“For the first time in history, the poor are on average fatter than the rich.”
How is it that we have created so much mental and emotional suffering despite levels of wealth and comfort unprecedented in human history? The luxury and extravagance of our lives is so great that it threatens the planet.
At the pinnacle of human material and technical achievement, we find ourselves anxiety-ridden, prone to depression, worried about how others see us, unsure of our friendships, driven to consume and with little or no community life. Our societies are, despite their material success, increasingly burdened by their social failings.
If we are to gain further improvements in the real quality of life, we need to shift attention from material standards and economic growth to ways of improving the psychological and social wellbeing of whole societies. It is possible to improve the quality of life for everyone. We shall set out the evidence and our reasons for interpreting it the way we do, so that you can judge for yourself.
Social theories are partly theories about ourselves; indeed, they might almost be regarded as part of our selfawareness or self-consciousness of societies. The knowledge that we cannot carry on as we have, that change is necessary, is perhaps grounds for optimism: maybe we do, at last, have the chance to make a better world.
The truth is that both our broken society and broken economy resulted from the growth of inequality. The problems in rich countries are not caused by the society not being rich enough (or even by being too rich) but by the scale of material differences between people within each society being too big. What matters is where we stand in relation to others in our own society.
Why do we mistrust people more in the UK than in Japan? Why do Americans have higher rates of teenage pregnancy than the French? What makes the Swedish thinner than the Greeks? The answer: inequality.
This groundbreaking book, based on years of research, provides hard evidence to show:
- How almost everything from life expectancy to depression levels, violence to illiteracy is affected not by how wealthy a society is, but how equal it is.
- That societies with a bigger gap between rich and poor are bad for everyone in them including the well-off.
- How we can flnd positive solutions and move towards a happier, fairer future.
Urgent, provocative and genuinely uplifting, The Spirit Level has been heralded as providing a new way of thinking about ourselves and our communities, and could change the way you see the world.
Richard Wilkinson has played a formative role in international research on the social determinants of health. He studied economic history at the London School of Economics before training in epidemiology and is Professor Emeritus at the University of Nottingham Medical School, Honorary Professor at University College London and Visiting Professor at the University of York.
Kate Pickett is Professor of Epidemiology at the University of York and a National Institute for Health Research Career Scientist. She studied physical anthropology at Cambridge, nutritional sciences at Cornell and epidemiology at the University of California Berkeley.
People usually exaggerate the importance of their own work and we worry about claiming too much. But this book is not just another set of nostrums and prejudices about how to put the world to rights. The work we describe here comes out of a very long period of research (over fifty person-years between us) devoted, initially, to trying to understand the causes of the big differences in life expectancy, the ‘health inequalities’ between people at different levels in the social hierarchy in modern societies. The focal problem initially was to understand why health gets worse at every step down the social ladder, so that the poor are less healthy than those in the middle, who in turn are less healthy than those further up.
Like others who work on the social determinants of health, our training in epidemiology means that our methods are those used to trace the causes of diseases in populations, trying to find out why one group of people gets a particular disease while another group doesn’t, or to explain why some disease is becoming more common. The same methods can, however, also be used to understand the causes of other kinds of problems, not just health.
Epidemiology is the study and analysis of the distribution (who, when, and where) and determinants of health and disease conditions in defined populations.
Just as the term ‘evidence-based medicine’ is used to describe current efforts to ensure that medical treatment is based on the best scientific evidence of what works and what does not, we thought of calling this book ‘Evidence-based Politics’. The research which underpins what we describe comes from a great many research teams in different universities and research organizations. Replicable methods have been used to study observable and objective outcomes, and peer-reviewed research reports have been published in academic, scientific journals.
This does not mean that there is no guesswork. Results always have to be interpreted, but there are usually good reasons for favouring one interpretation over another. Initial theories and expectations are often called into question by later research findings which make it necessary to think again. We would like to take you on the journey we have travelled, signposted by crucial bits of evidence and leaving out only the various culs-de-sac and wrong turnings that wasted so much time, to arrive at a better understanding of how we believe it is possible to improve the quality of life for everyone in modern societies. We shall set out the evidence and our reasons for interpreting it the way we do, so that you can judge for yourself.
