from S. Bezruchka
Is Inequality Good for You? Financial Times Weekend December 7-8-2002 By
Michael Prowse and Amity Shlaes
http://news.ft.com/s01/servlet/ContentServer?pagename=FT.com/StoryFT/FullStory&c=StoryFT&cid=1037872634170&p=1012571727085

Michael Prowse: 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 decades 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 peoples sense of control and by low
levels of civic participation.
In market societies, the wealthy regard themselves as '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 Gilligan, 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, immunity, 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.

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