Paul Bissell

• Part I: • Description of basic findings from The Spirit Level • Supporting evidence:

Marmot Review Economic Inequality in the UK (Hills Report)

• Part II : • Explanations for inequality: The Spirit Level• Fraternal & hostile critiques• Overall assessment of The Spirit Level – a threat

to neo-liberal agenda?

W & P – social epidemiologists, background in health sciences.

Debate in social epidemiology centred on mortality / morbidity evidence – since extended to other ‘social’ problems.

Social position / position in ‘hierarchy’ is a fundamental influence on health (& other social problems).

Bottero (2005:187) “Health inequalities reflect the impact of disadvantage, exclusion and discrimination on people’s lives, an embodied index of hierarchy and inequality...hierarchy continues to be written on the body. Social class differences in health have stayed constant and – at certain points – have even widened.”

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Spirit Level arguments apply to countries which have gone through epidemiological transition. This is:

When countries reach a certain income threshold (around $5000 per capita in 1990).

And

The epidemic diseases of poverty are replaced by chronic & degenerative diseases - cardiovascular disease, dementias, cancers & diabetes.

Then Further increases in per capita income make little or no

difference to population health.

So.......

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Within a given country income has a relationship to health with lower income people having the worst health.

But between countries there is no relationship between mean income and health.

The relationship is between the extent of income inequality and health.

It is the extent of income division within a society that determines population health rather than mean income- more unequal societies have worse health.

It is the extent of income inequality within a society that determines population health rather than mean income - more unequal societies have worse health.

“If-for instance- a country does badly on health, you can predict with some confidence that it will also imprison a larger proportion of its population, have more teenage pregnancies, lower literacy scores, more obesity, worse mental health ...inequality seems to make countries socially dysfunctional across a wide range of outcomes.”p 174

“It is very difficult to see how the enormous variations which exist from one society to another in the level of problems associated with low social status can be explained without accepting that inequality is, in an essential respect, the common denominator, and a hugely damaging force.” p 193”

The Spirit Level

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Materialist: “a combination of negative exposures and lack of resources held by individuals, along with systematic under-investment across a wide range of human, cultural and political-economic processes.” Lynch et al.,2000.

Psychosocial: builds on material explanation; works via two mechanisms – biology and social position. Inequality impacts on quality of social relationships and increases our social evaluation anxieties.

Black Report (1980) Acheson Report (1998) Marmot Review (2010) WHO Commission on Social

Determinants of Health (2008)

How unequal is the UK? How has this changed over time? What does the income distribution

look like? Hills Report (2010) equips citizens

with basic information on extent of inequality (Spirit Level does not).

As does Institute for Fiscal Studies (www.ifs.org.uk)

Institute for Fiscal Studies: Poverty & Inequality in UK, 2010. 1951- UK at its most equal (probably in its history). From 1951-1961, relatively sharp widening of inequality (ending of food rationing & other wartime measures). 1960s - the pace of increase in inequality slowed. 1970s - pace of inequality began to pick up.Fastest rate of increase in the last century- Gini rose from 0.25 1979 to 0.36 2010 (was 0.34 by 1995).

"the scale of this rise in inequality has been shown... to be unparalleled both historically and compared with the changes taking place at the same time in most other developed countries" (IFS 2010 p29).

http://sticerd.lse.ac.uk/case/_new/publications/NEP.asp

Source: IFS, based on FES and FRS (equivalent net incomes).

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4

5

1961 1966 1971 1976 1981 1986 1991 1996-97 2001-02 2006-07

0

5

10

15

20

25

30

35

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Left-hand scale:90:10 ratio

Right-hand scale: Gini coefficient (%)

Income inequality (equivalent net household income)

Source: OECD (2008).

20 25 30 35 40 45 50

DenmarkSweden

LuxembourgAustria

Czech RepublicSlovakia

FinlandBelgium

NetherlandsSwitzerland

NorwayIcelandFrance

HungaryGermanyAustralia

OECD-30Korea

CanadaSpainJapan

GreeceIreland

New Zealand*United Kingdom

ItalyPoland

United StatesPortugal

TurkeyMexico

Gini coefficient (%): Equivalent net income, early 2000s

Source: DWP, based on FRS, 2007-08. Incomes are equivalent net income, adjusted for household size, before housing costs, at 2008 prices.

