How to Make Sick Societies Healthier
The Impact of Inequality: How to Make Sick Societies Healthier by Richard Wilkinson. New York: New Press, 2005.
reviewed by Mike Bulthuis
In this comprehensive book, social epidemiologist Richard Wilkinson uses data and scientific evidence from around the world to demonstrate that inequality is harmful to social relations, and as such, harmful to health.
Wilkinson describes health disparities within all societies – from western countries to those in the developing world. In each society, he shows not only better health among those with higher incomes, but demonstrates the cost of inequality, showing that areas with greater socio-economic equality have proportionately better health outcomes than comparable economies with greater inequalities.
Long intuitively recognized, The Impact of Inequality shows how socio-economic inequalities negatively affect the quality of social relations, contributing to higher rates of violence, lower rates of community involvement and greater fear of fellow citizens. Wilkinson finds three psycho-social risk factors correlated with poor health: living with low-income status, having few friendships or social ties, and experiencing stressful early childhood experiences. Each of these scenarios increase stress and emotional difficulties—worsening mental health, and contributing to higher incidences of cardiovascular disease and weakened immunity.
Wilkinson explains these phenomena by looking at how individuals relate to broader social structures. While basic material need is less severe in Canada than elsewhere globally, the social and psychological effects of inequality—within Canada—still loom large. Individuals desire to be valued and recognized by others; “we, as reflexive beings, come to know and experience ourselves through each other’s eyes”. Here is where poverty is keenly felt. Living on low-income, relative to a society’s ‘mainstream,’ may mean living with second-hand, or second-rate, material goods—often making one feel like a second-rate person.
This is particularly problematic in a society where well-being is equated with material achievement, with money the main arbiter of success. Day-to-day patterns of consumption reinforce a symbolic hierarchy, sustaining the feelings of inferiority by those unable to participate.
Poverty—and status-driven competition writ large—leaves individuals stressed, with poorer health a result. Wilkinson suggests that the drive for self-preservation and to maintain dignity explains conflictual, competitive relationships – from violence in poor neighbourhoods to competition amongst colleagues and peers in professional environments. Social groups already marginalized, including racialized, ethnic and religious minorities and women fare particularly poorly as those in positions of power and authority seek to maintain their status. In the USA, for instance, average life expectancy for blacks is 5-6 years less than for whites.
A more egalitarian scenario based on co-operation and affiliation is possible. Wilkinson refers to the Indian state of Kerala, where GNP per person in the late 1990s was only $1000/year, yet life expectancy was only 3-4 years less than in the USA. Wilkinson credits Kerala’s health to strong social relations and the state’s egalitarian characteristic. This and other examples give Wilkinson hope, speaking to the real potential for policy instruments (e.g. a non-market approach to health or education) to change the social structure and facilitate co-operative approaches that improve social life and psychological well-being.
Wilkinson’s arguments and evidence are persuasive. His understanding of poverty as a social relationship defined by ‘exclusion’ is increasingly being adopted in Canada as well. The ‘living wage’ movement re-conceptualizes a sufficient hourly wage to include enjoyment of a basic, modest quality of life, while the Market Basket Measure is a definition of poverty that assesses the cost of necessary household goods. Each of these understandings sees inclusion and the capacity to participate as benchmarks.
This work is also timely in other ways. Recent research shows widening disparities between Canada’s rich and poor, and some neighbourhoods becoming increasingly wealthy while others more poor, such that where you live increasingly says something about who you are. The persistent challenges facing Canada’s Aboriginal people are also troubling. Wilkinson’s work suggests that such growing inequalities, and the personal identities internalized from them (feelings of inferiority) will only worsen health outcomes among the poor and weaken the social fabric at-large.
Inequalities are socially distancing; we are more likely to build ties with those like us than unlike us, making it more difficult to care for those we do not know. Wilkinson’s work urges us to consider our responses to inequalities, to difference, to vulnerability, and to examine how we offer mutual assistance—ensuring our actions contribute to the prevention and removal of feelings of shame. Christians are called to build community across the differences that societies have created. Wilkinson advises us to do so not only in our day-to-day interactions, but in considering policy measures that could facilitate greater equality and improved social relations - challenging social systems, for example, that may (unintentionally, yet inherently) further differentiation and prejudice. Ultimately, we are encouraged to “change the wider climate of opinion,” and to advocate for policies that recognize our sociality and the vision of community we are called to further.
Mike Bulthuis is a CPJ board member living in Ottawa, working, studying and trying to stay well.
Citizens for Public Justice (CPJ) and our work of faith, justice and politics: