Unequal societies will remain unhealthy societies - By Michael Prowse

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"I have yet to see a serious act of violence that was not provoked by the experience of feeling shamed and humiliated, disrespected and ridiculed."
-- James Giuigan

Is Inequality Good for You?

Unequal societies will remain unhealthy societies, and also unhappy societies, no matter how wealthy they become'

By Michael Prowse
December 31, 2007

We have grown accustomed to the health warnings issued by surgeon generals. "Smoking causes lung cancer is no longer a controversial proposition. But recent epidemiological research suggests that finance ministers, too, may some day be required to issue health warnings. There are good reasons to believe that policies that promote greater economic inequality - such as budgets that slash top tax rates - cause higher rates of sickness and mortality.

The adverse physiological consequences of absolute poverty have long been understood. We know poor nutrition, damp housing, lack of heating, excessive working hours and pollution cause a higher incidence of many diseases and chronic disorders. Policymakers understand the argument for trying to eliminate these gross forms of material deprivation, even when they lack the will or capacity to enact the necessary legislation.

By contrast, the argument that economic inequality in itself causes sickness and premature death remains controversial.

But the case is persuasive enough to deserve a wider public hearing. It implies that governments need to rethink their policy objectives: to worry less about the sum total of material output and more about the way that income and wealth are distributed.

It implies that if greater efforts are not made to counter growing inequality, the incidence of cancer, heart disease and other chronic disorders will remain needlessly high, regardless of the level of gross domestic product.

In Britain, these new arguments are most closely associated with Richard Wilkinson, a professor at Nottingham University's medical school. Wilkinson has spent much of the past two decade painstakingly assembling the evidence for a link between inequality and sickness. But researchers elsewhere, such as Ichiro Kawachi and Bruce Kennedy of the School of Public Health at Harvard University, have independently confirmed many of his claims.

Those who would deny a link between health and inequality must first grapple with the following paradox. There is a strong relationship between income and health within countries. In any nation you will find that people on high incomes tend to live longer and have fewer chronic illnesses than people on low incomes.

Yet, if you look for differences between countries, the relationship between income and health largely disintegrates. Rich Americans, for instance, are healthier on average than poor Americans, as measured by life expectancy. But, although the US is a much richer country than, say, Greece, Americans on average have a lower life expectancy than Greeks. More income, it seems, gives you a health advantage with respect to your fellow citizens, but not with respect to people living in other countries.

We lack data on the relative health of the richest tiers in different countries, but it would not be surprising if even the wealthiest Americans paid a personal price for their nation's inequality.

The solution to the paradox, argues Wilkinson, cannot be found in differences in factors such as quality of healthcare, because this has only a modest impact on health outcomes in advanced nations. It lies rather in recognising that our income relative to others is more significant for our health than our absolute standard of living. Relative income matters because health is importantly influenced by "psychosocial" as well as material factors. Once a floor standard of living is attained, people tend to be healthier when three conditions hold: they are valued and respected by others; they feel "in control" in their work and home lives; and they enjoy a dense network of social contacts. Economically unequal societies tend to do poorly in all three respects: they tend to be characterised by big status differences, by big differences in people's sense of control and by low levels of civic participation.

In market societies, the wealthy regard themselves as p 'winners" in life's race. They enjoy high social status and considerable autonomy, both in the workplace and in their domestic lives. By contrast, people on low and moderate incomes are made to feel like "losers". They have no symbols of affluence to flaunt, they occupy subordinate positions in the workplace and face a great deal of uncertainty and insecurity. The way this humiliating lack of status and control weakens their health is by putting them under much higher levels of stress than the better off.

One of the signs that people are under intense stress is the prevalence of behavioural pathologies such as obesity, alcoholism and drug addiction. Sweet and fatty foods may well serve as natural anti-depressants. That millions of prescriptions for Prozac and other mood-altering drugs are also sold just confirms that unequal, competitive societies generate high levels of anxiety.

A steep social health gradient is statistically visible even among the relatively privileged. In a study of British civil servants (where rank is precisely defined by a grading system), researchers found that junior support staff were four times as likely to die of heart disease as the most senior administrators. Even after allowing for all the usual risk factors such as smoking,

alcohol consumption, high blood pressure and cholesterol, some 60 per cent of the difference in death rates was unexplained. The sheer number of different illnesses in which health inequalities are recorded is another reason for believing that psychosocial effects are real. Some 65 of the 78 most common causes of death in men are more common among manual than non-manual workers. A factor that adversely affects all manual workers - such as lack of social status and autonomy - seems more likely to explain their greater vulnerability to so many different illnesses than any physical cause.

Experiments with other primates also appear to support Wilkinson's arguments. For instance, researchers have manipulated the social status of macaque monkeys, while holding diet and other factors constant.

They have put high status monkeys from different troupes together so that some would have to decline in status. The stressed out, socially downgraded monkeys got ill and died prematurely in just the same way as socially marginalised humans.

