From Increasing Poverty to Societal Disintegration:
Economic Inequality and the Future Health of Canada
Dennis Raphael, Ph.D., C.Psych.
Department of Public Health Sciences, University of Toronto
Lecture Given as Part of the Series:
Philosophy and Contemporary Thought
University of Toronto School of Continuing Studies
Friday, January 29, 1999
The theme of the 1998-1999 Lecture Series was Singular Voices.
The 1998-1999 Lecture Series Topics were The Individual, The Community, The
Economic Fabric, and An Environmental Update.
This lecture was given as part of the Economic Fabric.
From Increasing Poverty to Societal Disintegration:
Economic Inequality and the Future Health of Canada
Dennis Raphael, Ph.D., C.Psych.
Department of Public Health Sciences, University of Toronto
Overview and Purpose
The purpose of my presentation today is to explore the issue of economic
inequality in Canada and its implications for the health of Canadian
society. Economic inequality simply refers to the reality that in Canada
economic resources are not distributed in a balanced way among the
population. This is nothing new in Canadian society. What is new is the
sudden increase in economic inequality within the past few years. One
by-product of increasing economic inequality in Canada has been increasing
poverty, since not surprisingly, a society that tolerates high levels of
economic inequality also tends to have higher levels of poverty. In the
course of my presentation today, I will first make the case, similar to the
1960's slogan about the effects of war, that, "Poverty is not good for
children and other living things." The evidence for this is overwhelming
with little basis for debate.
I will then argue that in addition to negatively impacting the health and
well-being of the least well-off of Canadian society, economic inequality
eats at the core of our civil society. An increasing number of studies
provide evidence that societies with high levels of economic inequality
begin to demonstrate what have been called the "symptoms of
disintegration." These symptoms of disintegration manifest themselves in
many forms ranging from increasing levels of sickness and premature death
to declines in civil commitment and participation, and community
infrastructure. These symptoms ultimately threaten the Canadian traditions
of "peace, order and good government." And, most interestingly, these
threats have the potential to affect the personal physical health and
well-being of all Canadians, including the most well-off.
Finally, I will consider the mechanisms by which economic inequality
produces societal disintegration. These mechanisms are varied and include
biological pathways within the individual, shifts in service provision that
affect communities, and changing tax structures that shape and ultimately
distort government policy. Other potential effects of economic inequality
such as decreased civil involvement and worker productivity will also be
considered. I will argue that these phenomena, rather than being an
inevitable sign of our times, are caused by identifiable forces, in other
words, "The growing gap between rich and poor has not been ordained by
extraterrestrial beings. It has been created by the policies of
governments."(1) The question that then is begged is How it is that
governments come to create these policies?
Economic Inequality and Individual Health
Economic inequality affects the health of individuals. My initial focus
is on poverty since it is among poor people that the health effects of
economic inequality are most obvious.
Poverty is Increasing in Canada
Statistics Canada reports indicate that by 1996, the poverty rate in
Canada had risen to 17.9 percent (2), and child poverty reached a 17-year
peak of 21%.(3) Similarly, by 1996, 21% of the elderly lived in
poverty.(3) Closer to home, Ontario has distinguished itself by reducing
welfare benefits 18%, including those to single parents living in poverty,
a magnitude that is unmatched in Canada.(4) The Child Poverty Action Group
and Campaign 2000, both social development organizations, have been the
most consistent advocates raising this issue.(5) Poverty has been less of a
focus in the day-to-day discourse of public health.
Ongoing reports by Campaign 2000 and The National Council on Welfare
highlight the poverty issue. In Campaign 2000's last report it noted that
by 1996 1.5 million Canadian children lived in poverty, up from 934,000 in
1989.(5) These ever increasing poverty numbers seem to have led to a
numbing of the Canadian public. Certainly, poverty is not a central concern
of our current provincial or federal governments. Indeed, at times it
appears that in light of changes to provincial policies such as the
reduction of welfare benefits and the ending of the provincial commitment
to social housing, and the Federal restriction of eligibility for
unemployment benefits, governments are working hard to increase poverty,
rather than decrease it. Levels of increasing poverty are not a secret.
