serious iUness between birthand ten years, was as frequent among downwardly mobile famiUes asamong the socially stable or the upwardly mobile. Although the differ-ences were small and not statistically significant, there was a general ten-dency for upwardly mobile fathers to be least likely to have healthychildren and for downwardly mobile fathers to be most likely. This evi-dence that a child's ill health does not occupationally disadvantage theirfather is consistent with the results of studies of the gender distribution ofdomestic labour within families which find that mothers are the mainsource of child care (Graham 1984, 1986). The situation may be slightlydifferent with respect to single-parent families, although the outcome islikely to be similar. Childhood mortality is highest among children whocannot be aUocated to a social class (OPCS 1988), and the size of thisgroup makes it likely that these are the children of single parent families.Where, as is usually the case, such families are headed by a woman, seri-ous illness among one or more of the children may weU affect her labourmarket position. Rather than producing downward social mobility, how-ever, this situation is likely to force her out of paid employment.

A second attempt to apply social selection ideas to childhood mortalitydifferentials has focused on the mother's social mobility. The RegistrarGeneral's classification assigns married women to a social class on thebasis of their husband's occupation, and for women marriage may there-fore involve social mobility. It has been suggested that differences inchildhood health could result from the health-related social mobility ofwomen at marriage, with healthy women being more likely to both marryup the social hierarchy and produce healthy children, while unhealthywomen are at greater risk of both downward mobility and ill children.This idea was addressed as part of the Aberdeen studies of maternal andperinatal health (Illsley 1955). Some evidence was found of a relationshipbetween a woman's health, the direction of any social mobility at mar-riage and the health of her first child during early infancy. However, ashas already been pointed out (Blane 1985), the majority of social mobilityat marriage was found to take place between sodal classes III and IV &V, and here it was assodated with very smaU differences in maternalhealth but large differences in prematurity and obstetric death rates. It isalso relevant that this study examined first children only and caution istherefore required before generalising its findings to aU births, which arethe subject of class differences in routinely published mortality statistics.An attempt has been made to replicate these findings, using data fromthe National Child Development Study cohort at age 23. The proportionof the social class differences in low birth weight which could beaccounted for by the mother's sodal mobility at marriage was estimatedat between 11 and 16 per cent (Joffe 1989). The sample, however, waslimited to those who had first babies by age 23.

Social selection S

The third response to the difficulty of applying selection ideas to classdiflerences in childhood health has been to question whether such differ-ences in fact exist, at least during later childhood and adolescence.Youth, it has been suggested, is 'characterised more by the absence thanby the presence of class variation' (West 1988). West cites evidence COVCT-ing the age range S-20 years and suggests several possible ways ofaccounting for this relative absence of class differences. Reminiscent ofStem's argument, these include the possibility that adult h^lth gradientsare created de novo by health-related sorting at labour market entry.

The claim that class gradients are relatively weak during youth is sup-ported by Decennial Supplement mortality statistics and by morbiditydata from the General Household Survey, the National Study of Healthand Etevelopment and the 15 year old cohort of the Twenty-07 Study(West et al 1990; Macintyre and West 1991a). The claim can be sustainedin relation to mortality only by the exclusion of accidental deaths, whichis justified on the grounds that accidents, unlike deaths due to non-acci-dental causes, do not index preceding health. This exclusion is crucial tothe mortality part of the argument, because data from Britain (OPCS1988), Sweden (Vagero and Ostberg 1989) and the United States (Mare1982) all show that mortality rates during youth are higher among man-ual groups and that this difference is primarily due to the class differen-tial in accidental deaths. Death at these ages, however, is a rare eventand, as accidents and violence are one of its major causes, their exclusionleaves a very small phenomenon from which to generalise.

