The standards of services provided by the French healthcare system are among the very best in the world. However, the divide in life expectancy between different social categories of the French population is one of the deepest among developed countries.
This disturbing paradox is detailed in a major recent study1 on the state of healthcare in France co-authored by Didier Fassin, a French physician, anthropologist and sociologist, and Boris Hauray, a sociologist and researcher.
It was in 1830 that the French surgeon and sociologist Louis-René Villermé, in a detailed study of the population of Paris, neighbourhood by neighbourhood, established a link between wealth and life expectancy.
Enlargement : Illustration 1
But neither the advances in medical knowledge and techniques, nor the considerable improvements in living conditions since have bridged the gaps in life expectancy among the different sociological and professional categories of the population. On the contrary, the divide has become deeper since the 1970s.
Fassin is a professor at the US Institute for Advanced Study, in Princeton, and Hauray is a research director with the French national health and medical research institute INSERM. Both are also attached to the French scientific research institute, the CNRS. Their study underlines disturbing inequalities that illustrate a structural weakness in French public healthcare policy.
Today, according to the French National Institute of Statistics and Economic Studies, (INSEE), a 35 year-old unskilled worker has a life expectancy rate that is nine years below that of a manager in the civil service. The gap is greater still concerning the average expectancy of life in good health; a 35 year-old manager can hope to live another 34 years without an incapacitating illness, ten years more than a manual worker of the same age2.
Over the past 25 years, the overall divide between white and blue collar workers has increased by 16%. Amid an accentuation in the gap between the very rich and the very poor, hardly any form of illness escapes this trend. Unemployed and inactive sections of the population are particularly disadvantaged; women are less markedly affected by social inequalities than men3.
On average, manual workers smoke and drink more than senior managers, they eat fewer fresh products, including fruit, and consume fattier foods; they practice sports less and, on average, receive medical attention to a given illness at a later stage in its development.
These cultural differences, often linked to the level of income, explain only part of the picture. One's social position also has implications on health conditions at work. Didier Fassin underlines the point that workplace accidents which lead to at least one day of sick leave are ten times more frequent among manual workers than managers. They occur, he reports, more frequently among those subject to environments involving noise and intensive working rhythms, and also increase according to the intensity of physical effort at work, of stress between personnel, and when employees work without the support of senior staff.
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1: Santé publique, l'état des savoirs (available in French only) published by La Découverte.
2: See also the following report in English by the French National Instiute for Demographic Studies (INED): A double disadvantage for manual workers: more years of disability and a shorter life expectancy
3: See INSEE report Les différences sociales de mortalité: en augmentation chez les hommes, stables chez les femmes (available in French only).
'The approach of health campaign must be based on social disparities'
The researchers also identified other, less obvious factors that affected life expectancy. Social networks play a decisive role, because people who are removed or even isolated from contact with others were found to have, at a given age, a period of life expectancy up to three times less than those with a high level of social contact. These findings were largely repeated in comparisons between those who do or do not involve themselves in collective activities.
As for the effects upon health of a person's hierarchical position at work, these were found to be less affected by income differences than by what the study describes as "disparities in the degree of control over work and the gratifications obtained by results."
Despite this, the reduction of the effects upon health of social inequalities "is not a priority target in France" complains Fassin, who notes that the 2004 French Public Health Act referred to this only once in its list of 100 objectives. It was also absent from the July 2009 law for the re-organisation of hospitals and health services (called Patients, la santé et les territoires - HPST). "A well identified paradox," observes Fassin, "is that health information and education campaigns further accentuate inequalities according to their success; for example, anti-smoking campaigns produced clearly better results among the well-off than lower-income groups."
He adds: "This problem naturally must not lead to the abandoning of the campaigns, but rather to re-thinking an approach based on social disparities, and therefore with the best possible relation to the life styles and living conditions of population groups."
Access to healthcare has also become more complicated over recent years for the most vulnerable in society. This has been caused by a number of factors including the increase in the consultation fees of healthcare professionals and the refusal by some of them, highlighted in a report by Doctors Without Borders, to apply a 1999 law that dispensed very low income groups from advancing fees for medical care, notably concerning dental treatment.
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English version: Graham Tearse