Indeed, even the Conservative Globe and Mail has presented a virtual
drumbeat of stories documenting the increasing extent of poverty among
Canadians.(6-8).
Poverty Affects Health
Evidence of the effects of poverty on health in the United Kingdom were
first highlighted in the Black and the Health Divide Reports.(9) In these
reports there were consistent evidence that those at the bottom of the
economic ladder showed a greater likelihood of suffering from a wide range
of diseases as well as having a greater likelihood of death at every age.
In the USA the recent Health, United States, 1998: Socioeconomic Status and
Health Chartbook (10) provides table after table documenting how poor
people suffer from a range of illnesses at rates higher than the not poor.
Compounding the American problem is the increasing lack of health insurance
by this same at-risk for illness population group.
Using Statistics Canada data, Wilkins, Adams, & Brancker (11) obtained
findings showing that Canadians at the bottom of the economic ladder were
more likely to die from just about every disease from which people can die
from than the more well-off. These diseases include cancers, heart
disease, diabetes, and respiratory diseases among others. In Canada, data
on individuals' social status is not routinely collected so Wilkins and his
colleagues had to depend on neighbourhood level data. That is, the
analysis examined mortality rates in poor and not poor neighbourhoods.
Even with the inevitable slippage that must occur since some poor people
live in well-off neighbourhood and vice versa, it was conservatively
estimated that 22% of premature years of life lost to Canada can be
attributed to income differences.
Within Canada, the most cogent presentation of the health effects of
poverty is the Health of Canada's Children Report (12) that documents the
profound variation in health and well-being between poor and not-poor
children. These health differences are seen in incidence of illness,
hospital stays, and death, accidental injuries, mental health and
well-being, school achievement and drop-out, family violence and child
abuse. In fact, betting that poor children would show higher incidence of
just about any health-related problem -- however defined -- would make you
a rich person.
How Does Poverty Affect the Health of Adults and Children?
How can we explain these health-related differences among poor and not
poor? In the initial British studies (9), health differences among the poor
and not poor were considered in four ways: artifactual; lifestyle;
materialist; and psychosocial. Artifactual arguments saw the income level
and health status relationship as reflecting faulty data definition and
collection or due to poor health causing lower income. These arguments have
been easily dismissed as many analyses have indicated that poverty usually
does not result from poor health but is usually a precursor to it.
Lifestyle arguments have suggested that poor individuals engage in
behaviours that essentially bring illness upon themselves. They smoke,
drink to excess, are inactive, and have poor nutritional habits. Most
recently the Toronto Globe and Mail, for example, has focussed on the
parenting styles of poor people. These arguments however, are not supported
by studies that indicate that health differences remain even after these
lifestyle factors are considered. Additionally, a lifestyle focus does not
consider the societal conditions under which lifestyle differences occur.
Materialist arguments may be especially relevant when we focus on the
effects of poverty. Clearly, conditions of poor housing, sanitation, and
poor diet, resulting from lack of income can and do contribute to poor
health. The recent Golden Report on Homelessness (13) highlights some of
the issues related to the most extreme, and sadly, ever increasing
indicator of low income, homelessness, and for those not yet homeless,
grossly inadequate, yet costly housing. Val Tarasuk at the University of
Toronto has produced poignant reports that document the impacts of lack of
food and hunger on mothers and children as well as the homeless.(14-15)
Even for those who through visits to food banks, assistance from
government, agencies, and friends, and housing in make-do shelters, may
meet basic needs, there are strong psycho-social effects associated with
being poor.
Not surprisingly, being poor is associated with feelings of helplessness,
lack of control and continuing feelings of uncertainty.(16) And recent
research indicates that these feelings of uncertainty and lack of control
are strong predictors of health and well-being. The health effects of
uncertainty and lack of control are not simply a reflection of a
"jealousy factor" but rather an understandable biologically-based defensive
reaction that is wired into our bodies. As one author in the British
Medical Journal recently suggested, "Inequality may make people miserable
long before it kills them."(17) Poverty is a life experience in addition
to being a statistic to be tabulated.