A quirky item of medical history - uncovered by Robert Sapolsky, the biologist is also suggestive. In the century to 1930, corpses dissected in London medical schools were nearly always those of paupers. On the basis of these dissections, anatomists estimated the size of the human adrenal gland. When they occasionally saw the adrenal glands of the better off, they found that they were often oddly small, and they invented a new disease "idiopathic adrenal atrophy" - to explain the discrepancy. It was, of course, the adrenal glands of the paupers that were artificially enlarged: a result of lives lived under unremitting stress.

Inequality is associated with higher mortality in another striking way: through its impact on homicide rates. International studies have confirmed what the casual tourist has always known: unequal societies tend to be violent.

Thus Sweden and Japan have among the most egalitarian income distributions of developed countries, and they have correspondingly low homicide ~ rates. The US is one of the most unequal and also the most violent.

Kennedy and Kawachi, of Harvard University, found the same close correlation between violence and inequality among the 50 US states. The greater the disparity in household incomes, the higher the state homicide rate. Significantly, the relationship between property crime (such as burglary) and inequality is much weaker than the relationship between violent crime and inequality.

Why is this? The answer, according to Wilkinson and his US collaborators, is that violence is a social crime in a way that others are not. It reflects not a desire for personal gain but a perverse expression of the universal human desire for respect. They quote American prison psychiatrist James Giuigan, who wrote in a book on violence: "I have yet to see a serious act of violence that was not provoked by the experience of feeling shamed and humiliated, disrespected and ridiculed." Violence is thus frequently an attempt to assert status on the part of those who feel they have no non-violent ways of commanding the respect of others, often because they are unskilled and illiterate and so incapable of advancing economically and socially.

Conversely, greater income equality is linked, internationally and within the 50 US states, with increased levels of social trust. In his influential research on civic participation, Robert Puttnam, the US sociologist, uncovered a strong correlation between equality and "social capital" (his composite measure of the degree to which people bond together socially).

The link makes sense. If people think of themselves as the equals of others, they are surely more likely to be public-spirited and to participate in civil and political projects. Participation matters because research indicates that people's vulnerability to illness increases with social isolation.

There is one piece of the puzzle still missing: how and why does socially induced stress and anxiety cause higher rates of cancer, heart disease and other degenerative disorders? The answer comes in two parts.

Our pre-human ancestors evolved methods for coping with sudden physical threats - the so-called "fight or flight" response. This mobilises energy for muscular exertion by diverting resources from biological "housekeeping" functions - tissue maintenance and repair, inimnunty, growth, digestion and reproduction - inessential for a rapid response to danger. When the threats are short-lived, this diversion of physiological effort does little lasting harm. But with the chronic stress caused by feelings of social and economic inferiority, the body is put on a war footing for months or years. The health costs of neglecting the housekeeping functions escalate rapidly.

In effect, stressed-out social inferiors experience faster ageing than their more fortunate rivals.

But why didn't our ancestors evolve ways of coping with socially induced stress? A possible answer is that stark differences in wealth and status are relatively recent. They probably date only from the beginnings of agriculture. Today's hyper-competitive world reflects something that has emerged, metaphorically speaking, only in the last few minutes of human history: capitalism.

For the great majority of human pre-history, we were hunters and gatherers, and we lived in small egalitarian groups. We shared food and we reached decisions in a consensual manner. No wonder, then, that capitalism makes people feel so ill.

The significance of these ideas shouldn't be underestimated. They reveal the true poverty of the "don't mind the gap" argument that now finds favour even with centre-left political parties such as New Labour: the argument that inequality as such does not matter so long as we do something for the poorest.

Economic inequality is correlated with status differentials, with declining civic participation, and with lack of control for those at the bottom of hierarchies. Such adverse social environments create high levels of stress, anxiety, and insecurity as well as feelings of shame and inferiority. And these, in turn, cause higher rates of serious illness and death, including death as a result of violent crime.

Unequal societies, in other words, will remain unhealthy societies - and also unhappy societies no matter how wealthy they become. Their advocates those who see no reason whatever to curb ever-widening income differentials - have a lot of explaining to do.

Michael Prowse recommends... Unhealthy Societies: The Afflictions of inequality by Richard G. Wilkinson (Routledge £19.99/$30).

Mortality: The Social Environment, Crime and Violence by Richard G. Wilkinson A Ichiro Kawachi and Bruce P. Kennedy, Sociology of Health and Illness Vol. 20, No.5 1998.

Mind the Gap: Hierarchies, Health and Human Evolution by Richard G. Wilkinson (Weidenfeld £7.99/Yale $9.95).

Psychosocial and Material Pathways in the Relation between income and Health by Michael Marmot and Richard G. Wilkinson, British Medical Journal, May 2001.

Violence: Our Deadly Epidemic and its Causes by James Gilligan (Putnam £9.95/$12)