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Why do the poor suffer more from almost every health and social problem? Death rates are higher from cardiovascular disease, infections and many cancers among the least well-off; so too are violence, drug abuse, obesity, teenage births and school failure. Some people might think this is caused by the most vulnerable and least healthy people moving down the social hierarchy. Others suggest that these problems are caused by lower material standards of living—poor housing, poor diets, etc. Some think that intelligence or genetic factors are the explanation. But increasingly, people doing research on inequalities in health have suggested that it is low social status itself that is the problem. Whatever the reasons for the common link with poverty and deprivation, all of these problems tend to be treated separately. Different academic researchers study health and crime; different governmental departments deal with education and justice. Given that maps of any one of these problems across local areas in Britain would look the same, it’s surprising that the common roots in relative deprivation receive so little attention.
After many years of research, we have discovered another feature that is shared by all these health and social problems. They are all more common in more unequal countries. By more unequal, we mean bigger differences between rich and poor. Among the rich market economies of the world, there are stark differences in income inequality. Among the more equal societies are the Nordic countries and Japan, where the incomes of the top 20% are 3-4 times as big as the incomes of the poorest 20%. Among the more unequal societies are countries like the US, Portugal and the UK, where the richest 20% are 8 or 9 times as rich as the poorest 20%. It looks then as if the problems associated with deprivation within a country all become more frequent as material differences increase.
What is surprising is how big the differences are. Mental illness is three times more common in more unequal countries than in the most equal, obesity rates are twice as high, rates of imprisonment eight times higher, and teenage births increase ten-fold.
Another surprising finding is that there is no relationship at all between average levels of income, such as Gross National Income per capita, and health or child well-being. A country can be twice as well off as another and still not have better life expectancy, infant mortality or standards of child well-being. Everyone getting richer appears to make no difference to the levels of health and social problems in a society. Yet, within each country, all these problems are closely related to any measure of income, education, social class, etc. So differences in living standards within countries seem to matter, but differences in living standards between countries don’t. How can we explain this paradox?
If health and social problems are concentrated among the poor because the vulnerable and unhealthy drift down the social scale, this doesn’t explain why they are so much more frequent in more unequal countries. Similarly, it can’t be explained in terms of any fixed factor, such as genetics, because levels of these problems change over time—think of the current obesity epidemic or the rise in imprisonment. If they were the result of low material living standards, they would surely diminish with economic growth. What seems to matter is not absolute standards of living but the differences between us.
In our book, The Spirit Level: Why More Equal Societies Almost Always Do Better, we test these patterns in two separate test-beds, not only among the rich, developed countries, but also in comparisons of the 50 US states. The picture that emerges is almost identical in both settings. Our findings confirm the widely-held intuition that inequality is socially corrosive.
Although it has been said that there are “lies, damned lies and statistics,” statistical methods provide us with a sort of social microscope, they show us important patterns that we fail to see unaided. For example, civil servants working in government oﬃces were completely unaware that age-adjusted death rates were 3 times as high among staff low down in the oﬃce hierarchy than among those in more senior positions.
The picture that emerges from the statistics is that inequality damages social relationships. Measures of trust and social cohesion are higher and violence is lower in more equal societies. And similarly, studies show the reason that rates of imprisonment have increased in more unequal countries and US states owes much more to harsher sentencing than to rising crime rates. Even small differences in inequality seem to make a huge difference to our quality of life. We’re not examining the effects of some imaginary egalitarian utopia. We’re analysing the effects of existing differences in the amount of inequality among advanced market economies.
It might be thought that more unequal societies do worse because they have more poor people, but this is only a small part of the explanation. Just as health inequalities are not simply differences between the health of the poor and everybody else, but instead go all the way up the social ladder, with even those close to the top doing a bit worse than those above them, nor is the impact of inequality confined to the poor. Indeed, you cannot explain such big differences in rates of health and social problems between more equal and more unequal societies by what is happening among the poor. The differences are big because everybody is affected. Greater inequality seems to harm almost everyone.
What seems to matter is not absolute standards of living but the differences between us.
Where the data allow us to compare people at each level of income or education or social class between one country and another, it is clear that even the comfortable middle class does better in more equal countries. Even well educated people with good incomes will be likely to live longer and enjoy better health, and their children will do better in school, will be less likely to take drugs and less likely to become teenage parents. Everyone will enjoy the benefits of living in a more trusting, less violent society. Although the benefits of greater equality are much larger lower down the social scale, they are still apparent even among the well-off.
The reason why almost everyone benefits from greater equality is that more equal societies are more collaborative, with less status competition. With bigger material inequalities, people become more worried about how they are seen and judged, more vulnerable to status anxieties. So much so that more unequal societies become more consumerist—people work longer hours, save less of their income and are more likely to get into debt. Greater sensitivity to how we are valued or respected explains why violence is more common in more unequal societies. Disrespect, humiliation and loss of face are common triggers to violence. Perhaps the reason why rates of mental illness are so much higher in more unequal countries is because the quality of social relationships and feeling valued have always been crucial to human well-being.
Other human beings have the capacity to be our most feared rivals or our greatest support, cooperation and security. We have evolved to be very sensitive to the quality of social relationships. Status matters, but so does friendship among equals. Material inequalities play a crucial role in putting barriers between us. When these differences are larger, the balance shifts from us trusting other people and viewing them as friends to mistrust and competition for status.
More equal societies don’t just function better internally; this seems to carry over into their external relations. More equal countries give more in foreign aid and score better on the Global Peace Index. They recycle a higher proportion of their waste and think it more important to abide by international environmental agreements.
Injustices of wealth and poverty have always been central to the Christian message. In our book, we include a cartoon that shows a rich business man instructing his secretary to buy up the rights to the Bible and “get that part changed about the rich man and the eye of the needle.” It is, of course, one thing to explore these issues from an academic standpoint, but quite another to change the society we live in. As well as outlining the evidence in our book, we have also helped to set up The Equality Trust (www.equalitytrust.org.uk) with the help of a grant from the Joseph Rowntree Charitable Trust to campaign for a fairer society, to benefit us all.
Note. This article was originally published in the Church Times, London. ©Richard Wilkinson.
Richard Wilkinson, MMedSci is an Emeritus Professor of Social Epidemiology at the University of Nottingham Medical School and an Honorary Professor at University College London. He has played a formative role in international research and his work has been published in 10 languages.
Kate Pickett, PhD is a Senior Lecturer of Epidemiology at the University of York and a National Institute for Health Research Career Scientist. She studied physical anthropology at Cambridge, nutritional sciences at Cornell and epidemiology at Berkeley before spending four years as an Assistant Professor at the University of Chicago. With Richard Wilkinson (also shown in photo), Kate co-wrote The Spirit Level: Why More Equal Societies Almost Always Do Better