Poverty in Canada is highly gendered. The highest risk group for poverty,
and associated health effects, are single parent families, virtually all of
which are headed by women. The incidence of poverty among children in
lone-female parent families in Canada is 65%.(18) In North America it
seems that such an association is assumed as having been ordained. Yet as
Linda McQuaig has pointed out, the single parent with poverty association
is common only in the USA and Canada.(19) It does not exist at this
magnitude in other countries that seem to appreciate the consequences of
children living in poverty. And as a colleague from Campaign 2000
repeatedly reminds us, poor children live in poor families. Child poverty
is simply a reflection of the true problem, family poverty. The Growing Gap
(20), published by the Centre for Social Justice in Toronto, provides a
critical analysis of how adoption in Canada of specific policies by
governments has contributed to the poverty situation. I return to these
causes later.
There are many reasons why Canadians should be concerned about poverty.
First, it is unjust and violates any number of international rights
covenants that Canada has signed.(21) Samuel Johnson stated it well over
200 years ago: Where a great proportion of the people are suffered to
languish in helpless misery, that country must be ill-policed and
wretchedly governed: a decent provision for the poor is the true test of
civilization.(22) Second, it should be an embarrassment to Canadians to
live in a country that, while identified by the World Bank as the second
richest in the world, has over one in five of its children and families
living in poverty.(23). Third, on a practical level, Canadians should be
concerned that increasing poverty, a precursor to increasing illness, will
begin to strain the health care and other systems that make this country a
place where people wish to live. And finally, if none of these arguments
persuade, poverty can be a threat to the health of all Canadians, even the
well-off. How this can be so, leads me into the story behind the poverty
story, the economic inequality saga.
Economic Inequality
Poverty is the most obvious outcome of economic inequality. And when
economic inequality increases, poverty increases. And economic inequality
is on the increase in Canada. The Growing Gap report (20) points out that
in 1973 the richest 10% of families in Canada made 21 times more than the
poorest 10% of families. By 1996, the richest 10% of families made 314
times more than the poorest 10% of families. While Canada has always been
an unequal society, the effects of economic inequality have always been
kept in check by the presence of strong social programs that compensated
for this. But recently, this has begun to change. Since 1993, with the
weakening of social programs, the after taxes gap has begun to grow;
Statistics Canada has reported that while during the 1980's the real income
of most Canadians has decreased and child poverty increased, the rich in
Canada became richer.(24). This does not bode well for the poor.
But careful examination of income and health data reveals that there is
more to the relationship than simply poor people becoming ill at a greater
rate than non-poor people. In fact, it appears that differences among
Canadians in health and illness exist across the socioeconomic gradient not
just between the poor and not poor.(11) These findings suggest that the
factors that make poor people at most risk, also affect just about
everybody but in somewhat lesser degrees. And consistent with the view that
we are all affected by these social forces, it is now accepted that
societies with greater economic inequality have higher death rates than
more equalitarian societies.(25) This had been seen as reflecting the
poverty and illness relationship already described. But recent analyses
have suggested that these socioeconomic differences in health actually
reflect basic structures and functions of a society -- and how the
population responds to these structures and functions -- not simply that
this group or that group are lacking resources that can be remedied by
directing programs to assist the poor.
Inequality Affects Everyone Not Just the Poor
If the issue was simply one of poor people becoming ill then we would not
expect the well-off in highly unequitable societies to begin showing
deteriorating health. But this appears to be happening. For example, after
decades of rapidly increasing economic inequality, the most well-off in
Britain now have higher death rates among adult males and infants than the
least well-off in Sweden.(26-27) Other data indicate that societies with
less inequality have lower death rates -- even controlling for absolute
level of economic resources.(25) According to an editorial in the British
Medical Journal "What matters in determining mortality and health in a
society is less the overall wealth of that society and more how evenly
wealth is distributed. The more equally wealth is distributed the better
the health of that society."(28). This is also so in American communities:
more economic inequality is associated with greater death rates among the
well-off as well as the poor.(29) As another example, homicide rates in USA
states are correlated with degree of economic inequality.(30) Why would
this be so?