The claim in relation to morbidity needs to be assessed in the light ofthe measures used. The Twenty-07 Study, for example, found no classdifferences at age 15 in self-assessed health, chronic illness and symptomexperience. Measures of morbidity, however, need to be appropriate tothe age group under study and it is unclear whether the measures used byTwenty-07 validly reflect the experience of illness in a young, generallyhealthy, population. Social class differences in reporting, due perhaps todiffering expectations or environmental demands, could influence thefindings (Blaxter 1989; Blane et al 1991). A suggestion that this might bethe case comes from Health and Lifestyle Study data. Among those whoreported long-standing illness, working class respondents were more likelyto be suffering from serious conditions, such as emphysema and angina,while the middle class individuals tended to experience less serious dis-eases, such as hay fever and eczema (O'Donnell & Propper 1991). A simi-lar argument can be made in the case of reported accidents. A weak classgradient was reported for accidents in the Twenty-07 study. However adifferent study by Stewart-Brown et al (1986), found that a significantgradient in accidents leading to hospital admission was not reflected inthe parental reporting of accidental injuiy among the same children. Thuswhat constitutes an accident, good health, chronic illness or symptoms,may be different in working class and middle class groups.

6 David Blane, George Davey Smith and Mel Bartley

Measures of morbidity which are appropriate to childhood do revealclass difTerences, particularly where these concem lasting health impair-ments and conditions which predispose to poor health in later life. Socialclass differences have been shown for a variety of conditions which affectchildren and influence their health when entering adulthood. Among oth-ers, these include childhood bronchitis, hearing impairment, disability dueto cerebral palsy, physical development, middle ear infections, dentalhealth, lead poisoning, visual problems which cannot be easily correctedand the length of survival with cystic fibrosis (Davey Smith et al 1991).The suggestion that health inequalities decrease after birth, to be re-cre-ated at labour market entry, does not adequately take into account theeffects of the socioeconomic environment on such important aspects ofchildhood health and development.

Labour market mtry and early adulthood

Labour market entry is staggered by social class between the ages of 16and roughly 25, and a high level of social mobility is found around thistime (Jones 1987). It involves movement between adolescent social class,which is derived from parental occupation, and adult social class, basedon own occupation. These high rates of mobihty are a relatively short-lived phenomenon, with movement between the middle class and theworking class becoming much rarer after the mid-twenties age group(Goldthorpe 1980). Much of this mobility is between adjacent classes and,because young workers are more likely to change jobs, is often transitoryand quickly reversed (Marshall et al 1988). Significant levels of sustainedinter-generational mobility nevertheless remain between the age of 16 to,say, 25 years. If an individual's health strongly influenced their chances ofmobility, and its direction, then social selection at this point in life couldmake a major contribution to class differentials in adult health.

This issue has been addressed by the National Survey of Health andDevelopment, using data on their cohort's 26 year old men. Among chil-dren from middle class homes, those who had b^n seriously ill as chil-dren were somewhat more likely to have been downwardly mobile thanthose who had healthy childhoods. Similarly, among children from work-ing class homes, those who had been seriously ill during childhood weresomewhat less likely to have been upwardly mobile than those who werehealthy children. The differences, however, were not large and reachedstatistical significance only in the case of those from working class fami-lies (Wadsworth 1986; Wadsworth 1991). A different type of analysisfoimd a similarly weak relationship among the National ChildDevelopment Study's cohort at age 23. Adjustment for a wide range ofmeasures of childhood health did not reduce the class differences inhealth evident in early adulthood. Adjustment for measures of adolescent

Social selection 7

health, however, particularly school absence due to ill-health at age 16,did somewhat reduce the class differences in health at age 23 (Power et al1986; Power et al 1990).

The credibility of these results is strengthened by their compatibUitywith those from more general studies of social mobUity. Health duringchildhood and adolescence may be weakly related to social mobility dur-ing the early years of working life, but the main determinants of thismobility have been shown to lie elsewhere. Educational qualifications, thetype of secondary school attended and the material and cultural resourcesof the family of origin remain the main determinants of social mobility(Richardson 1977; Halsey et al 1980; Marshall et al 1988). Health mayplay a small part in this process but, as further analysis of National ChildDevelopment Study data has shown, socio-economic characteristics ofchildhood such as housing tenure, residential overcrowding, family sizeand receipt of free school meals are considerably more important (Power1991; Power et al 1991).