P10 = £191

P30 = £292Median = £393

P70 = £523

P90 = £806

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95

Percentile of distribution of equivalent net income

£ pe

r wee

k

Source: ONS, based on Wealth and Assets Survey, 2006/08 (excludes state pension rights).

Data based on period 2006-2008 Median hourly wage was £9.90; the 90:10 ratio was 3.9, with

10% having wages below £5.50 and 10% above £21.30 per hour. Top 1% had wages above £43 per hour.

Median monthly earnings (employed full-time) was £448. 90:10 ratio was 3.7, with 10% having earnings below £240, 10 % above £893 per week (equivalent to annual earnings of £46,000). Top 1% had earning above £1,910 per week.

Median net individual income (including those not employed) was £223. 90:10 ratio was 9.6, with 10% having individual incomes below £56 and 10% above £542 per week. 1% had individual incomes about £1300 per week.

Median total wealth (inc. personal possessions, financial assets, housing and pension rights) was £205,000. The 90:10 ratio was just less than 100, with top 10% having wealth above £853,000 and the bottom tenth having less than £8,800. 1% of households had total net wealth above £2.6m.

Two types of explanations:

Neo-materialist

Psychosocial

“the effect of low income on health [is] via its social meanings and implications for social position rather than through the direct physical effects which material circumstances might have.” Wilkinson 1996.

“Social status, social networks and stress in early childhood are what researchers label “psychosocial factors”, and these are of increasing importance in the rich, developed countries where material living standards are now high enough to have ceased to be important direct determinants of population health”. Spirit Level, 2009.

“a combination of negative exposures and lack of resources held by individuals, along with systematic under-investment across a wide range of human, cultural and political-economic processes.” Lynch et al.,2000.

More hierarchical societies will be less willing to invest in the provision of public goods-from benefits to housing (Lynch et al., 2000, 2001. Davey- Smith, 1996).

Unemployment and sickness benefits are more minimal in unequal societies; so unemployment and illness have different health consequences.

Poorer people have less material goods or less high quality goods.

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The experience of the US- an extreme example both materially and psychosocially.

Neo- material explanations don’t say how ‘the things’ that people own may confer a direct, material advantage for health. Eg. 2 or 3 cars…

The provision of services makes a difference but not as much as you would expect. Eg.- Japan vs US: 1995, Japan spent 7% of GDP on health care (14.5% in US) and 50% of Japanese men smoked (around 25% in US).

Life expectancy in US- 73.9 (men) 79.5 (women); Japan 77.5 and 84.7.

Sweden and the Nordic countries have better life expectancy for all but still health inequalities despite more comprehensive public provision. (Mackenbach, 1997).

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Theories of causation- Psychosocial

Starts with material and then attempts to account for what is left and for the gradient in health.

Hierarchical societies do something to the self which has emotional, social and physiological consequences?

“the social processes related to income distribution are involved in the deeper ways our personal and class characteristics are constituted” Wilkinson, 2007.

How does society get inside the body?

Biological mechanisms

Social mechanisms

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Theories of causation – psychosocial. 2.

Biology of the Stress Response. Variety of mechanisms which have been explored in both animal

studies and with human populations. Allostatic load (Sterling and Eyer, 1988 but primarily McEwen,

1998, 1999, 2003)

“wear and tear on biological regulatory systems as they are forced to adapt repeatedly to life’s demands” (Steptoe, 2006 )

Results in both an inability to respond efficiently to the demands being made on the body and to a failure of post stress recovery.

Can also impact on blood pressure, cortisol levels, inflammatory response neuro-endocrine response and others.

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Theories of causation- psychosocial. 3.

Evidence from biology.

Baboons (Sapolsky,1993) and cortisol levels. High status animals had better health even in conditions where diet and access to food were controlled. Not just “fitness” - when high status animals moved and became low status, their health deteriorated.

Coronary heart disease in Sweden and Lithuania. Four times the incidence in Lithuania. Kristenson et al (1998) – found a gradient in cortisol levels and a raised but blunted response. The difference could not be explained by diet or smoking

Childhood height predicts number of years in low job control (Holland et al 2000) and high status men in the Whitehall studies were 5cm taller than low status.