At an intuitive level people have always recognized that inequality is socially corrosive. But there seemed little reason to think that levels of inequality in developed societies differed enough to expect any measurable effects. The reasons which first led one of us to look for effects seem now largely irrelevant to the striking picture which has emerged. Many discoveries owe as much to luck as judgement.
The reason why the picture we present has not been put together until now is probably that much of the data has only become available in recent years. With internationally comparable information not only on incomes and income distribution but also on different health and social problems, it could only have been a matter of time before someone came up with findings like ours. The emerging data have allowed us, and other researchers, to analyse how societies differ, to discover how one factor is related to another, and to test theories more rigorously.
It is easy to imagine that discoveries are more rapidly accepted in the natural than in the social sciences, as if physical theories are somehow less controversial than theories about the social world. But the history of the natural sciences is littered with painful personal disputes, which started off as theoretical disagreements but often lasted for the rest of people’s lives. Controversies in the natural sciences are usually confined to the experts: most people do not have strong views on rival theories in particle physics. But they do have views on how society works. Social theories are partly theories about ourselves; indeed, they might almost be regarded as part of our selfawareness or self-consciousness of societies. While natural scientists do not have to convince individual cells or atoms to accept their theories, social theorists are up against a plethora of individual views and powerful vested interests.
In 1847, Ignaz Semmelweiss discovered that if doctors washed their hands before attending women in childbirth it dramatically reduced deaths from puerperal fever. But before his work could have much benefit he had to persuade people, principally his medical colleagues to change their behaviour. His real battle was not his initial discovery but what followed from it. His views were ridiculed and he was driven eventually to insanity and suicide. Much of the medical profession did not take his work seriously until Louis Pasteur and Joseph Lister had developed the germ theory of disease, which explained why hygiene was important.
We live in a pessimistic period. As well as being worried by the likely consequences of global warming, it is easy to feel that many societies are, despite their material success, increasingly burdened by their social failings. And now, as if to add to our woes, we have the economic recession and its aftermath of high unemployment. But the knowledge that we cannot carry on as we have, that change is necessary, is perhaps grounds for optimism: maybe we do, at last, have the chance to make a better world. The extraordinarily positive reception of the hardback editon of this book confirms that there is a widespread appetite for change and a desire to find positive solutions to our problems.
We have made only minor changes to this edition. Details of the statistical sources, methods and results, from which we thought most readers would want to be spared, are now provided in an appendix for those with a taste for data. Chapter 13, which is substantially about causation, has been slightly reorganized and strengthened. We have also expanded our discussion of what has made societies substantially more or less equal in the past. Because we conclude that these changes have been driven by changes in political attitudes, we think it is a mistake to discuss policy as if it were a matter of finding the right technical fix. As there are really hundreds of ways that societies can become more equal if they choose to, we have not nailed our colours to one or other set of policies. What we need is not so much a clever solution as a society which recognizes the benefits of greater equality.
If correct, the theory and evidence set out in this book tells us how to make substantial improvements in the quality of life for the vast majority of the population. Yet unless it is possible to change the way most people see the societies they live in, the theory will be stillborn. Public opinion will only support the necessary political changes if something like the perspective we outline in this book permeates the public mind.
We have therefore set up a not-for-profit organization called The Equality Trust (described at the end of this book) to make the kind of evidence set out in the following pages better known and to suggest that there is a way out of the woods for us all.
Material Success, Social Failure
1 The end of an era
“I care for riches, to make gifts to friends, or lead a sick man back to health with ease and plenty. Else small aid is wealth for daily gladness; once a man be done with hunger, rich and poor are all as one.” Euripides, Electra
It is a remarkable paradox that, at the pinnacle of human material and technical achievement, we find ourselves anxiety-ridden, prone to depression, worried about how others see us, unsure of our friendships, driven to consume and with little or no community life. Lacking the relaxed social contact and emotional satisfaction we all need, we seek comfort in overeating, obsessive shopping and spending, or become prey to excessive alcohol, psychoactive medicines and illegal drugs.