The direct influence of health on social mobility, then, is unlikely tomake a major contribution to class differences in the health of youngadults, and recognition of this has led to the idea of indirect social selec-tion. Some background factor is held to determine both the chances ofsocial mobility and adult health. It is worth pointing out that this type ofselection is not health-related social mobility within the literal meaning ofthe term, because the social sorting is not by health status but accordingto some other characteristic. Such characteristics have to be known orplausibly hypothesised determinants of social mobility, whose antecedentscan also influence health in later life. The idea of indirect selection leads,therefore, to the question of which factors affect known determinants ofsocial mobility and predict adult health.

Several mechanisms have been suggested by which adolescent charac-teristics, other than health, could influence health in later life (DaveySmith et al 1991). Behavioxirs adopted during adolescence may persistinto adulthood. Cigarette smoking during adolescence, for example,might be associated with poor educational achievement, and hencereduced chances of upward mobility, and if continued into adult lifecould dama^ health at that stage. Second, the resources of the family oforigin might influence social mobility and hence achieved social class andthe hazards, or lack of them, associated with achieved social class couldaffect adult health (Ben-Shlomo and Davey Smith 1991). Third, adultmortality risk could be set at an early age, determined by factors such asmaterial deprivation (Barker 1990) which also aff«:t education andchances of social mobility (Barker 1991). Any specific adolescent charac-teristic may be subject to more than one of these mechanisms. Height, forexample, is influenced by early life environment and independently affectsthe chances of social mobility (Nystrom Peck 1992). The associationbetween height and adult health could either be due to adult mortality

8 David Blane, George Davey Smith and Mel Bartley

risk being set at an early age by some factor of which height acts as anindicator or be due to height-related social mobility determining the levelof hazard exposure encountered during adulthood (Macintyre and West1991b). Whitehall Study data support the latter of these hypotheses,because controlling for Civil Service grade and car ownership accountsfor much of the relationship between height and mortality, whereas con-trolling for height has little effect on the mortality differentials betweengrades (Davey Smith et al 1990).

To be convincing, the notion of indirect social selection needs to beboth biologically and socially plausible, and suggested examples often failto meet one or other of these criteria. Adult blood pressure, for example,may be influenced by intrauterine or early childhood environment (Barker1990) but there is no reason to think that blood pressure level affa:tssocial mobility. Conversely, educational qualifications may influencesocial mobility but they cannot directly affect health. In the meanwhile itis perhaps most useful to see indirect selection as the process by whichsocio-economic influences on health accumulate throu^ the life course.Whether it is helpful to consider this process as a form of selection isdebatable. What is certain, however, is that it is very different from theidea of health related social selection as originally conceived.

Middle age

Cause-specific mortality data from the Decennial Supplement have longsuggested that social selection plays little part in the creation of socialclass differences in mortality during middle age. During the years ofworking life, the class gradients in mortality due to lung cancer andchronic bronchitis, for example, are remarkably similar despite great dif-ferences in the speed with which these two diseases result in death. Inlung cancer the time between diagnosis and death is usually a matter ofmonths, which effectively rules out downward mobility as the result ofthe disease. In contrast, the time between the diagnosis of chronic bron-chitis and death due to this disease is usually measured in decades whichin theory offers adequate time for significant social mobility. If socialselection at these ages were important one would therefore expect astwper gradient in mortality from chronic bronchitis than from lung can-cer. As such a difference in gradients is not observed (OPCS 1978, 1986)it suggests that social selection is not important.