Theories of causation- psychosocial. 4.

Wilkinson proposes that stressors are:

“intensely social” and falling into three categories; “low social status, lack of friends and stress in early life” (p39).

“Greater inequality seems to heighten people’s social evaluation anxieties by increasing the importance of social status. Instead of accepting each other as equals on the basis of our common humanity as we might in more equal settings, getting the measure of each other becomes more important as status differences widen…If inequalities are bigger, so that some people seem to count for almost everything and others for practically nothing, where each one of us is placed becomes more important.” (Wilkinson & Pickett 2009 p43-44).

“each hypothesis has been presented as mutually exclusive of (and, in fact in competition with) the others…however, it is our belief that these pathways operate together in different combinations and permutations in different contexts” (Hertzman & Siddiqui 2009).

“this…requires us to look beyond individual variables, or contests between two variables, and instead to focus on how the various inputs may be systematically coordinated such that the complexity of processes yields the observed regularity of outcomes” (Keating 2009 p57).

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What are the “causes of the causes”?

“The Spirit Level.”

•It is inequality which is the common denominator; this is the underpinning/overarching explanation.

• Particularly for problems known to have a social gradient.

•It is not just the poor that suffer from inequality- everyone in unequal societies loses out.

Criticisms & policy implications.

Pyschosocial explanations can lead in the direction of “cultural” solutions which ignore the real impacts and responsibilities for inequality.

More recently (“Spirit Level Delusion”), neo-material ideas have been used as an attack from opponents.

But if the health gradient and negative social factors are caused by inequality, then tackling inequality is better than…

“providing ever more prisons, doctors, health

promoters, social workers educational psychologists and drug rehab units in expensive and at best only partially effective attempts to offset the problems of relative deprivation.” Wilkinson 2007.

Accusations of cherry-picking data on particular countries.

Inclusion (or not) of Nordic countries / USA as ‘outliers’.

Robustness of relationship between inequality and mortality, robustness of regression analysis employed...

See Spirit Level Delusion (Philip Snowden / Peter Saunders)

Considerable concern around homicide stats (US obvious outlier)

Goldthorpe – use of ‘social status’ as core explanation without reference to other work.

Deterministic / ‘hydraulic’ model of impact of income inequality eg. no account of resistance / local social capital / investments individuals might have.

Human agency entirely absent. Social class literature (largely) absent. Lack of reference to other sociological theories around

stratification, social class & health, recognition and redistribution (eg. Axel Honneth, Fundamental causation theory, phenomenology of working class).

Can data bear the weight of the theory (eg. abstracted empiricism).

Centrality of shame / social comparison & social evaluative anxieties in The Spirit Level – this could be tested empirically...

Refusal to acknowledge that neo-materialist & psycho-social theories might ‘work together’.

What about considerations of history and culture in all of this (eg. Social democratic tradition in Nordic countries, not in Iberia, US).

Seeming unwillingness to engage with other disciplines.

Evidence of link between income inequality & mortality / morbidity overwhelming.

Growing evidence in relation to many of the Health and Social problems identified.

Key questions remain about psychosocial explanation posited by W & P – social comparison / shame / social evaluative threats – needs researching in more detail (qual & quan).

Linkages with other disciplines researching stratification & inequality not made

There are ‘killer’ facts in Spirit Level (& other data sources.

Spirit Level, Marmot Review, CSDH, Hills Report – provide citizens with key information about extent of inequality & its potential impacts.

Opponents cannot ‘write off’ this argument. Opponents of Spirit Level want to emasculate

because of the fundamental nature of message – inequality is bad for health and social fabric.

Peter Saunders – the Right have a massive problem if they (W & P) are correct.

“The Commission’s report goes very far in describing how inequalities are killing people. But we know the names of the killers. We know about the killing, the process by which it occurs and the agents responsible . And we as public health workers must denounce not only the process, but the forces that do the killing. Disease is a social and political category imposed on people within an enormously repressive social and economic capitalist system, one that forces disease and death on the world's people” (2009, p 15).