In Unhealthy Societies: the Afflictions of Inequality (25), Richard
Wilkinson shows that societies with greater economic inequality begin to
"disintegrate" -- that is, they show evidence of decreased social cohesion
and increased individual malaise. These are all precursors of increased
illness and death. Kawachi and Kennedy (31) make the case that economic
inequality contributes to the deteriorating of what has been termed social
capital, or the degree of social cohesion or citizen commitment to society.
To illustrate, in North America the well-off increasingly opt out of the
public discourse. In Canada they may send their children to private
schools, lobby for two-tiered medical systems, hire security guards for
their property; all of which heightens societal disintegration. Kawachi and
Kennedy argue that the well-off grow wealthier, but become subject to the
same threats that the less-well off experience -- deteriorating health and
educational systems, increased crime and violence, and greater danger on
the roads -- among others. All of which is associated with a lack of
personal control; an important predictor of illness and death. I will
return to the idea that all individuals within a society can be expected to
show health effects as economic inequality increases, but I wish to
consider two more issues related to poverty.
Economic Inequality is Especially Bad for Poor People
As I mentioned, inequality affects poor people as more and more of a
society's resources get shifted to the well-off. Some of this occurs
through the reorganization of the tax system whereby the well-off have
their tax rates decreased and benefits to the poor are reduced. The most
obvious example is the reduction in welfare benefits in Ontario to people
who were already living in poverty. And at the same time large income tax
breaks were provided for the wealthy. Another Canadian example has the
federal government reducing benefits for the unemployed by reducing
eligibility for insurance. It is most striking how the federal employment
insurance fund has accumulated billions of dollars in surplus as poverty
has increased in Canada. And societies with greater economic inequality
tend to have weaker social safety nets (32), an important determinant of
health for all individuals, but especially the poor(33).
Economic Inequality Compounds the Problems Poor People Experience
Another way that economic inequality affects the poor is through reduction
of services. Poor people are more likely to become ill and cutbacks in
health services affect them the most. Similarly, the community
infrastructures that help support people in poverty such as community
programs, local health and community centres see their budgets reduced. In
two community studies I recently carried out in Riverdale and Lawrence
Heights, I saw the profound importance of community agencies and resources
for low income people.(34-35) These are the very institutions that are
under threat as economic inequality increases. Government policies are
increasingly creating poverty, and at the same time removing supports that
make poverty bearable for many.
Economic Inequality and the Health of Societies
I alluded earlier to how economic inequality affects the health of
individuals, both poor and well-off. I now wish to talk about some of the
societal affects that accrue as economic inequality increases.
Economic Inequality is Associated With Lack of Health and Social Services
First of all, societies that tolerate high levels of inequality tend to
provide less health and social services.(32) The means by which this
relationship comes about seem to involve the presence of smaller tax bases
for the provision of health and social services. In the Wealthy Banker's
Wife: The Assault on Equality in Canada (19) Linda McQuaig contrasts the
European approach to health and social services with that of the United
States. In Behind Closed Doors: How the Rich Won Control of Canada's Tax
System -- And Ended Up Richer(36), she documented how the tax system was
shifted in Canada to favour the rich. Increasingly then, Canadian society
is heading towards the American model of increasing inequality, lowered tax
bases, and decreased services. Lest Canadians be misled to believe that
lower tax rates will benefit them, it should be recalled that in most cases
tax breaks especially favor the well off. The Ontario income tax
reductions are a prime example of this. If you were in the richest top
half of 1% of families you benefitted by $15,586. If you were among the
poorest 10% of Ontario families you received $150.(20) However to pay for
these tax cuts, the services that are being reduced are the ones most
likely to be needed by those receiving the least tax relief. Seniors, for
example now must pay for drugs, and services such as ambulance now carry a
fee associated with their use. Few seniors, 21% of which in Ontario live in
poverty, benefit much from the income tax reduction and services tradeoff.
Economic Inequality is Associated With Decay of Civil Society
Wilkinson provides compelling evidence of how societies with high levels
of economic inequality begin to show characteristics of what he termed "the
symptoms of societal disintegration."(25) Some of these symptoms in
Britain have included increased alcoholism, crime rates, deaths by road
accidents and infectious diseases, lowered reading scores, drug offences,
family functioning, and decreased voter turnout among others. The form that
societal disintegration takes in each society may be unique.(30) In the
United States economic inequality is related to unemployment,
incarceration, homicide, low birthweight, smoking, income assistance, use
of food stamps, less spending on education, and disability. In Canada,
little attention has been paid to considering the economic inequality and
health relationship beyond documenting the lower health status of those
living in poverty.
