Unhealthy Societies: The Afflictions of Inequality

268 Pages·1996·1.13 MB·English

by  Richard G. Wilkinson

Unhealthy Societies

Among the developed countries it is not the richest societies which
have the best health, but those that have the smallest income
differences between rich and poor. Inequality and relative poverty
have absolute effects: they increase death rates. But why? How can
smaller income differences raise average life expectancy?
Using examples from the USA, Britain, Japan and Eastern Europe,
and bringing together a mass of evidence from the social and
medical sciences, Unhealthy Societies provides the explanation.
Healthy, egalitarian societies are more socially cohesive. They have
a stronger community life and suffer fewer of the corrosive effects
of inequality. The public arena becomes a source of supportive
social networks rather than of stress and potential conflict.
As well as weakening the social fabric and damaging health,
inequality increases crime rates and violence. Unhealthy Societies
shows that social cohesion is crucial to the quality of life. Increased
inequality imposes a psychological burden which reduces the well-
being of the whole society. The pattern of modern disease shows
that the material standard of living in developed countries is no
longer the main issue. The problem is now the psycho-social quality
of life, which must be supported by greater material equality.
Without it, important social needs will go unmet and health will
suffer. But this does not mean choosing between greater equity and
economic growth; by lubricating the economy and society,
investment in ‘social capital’ increases efficiency.
Richard Wilkinson is Senior Research Fellow at The Trafford
Centre for Medical Research, University of Sussex.

Unhealthy Societies

The Afflictions of Inequality

Richard Wilkinson

London and New York
First published 1996
by Routledge
11 New Fetter Lane, London EC4P 4EE

Simultaneously published in the USA and Canada
by Routledge
29 West 35th Street, New York, NY 10001

© 1996 Richard G.Wilkinson

Routledge is an imprint of the Taylor & Francis Group

This edition published in the Taylor & Francis e-Library, 2002.
All rights reserved. No part of this book may be reprinted
or reproduced or utilized in any form or by any electronic,
mechanical or other means, now known or hereafter
invented, including photocopying and recording, or in any
information storage or retrieval system, without permission
in writing from the publishers.

British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.

Library of Congress Cataloguing in Publication Data
Wilkinson, Richard G.
Unhealthy societies: from inequality to well-being/Richard G.
Wilkinson.
p. cm.
Includes bibliographical references and index.
1. Social medicine. 2. Income distribution—Health aspects.
3. Equality—Health aspects. I. Title.
RA418.W45 1996
306.4´61–dc20 96–21560

ISBN 0-203-42168-X Master e-book ISBN

ISBN 0-203-72992-7 (Adobe eReader Format)
ISBN 0-415-09234-5 (hbk)
ISBN 0-415-09235-3 (pbk)
Contents

List of illustrations vii
Preface ix
1 Introduction: the social economy of health 1
Part I The health of societies
2 Health becomes a social science 13
3 Rising life expectancy and the epidemiological transition 29
Part II Health inequalities within societies
4 The problem of health inequalities 53
5 Income distribution and health 72
Part III Social cohesion and social conflict
6 A small town in the USA, wartime Britain, Eastern
Europe and Japan 113
7 An anthropology of social cohesion 137
8 The symptoms of disintegration 153
Part IV How society kills
9 The psychosocial causes of illness 175
10 Baboons, civil servants and children’s height 193
vi Contents
Part V Redistribution, economic growth and the quality of life
11Social capital: putting Humpty together again 211
Bibliography 233
Name index 247
Subject index 251
Illustrations

FIGURES
3.1 Life expectancy and income per capita for selected
countries and periods 34
3.2 Increases in life expectancy in relation to percentage
increase in GDPpc 37
4.1 Relative risk of death from coronary heart disease
according to employment grade, and proportions of
differences that can be explained statistically by
various risk factors 65
5.1 Income and mortality among white US men 73
5.2 GDP per capita and life expectancy in OECD
countries in 1990 74
5.3 The cross-sectional relationship between income
distribution and life expectancy (M&F) at birth in
developed countries, c. 1981 76
5.4 The annual rate of change of life expectancy in twelve
European Community countries and the rate of
change in the percentage of the population in relative
poverty, 1975–85 77
5.5 The relationship between income distribution and
mortality among fifty states of the USA in 1990 79
5.6 Life expectancy (M&F) and Gini coefficients of post-
tax income inequality (standardised for household
size) 84
5.7 Social class differences in infant mortality in Sweden
compared with England and Wales 87
5.8 Social class differences in mortality of men 20–64
years: Sweden compared with England and Wales 88
viii Illustrations
5.9 Widening income differences: distribution of disposable
income adjusted for household size, UK 95
5.10 Indices showing changes in death rates among young
adults, children and infants (M&F combined, England
and Wales, 1975–92) 97
5.11 Trends in life expectancy among blacks and whites
in the USA (M&F combined) 99
5.12 Three measures of self-reported health in relation to
income (M&F combined) 65 years and over living
alone or in two-person households 104
8.1 The relationship between income distribution and
homicide among the states of the USA in 1990 157
8.2 The decline in reading standards. (Chiltern reading
test scores for all 7–8 year old Buckinghamshire
schoolchildren) 160
10.1 The decline of mental ability in later life is strongly
affected by childhood environment 202
10.2 Behaviour problems age 10 years: social class, Great
Britain 1980 206
TABLES
5.1 The effect of different distributions of income on the
relative income of the poorest half of the population 108
6.1 Increases in life expectancy in England and Wales each
decade 1901–91 114
Preface

To have worked on the social and economic determinants of health
for the last 20 years has been an enormous privilege. I first became
involved when, after completing a Master’s thesis, I wrote a
newspaper article in the form of an open letter to the then Secretary
of State for Health and Social Security, David Ennals, in
Callaghan’s Labour government in 1976.1 Pointing out that, as a
Labour minister, he presided over the largest social class differences
in mortality then on record, I asked him to set up an ‘urgent
inquiry’. Three months later, after having read my article, he
announced the setting up of the DHSS Working Group under the
chairmanship of Sir Douglas Black. Three years later it produced
the Black Report entitled Inequalities in Health and ushered in a
new era of research on the social causes of health and illness
throughout the developed world. Sir Douglas Black, who had been
Chief Medical Officer in David Ennal’s department, described his
minister—with a characteristically neat turn of phrase—as ‘a man
who tried to do good and on the whole succeeded’.
The continuing research stimulated by this report is transforming
our understanding of both society and health. Having started off
with issues to do with the veracity of the basic figures, the progress
of research has felt like a long and difficult climb, but we are now
getting our first views of the landscape ahead. What we can see is
destined to transform social and economic policy and hopefully, the
direction of the social development of modern societies. It is now
clear that the scale of income differences in a society is one of the
most powerful determinants of health standards in different
countries, and that it influences health through its impact on social
cohesion. These basic facts have implications which go far beyond
the health data from which they have emerged.