The OPCS Longitudinal Study (LS) has provided evidence relating tototal mortality which supports this conclusion. Using data from the 1971and the 1981 censuses the LS explored the relationship between the direc-tion of social mobility and changes in mortality rates. No consistent rela-tionship was found between these two variables among men a ^ 45-64.From some social classes, the upwardly mobile were found to have higher

Social sdection 9

mortality rates than the socially stable, whereas from other classes theupwardly mobile had lower rates. Similarly, the downwardly mobile fromsome classes had lower mortality rates than the non-movers, while thedownwardly mobile from other classes had lower rates. The net effixt ofthese movements on overall class gradients in mortality was found to benegligible, and those who remained in the same social class between 1971and 1981 were found to have the same mortality gradient as the wholepopulation (Goldblatt 1989). To date these analyses have been completoifor men aged 45-64 only, but there is certainly no support here for theidea that health-related social mobility is an important cause of class dif-ferences in mortality at these ages.

Evidence from the Whitehall Study (Davey Smith et al 1990) points tothe same conclusion. Clear socioeconomic gradients in mortality werefound when these male civil servants were grouped according to employ-ment grade and car ownership. These differences, however, could havebeen due to social selection, with those in poorer health having been dif-ferentially recruited into the lower grades. That this was possible was sug-gested by the finding that those in the lower grades were more likely tosuffer from cardio-respiratory and other morbidity at the time of entry tothe study. To examine this possibility the analyses were repeated exclud-ing the 22 per cent of subjects with disease at entry to the study. Theseexclusions had little effect on the socio«x>nomic mortality differentials.Social mobility due to detectable illness does not appear to explain themortality differentials in this study.

Other evidence casts doubt on the importance of the social selection ofwomen at marriage. Serious illness is relatively uncommon among peopleof the ages at which most people marry. In the National Survey of Healthand Development, for example, only 10 per cent of males and females atages 16-25 were suffering from serious illnesses (Wadsworth 1986), so itwould have been difficult for health to act as a significant criterion whenthe great majority were selecting marriage partners. Further, as studies ofepilepsy have demonstrated, those whose serious illnesses are not immedi-ately apparent frequently wait until after marriage before informing theirspouse (Scambler & Hopkins 1986). These two pieces of evidence, whentaken together, suggest that poor health could potentially affect the mar-riage prospects of only a small proportion of women, and even in thesecases everyday experience suggests that other factors are likely to be moreimportant.

One strength of the Aberdeen study (IUsley 1955) is its concem withthe social mobility of women. When this emphasis is pursued beyondmarriage, however, to include the rest of adulthood further doubt is caston the importance of health-related social mobility. The RegistrarGeneral's classification assigns a married woman to a social class on thebasis of her husband's occupation, and any social mobility which she maysubsequently experience depends on her husband changing social class.

10 David Blane, George Davey Smith and Mel Bartley

Even in theory, therefore, her health is unable to directly influence hersocial mobility. Social class differences in mortality among marriedwomen are, nevertheless, virtually identical to those among men (OPCS1986). To maintain an explanation based on social selection despite thisevidence, it is necessary to accept that health in middle age is determinedby health at marriage rather than by post-marriage environment andbehaviour, for example housing quality, number of children and cigarettesmoking status. It is also necessary to accept a high level of assortativemating according to health, at an age when disease is imusual.Proponents of the selection argument appear to resolve this contradictionby arguing that general health, not disease or its absence, is the selectioncriterion. In this context, however, it is unclear what 'general health'means. Does it refer to general susceptibility theory, for example, and isit measured by self-assessed health? As general health has become amajor explanatory variable in this debate, its definition and measurementneed to be made more clear.

PostHretirNnent

Within the Registrar General's classification, the social class position of aretired individual is derived from their last significant period of employ-ment. Social mobility within the scheme is not possible for the vastmajority of this age-group, because they do not continue in paid employ-ment beyond the statutory retirement age (OPCS 1990). Any social classdifferences in health which are found among those over retirement age,therefore, cannot be due to social selection, whether health-related or oth-erwise. Reliable data on class differences in mortality after retirementwere first made available by the OPCS Longitudinal Study (LS). Theseshowed mortality differentials which are similar to those in earlier adult-hood (Fox et al 1985). As these gradients could not have been created bypost-retirement social selection, their existence would appear to castdoubt on the part played by selection in sustaining similar gradients atearlier ages.