Even without the careful studies that are needed, in Canada we see around
us signs of civil decay. There are record levels of poverty and
homelessness. Thirty seven percent of Toronto children now live in
poverty, an increase of 66% since 1989.(37) There are decreasing
percentages of Canadians turning out to vote in Federal Elections.(38)
Percentage turnout in Federal elections was 75.3% in 1984 and by 1997 has
decreased to 67%. In Ontario the figures have been 76% and 66%
respectively. It is obvious to anyone in Ontario that road behaviour has
significantly decayed since the 1970's. The idea that drivers would stop
at a Stop sign or even red lights is Toronto has become an anachronism. The
social safety net is clearly fraying. Many of us are one job loss or
illness away from destitution. It is apparent that we are increasingly
living in a conflict ridden period in Canadian society.
The idea of social capital is becoming an important idea in this debate.
If, as the World Bank argues social capital "refers to the institutions,
relationships, and norms that shape the quality and quantity of a society's
social interactions... Social capital is not just the sum of the
institutions which underpin a society – it is the glue that holds them
together"(39) we can begin to consider how economic inequality may be
loosening the glue of Canadian society.
Mechanisms by Which Economic Inequality Leads to Societal Disintegration
I now briefly consider some of the mechanisms by which economic inequality
contributes to societal disintegration.
Biological and Psychological Pathways
Poverty breeds a lack of control and feelings of hopelessness. Wilkinson
(25) reviews how such feelings operate through biological pathways to
produce illness and death. High levels of stress produce calming
behaviours such as eating sweets and smoking. Clearly many individuals
engage in high risk behaviours such as use of alcohol and drugs to somehow
meet needs that are not fulfilled by society. A series of studies by
animal researchers (40-41) have identified the mechanisms by which chronic
stress and hierarchy creates illness and eventually death. Such stress
models may go a long way to explaining the socioeconomic status illness
relationship documented earlier.
Changes in Service Provision
As noted economic inequality is associated with provision of fewer
services. For those who are not rich, the lack of such services are a
clear threat to health and well-being. A series of studies have explored
how the lack of social supports and services contributes to the incidence
of illness and death within societies.(33,42,43)
Changes in Tax Structures
My colleague David Coburn (44) has commented on how neo-liberalism -- the
emphasis on the market as the arbiter of societal values and resource
allocations -- breeds social disintegration and alienation. But an
important aspect of this is the exaggerated emphasis on reducing taxes
which directly translates into both increasing economic inequality and
reduction in the institutions that help promote civil society. Societies
with high levels of economic inequality are those with lower tax bases,
higher incidences of poverty, decreased labour productivity, and as noted,
lower levels of health.(45) All of these aspects are inter-correlated, but
tax structure seems to be an important theme that runs through all of it.
When a society emphasizes tax decreases, inequality becomes rampant, and
social and civil structures deteriorate. Social cohesion collapses.
The Role of Ideology
There are instances where ideology plays an overwhelming role. In Ontario
we are faced with a provincial government that seems to be working very
hard to not only increase economic inequality but to remove the services
and supports that make inequality bearable for some. This government has
supervised a tremendous shift of resources from the poor to the rich
through welfare reductions and income tax breaks for the well-off.(20) It
has removed rent controls, ended social housing, reduced social and
hospital spending, removed free prescriptions for the elderly, removed
local control over the six municipalities of Toronto, cut back spending for
public transportation, reduced environmental control, downloaded public
health services, and reduced pregnancy benefits for those on welfare. In
fact, this government has been a case study in what we call in health
promotion might jokingly call "Unhealthy Communities" or if you wish to
adjust a current project of the New Trillium Foundation, Ontario has become
a case study in "Uncaring Communities."
The Question to Be Answered: Why is This Happening?