How is it that we have created so much mental and emotional suffering despite levels of wealth and comfort unprecedented in human history? Often what we feel is missing is little more than time enjoying the company of friends, yet even that can seem beyond us. We talk as if our lives were a constant battle for psychological survival, struggling against stress and emotional exhaustion, but the truth is that the luxury and extravagance of our lives is so great that it threatens the planet.
Research from the Harwood Institute for Public Innovation (commissioned by the Merck Family Foundation) in the USA shows that people feel that ‘materialism’ somehow comes between them and the satisfaction of their social needs. A report entitled Yearning for Balance, based on a nationwide survey of Americans, concluded that they were ‘deeply ambivalent about wealth and material gain’. A large majority of people wanted society to ‘move away from greed and excess toward a way of life more centred on values, community, and family’. But they also felt that these priorities were not shared by most of their fellow Americans, who, they believed, had become ‘increasingly atomized, selfish, and irresponsible’. As a result they often felt isolated. However, the report says, that when brought together in focus groups to discuss these issues, people were ‘surprised and excited to find that others share[d] their views’. Rather than uniting us with others in a common cause, the unease we feel about the loss of social values and the way we are drawn into the pursuit of material gain is often experienced as if it were a purely private ambivalence which cuts us off from others.
Mainstream politics no longer taps into these issues and has abandoned the attempt to provide a shared vision capable of inspiring us to create a better society. As voters, we have lost sight of any collective belief that society could be different.
Instead of a better society, the only thing almost everyone strives for is to better their own position as individuals within the existing society.
The contrast between the material success and social failure of many rich countries is an important signpost. It suggests that, if we are to gain further improvements in the real quality of life, we need to shift attention from material standards and economic growth to ways of improving the psychological and social wellbeing of whole societies. However, as soon as anything psychological is mentioned, discussion tends to focus almost exclusively on individual remedies and treatments. Political thinking seems to run into the sand.
It is now possible to piece together a new, compelling and coherent picture of how we can release societies from the grip of so much dysfunctional behaviour. A proper understanding of what is going on could transform politics and the quality of life for all of us. It would change our experience of the world around us, change what we vote for, and change what we demand from our politicians.
In this book we show that the quality of social relations in a society is built on material foundations. The scale of income differences has a powerful effect on how we relate to each other. Rather than blaming parents, religion, values, education or the penal system, we will show that the scale of inequality provides a powerful policy lever on the psychological wellbeing of all of us. Just as it once took studies of weight gain in babies to show that interacting with a loving care-giver is crucial to child development, so it has taken studies of death rates and of income distribution to show the social needs of adults and to demonstrate how societies can meet them.
Long before the financial crisis which gathered pace in the later part of 2008, British politicians commenting on the decline of community or the rise of various forms of anti-social behaviour, would sometimes refer to our ‘broken society’. The financial collapse shifted attention to the broken economy, and while the broken society was sometimes blamed on the behaviour of the poor, the broken economy was widely attributed to the rich.
Stimulated by the prospects of ever bigger salaries and bonuses, those in charge of some of the most trusted financial institutions threw caution to the wind and built houses of cards which could stand only within the protection of a thin speculative bubble. But the truth is that both the broken society and the broken economy resulted from the growth of inequality.
WHERE THE EVIDENCE LEADS
We shall start by outlining the evidence which shows that we have got close to the end of what economic growth can do for us. For thousands of years the best way of improving the quality of human life was to raise material living standards. When the wolf was never far from the door, good times were simply times of plenty. But for the vast majority of people in affluent countries the difficulties of life are no longer about filling our stomachs, having clean water and keeping warm. Most of us now wish we could eat less rather than more. And, for the first time in history, the poor are on average fatter than the rich.
Economic growth, for so long the great engine of progress, has, in the rich countries, largely finished its work. Not only have measures of wellbeing and happiness ceased to rise with economic growth but, as affluent societies have grown richer, there have been long-term rises in rates of anxiety, depression and numerous other social problems. The populations of rich countries have got to the end of a long historical journey.
Figure 1.1 Only in its early stages does economic development boost life expectancy.
