Commentary: what can we learn from studies of occupational class and cardiovascular disease?

Abstract

The occurrence of coronary heart disease (CHD) mirrors a society's stage of economic development. During the 1950s, Yerushalmy and Hilleboe (1) noted a close correlation between the increase in motor vehicle licenses, radio and television ownership, and a rising mortality rate from CHD in the United States. Although this study is seldom cited today except as a reminder of the perils of drawing ecologic inferences, most researchers would agree that for the first half of this century at least, CHD was a disease of affluence. Epidemics of CHD emerged in tandem with increasing prosperity in the Western world; moreover, affluent members of society seemed to be the most afflicted. Beginning in the mid-1960s, however, as death rates from CHD started to decline in countries such as Britain (2), the United States (3), and New Zealand (4), the burden of disease progressively shifted to those at the lower end of the socioeconomic hierarchy. In most developed countries, the risk of coronary disease is now higher among the poor, and the gap between the rich and the poor continues to widen (5). Meanwhile, CHD is emerging as a major cause of death in many less-developed countries, and rates are rising in the former communist countries of Central and Eastern Europe (6). The ability of CHD to mirror a society's stage of economic development was strikingly illustrated by the patterns of disease among migrants to England and Wales (7). Immigrants from Ireland exhibited the same social class pattern of CHD (more heart attacks in the lower classes) as in England and Wales. By contrast, immigrants from the Indian subcontinent showed little relation between class and mortality. Finally, immigrants from the Caribbean showed the reverse pattern of higher mortality rates in