I will conclude by briefly suggesting three ways of thinking about all of
this. As Brecht asks in the Good Person of Szechwan: "So why can't the
gods share out what they've created, come down and distribute the bounties
of nature and allow us, once hunger and thirst has been sated to mix with
each other in friendship and pleasure? (46)" I have termed these the
benevolent or lack of knowledge view, the critical view, and the Marxist view.
The Benevolent View: Lack of Knowledge
The benevolent view is illustrated by Richard Wilkinson (25) in his book
Unhealthy Societies: The Afflictions of Inequality. He suggests that now
that we understand how economic inequality plays itself out within
societies, we can respond to its challenges. He is optimistic that once
people realize how inequality "affects the quality of life for all of us"
there will be concerted action on the parts of citizens and governments to
address it. This may be the case in other societies. While there is
increased awareness of the presence of economic inequality in Canada, to
date, I see little evidence of a sincere willingness to address this issue.
The Critical View: The Role of Ideology and Power
I illustrate what I call the critical view by reference to John Ralston
Saul's The Unconscious Civilization.(47) Saul discusses the current state
of Canadian society in terms of the rise of corporatism and the grasping
for power by economic elites. Saul points out the corporatism is nothing
new in our century and history suggests that its influence can be resisted.
Citizen movements are one such means of resisting such influence.
Associated with this view would be elements of the ideas outlined by James
Laxer in his In Search of a New Left: Canadian Politics After the
Neo-Conservative Assault (48). Laxer argues that "Everywhere in the world,
multinational business has launched a frontal assault on the state (p.
163). He sees two potential visions of society emerging. The first is the
unbridled market economy associated with big business. The other is the
society "made up of communities based in every region of the country that
have formed around churches, trade unions, cultural bodies, associations of
various kinds and sporting and recreational societies." (48, p. 188). In
The Cult of Impotence: Selling the Myth of Powerlessness in the Global
Economy, Linda McQuaig demonstrates how the acceptance of the questionable
economic vision of Milton Friedman has led to the systematic weakening of
the Canadian economy. Certainly, the elites have benefitted from this
acceptance, but at the expense of most Canadians.(49) Buzz Hargrove also
considers these issues in Labour of Love: The Fight to Create a More Humane
Canada.(50) In all of these analyses, the post-war consensus between
labour and business is seen as breaking down: primarily a result of greed
on the part of large business.
The Marxist View: The Role of Capital
The final view is in many ways the most pessimistic and unsettling. The
Marxist view emphases the role and power of capital argues that economic
inequality is inevitable considering the powerful and vested interests who
are benefitting from it.(50) Interestingly, such a belief in inevitability
is shared by those who trumpet economic globalization. In this analysis,
the increasing economic inequality we see in Canada is an inevitable
outcome of the increasing domination of Canadian life by powerful economic
interests. Economic and class conflict is inevitable and will worsen.
James Laxer's most recent book: The Undeclared War: Class Conflict in the
Age of Cyber-Capitalism strongly states this view: "Wars are no less
vicious for being undeclared. Such is the case with the conflict that now
rages between the social classes. This is a civil war, and by definition,
civil wars are not declared" (51, p. 1).
Conclusion
Are increased economic inequality and its partners, increasing poverty,
alienation, and illness inevitable? Is it possible to reverse the trends
that are becoming only so apparent in Canadian life? Or are we heading on
the same path at the United States where: "In the U.S., government
policies of the past 20 years have promoted, encouraged and celebrated
inequality. These are choices that we, as a society, have made. Now one
half of our society is afraid of the other half, and the gap between us is
expanding. Our health is not the only thing in danger. They that sow the
wind shall reap the whirlwind."(1)
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Visit our Web Site for Free Copies of Our Community Quality of Life Reports!
http://www.utoronto.ca/qol
****************************************************
Canalising a river
Grafting a fruit tree
Educating a person
Transforming a state
These are instances of fruitful criticism
And at the same time instances of art.
-Bertolt Brecht
****************************************************
Dennis Raphael, Ph.D.
Associate Professor and Associate Director,
Masters of Health Science Program in Health Promotion
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 101
Toronto, Ontario, CANADA M5S 1A8
voice: (416) 978-7567
fax: (416) 978-2087
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