It is, nevertheless, still possible that post-retirement gradients are cre-ated by health-related social mobility earlier in the work history, prior toretirement. The LS has provided two pieces of evidence which make thisunlikely. As was reported earlier, the LS failed to find evidence thathealth-related sorting made a significant contribution to mortality differ-entials during the two decades prior to the statutory retirement age(Goldblatt 1989). Any contribution of social selection to post-retirementclass differentials must therefore occur before age 45. Second, the LSfound that class differences after retirement do not narrow with increas-ing age; if anything, the differences are slightly wider among those agedover 75 than in the 65-74 years age group (Fox et al 1985). As Fox and

Social selection 11

Goldblatt (1982) have argued, mortality differences which do not narrowwith increasing length of follow-up are unlikely to be due to health sel^-tion. If post-retirement gradients were the creation of pre-retirementselection one would expect the differences to narrow as the result of themore seriously ill members of the cohort dying early in retirement, andhence falling out of the analysis. Post-retirement differences which do notnarrow with increasing age are unlikely to be due to pre-retirement socialselection.

Summary and

The present paper has reviewed the evidence relating to social selection asan explanation of sodal class differences in health. The idea of sodalselection is least plausible as an explanation of class gradients in mortal-ity among the retired, who cannot move class within the RegistrarGeneral's classification, and among children and married women whosesocial mobility within the classification is dependent on another personchanging class. Social selection demands both the possibility of sodalmobility and that health and social mobility refer to the same person.The retired, children and married women do not meet these two criteria.The selectionst argimient can only be pursued in relation to these groupsby shifting the selection process to an earlier phase in the life cycle. Classgradients in mortality after retirement, it is argued, could be due tohealth-related social mobility during the years of work. The gradients inchildhood could be the result of, and gradients among married womenmight be created by, health-related mobility at marriage. Fitter men arechosen for promotion by employers and fitter women are chosen for mar-riage by socially successful men, and this process of assortative mating inturn creates gradients in their offspring. A eugenicist scenario, unleavenedby the lay notion that cream is not the only substance which rises.

The health of men during the normal years of paid employment coulddirectly influence their social mobility within the Registrar General'sscheme, and this is the largest group to whom selectionist argumentsstraightforwardly apply. Here the evidence is relatively clear cut and sug-gests strongly that selection plays little part in creating class gradients inmortality. The only reasonable proviso concerns health selection atlabour market entry, where the evidence suggests a minor effect.Projecting this minor effect forward, so that it significantly influences thedistribution of health during the remaining two-thirds or more of the lifespan, involves implausibly distorting the idea that childhood health 'castsa long shadow'. It also risks diverting attention from the effects of haz-ards during the rest of life.

One of the most enduring legacies of the Black report may prove to beits explanatory framework. Its delineation of the four types of explana-

12 David Blane, George Davey Smith and Mel Bartley

tion of class differences in health did not imply that they were of equalweight, and subsequent research suggests that artefact and selectionexplanations are of minor importance. Within the selectionist corpus theidea of indirect selection may prove the most fruitful, although this ideacan be seen most usefully as referring to the process by which advantagesor disadvantages accumulate during the life course, rather than describinga process of selection according to health. Despite the Black report'sadvocacy of materialist explanations, it is noticeable that the researchcommunity during the past decade has been considerably more concernedwith social selection. It can be argued that this emphasis on social mobil-ity has been at the expense of an interest in social continuities. The abOityof middle class parents to ensure middle class occupations for their chil-dren, and the frequency with which chOdhood deprivation is follow^ bya life of manual labour, illustrate the ways in which social advantage ordisadvantage can accumulate during the life course. The concept of socialclass involves the interconnectedness of social advantages and disadvan-tages, and the study of these would seem a useful way of investigating thecauses of social class differences in health.

Charing Cross and Westminster Medical School, London;Department of Public Health, University of Glasgow;

and Social Statistics Research Unit, City University, Lortdon.

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