ohan Mackenbach  Department of Public Health, Erasmus University,
University Medical Center
Rotterdam, 3000 DR Rotterdam, Netherlands

Lancet Nov 30, 2002, pg 1794.  Inequality, health, and the economy
The Health of Nations: Why Inequality is Harmful to your Health Ichiro
Kawachi, Bruce P Kennedy. New York: The New Press, 2002. Pp 240. $25.95
ISBN 1 565 84582 X.

With recommendations on this book's cover by Robert Wilkinson, Amartya
Sen, Katherine Newman, Alvin Tarlov, and Robert Putnam, The Health of
Nations looks like a well orchestrated attack on those who defend
inequalities in income because they are good for the economy. Harvard
scholars Ichiro Kawachi and Bruce Kennedy have synthesised an enormous
amount of evidence that suggests more inequality not only is bad for
health, but also may ultimately threaten all the freedoms that economic
development is meant to bring about. For many readers of The Lancet, their
conclusion that wider disparities in income lead to wider inequalities in
health--and may even lead to higher average levels of ill-health because
of the curvilinear effect of income on health--will not come as a
surprise. What Kawachi and Kennedy add to this story, however, is a
provocative analysis of all the other harmful effects of income
inequalities. They argue that income inequality, contrary to popular
belief, does not promote economic development but fosters certain
dysfunctional factors, such as social exclusion, that may threaten
economic growth. Furthermore, they contend that the surge in income
inequality that occurred in the USA and some other countries in the 1980s
and 1990s resulted in individuals working longer hours and spending less
time with family and friends, higher crime rates, and a generalised
increase in competition that threatens civil society.

"Conservatives will hate this book", according to Putnam on the back
cover, but will they read it? Not on the basis of Putnam's recommendation,
but perhaps some of the lively stories in the book could generate their
curiosity. Consider this one: the authors cite a case-study by Matt Bloom
on the effects of income disparities among baseball players. Major-league
baseball salaries in the USA have risen tremendously, and with them income
inequalities between players. Do players in teams with more variation in
pay perform better, as conventional economic theories would predict? No,
according to Bloom's study, they don't: unequal pay distribution within
teams did not only have a negative effect on individual performance, as
measured by fielding and pitching runs, but also had a negative effect on
team performance, as measured by finishing position and fan attendance.
Kawachi and Kennedy postulate that the effect of such unequal pay was to
increase resentment and act as a disincentive to cooperation; they suggest
that similar mechanisms may work within manufacturing firms and other
parts of the labour market.

The book inevitably ends in a discussion of politics, and explores why
some populations accept income inequalities more than others. The authors
provide a telling example, taken from a study by Sidney Verba, which
showed that the proportion of low-income Americans who agree that
government has a role in ensuring a decent standard of living for its
worst-off citizens is lower than the proportion of high-income citizens in
European countries who agree with this position. They conclude: "It is a
paradox to be living in a country with the most clear-cut need of
redistributive policies, we remain the least capable of getting them on
the political agenda." As a partial explanation, Kawachi and Kennedy cite
J K Galbraith's view that at European--ie, high--levels of spending on
public services, these services come to be seen as collective assets from
which everybody benefits. By contrast, in the USA, low levels of
government spending on education, child care, or mass transportation, do
not benefit middle-class citizens who, consequently, do not feel they have
a stake in these facilities and will vote against increased or even
maintained spending. An additional negative feedback loop involves the
destructive effects of income inequality on social capital and political
participation.

Kawachi and Kennedy have written a lucid account that draws on a wide
range of evidence. Although it cannot be expected to convince every
reader, this book certainly deserves to be read by everybody interested in
the politics of health.
Johan Mackenbach  Department of Public Health, Erasmus University,
University Medical Center
Rotterdam, 3000 DR Rotterdam, Netherlands

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