The course of the journey we have made can be seen in Figure 1.1. It shows the trends in life expectancy in relation to Gross National Income per head in countries at various stages of economic development. Among poorer countries, life expectancy increases rapidly during the early stages of economic development, but then, starting among the middle-income countries, the rate of improvement slows down. As living standards rise and countries get richer and richer, the relationship between economic growth and life expectancy weakens. Eventually it disappears entirely and the rising curve in Figure 1.1 becomes horizontal showing that for rich countries to get richer adds nothing further to their life expectancy. That has already happened in the richest thirty or so countries nearest the top righthand corner of Figure 1.1.
The reason why the curve in Figure 1.1 levels out is not because we have reached the limits of life expectancy. Even the richest countries go on enjoying substantial improvements in health as time goes by. What has changed is that the improvements have ceased to be related to average living standards. With every ten years that passes, life expectancy among the rich countries increases by between two and three years. This happens regardless of economic growth, so that a country as rich as the USA no longer does better than Greece or New Zealand, although they are not much more than half as rich. Rather than moving out along the curve in Figure 1.1, what happens as time goes by is that the curve shifts upwards: the same levels of income are associated with higher life expectancy. Looking at the data, you cannot help but conclude that as countries get richer, further increases in average living standards do less and less for health.
While good health and longevity are important, there are other components of the quality of life. But just as the relationship between health and economic growth has levelled off, so too has the relationship with happiness. Like health, how happy people are rises in the early stages of economic growth and then levels off. This is a point made strongly by the economist Richard Layard, in his book on happiness.
Figure 1.2 Happiness and average incomes (data for UK unavailable).
Figures on happiness in different countries are probably strongly affected by culture. In some societies not saying you are happy may sound like an admission of failure, while in another claiming to be happy may sound selfsatisfied and smug. But, despite the difficulties, Figure 1.2 shows the ‘happiness curve’ levelling off in the richest countries in much the same way as life expectancy. In both cases the important gains are made in the earlier stages of economic growth, but the richer a country gets, the less getting still richer adds to the population’s happiness. In these graphs the curves for both happiness and life expectancy flatten off at around $25,000 per capita, but there is some evidence that the income level at which this occurs may rise over time.
The evidence that happiness levels fail to rise further as rich countries get still richer does not come only from comparisons of different countries at a single point in time (as shown in Figure 1.2). In a few countries, such as Japan, the USA and Britain, it is possible to look at changes in happiness over sufficiently long periods of time to see whether they rise as a country gets richer. The evidence shows that happiness has not increased even over periods long enough for real incomes to have doubled. The same pattern has also been found by researchers using other indicators of wellbeing such as the ‘measure of economic welfare’ or the ‘genuine progress indicator’, which try to calculate net benefits of growth after removing costs like traffic congestion and pollution.
So whether we look at health, happiness or other measures of wellbeing there is a consistent picture. In poorer countries, economic development continues to be very important for human wellbeing. Increases in their material living standards result in substantial improvements both in objective measures of wellbeing like life expectancy, and in subjective ones like happiness. But as nations join the ranks of the affluent developed countries, further rises in income count for less and less.
This is a predictable pattern. As you get more and more of anything, each addition to what you have, whether loaves of bread or cars, contributes less and less to your wellbeing. If you are hungry, a loaf of bread is everything, but when your hunger is satisfied, many more loaves don’t particularly help you and might become a nuisance as they go stale.
Sooner or later in the long history of economic growth, countries inevitably reach a level of affluence where ‘diminishing returns’ set in and additional income buys less and less additional health, happiness or wellbeing. A number of developed countries have now had almost continuous rises in average incomes for over 150 years and additional wealth is not as beneficial as it once was.
The trends in different causes of death confirm this interpretation. It is the diseases of poverty which first decline as countries start to get richer. The great infectious diseases such as tuberculosis, cholera or measles which are still common in the poorest countries today, gradually cease to be the most important causes of death. As they disappear, we are left with the so-called diseases of affluence, the degenerative cardiovascuiar diseases and cancers. While the infectious diseases of poverty are particularly common in childhood and frequently kill even in the prime of life, the diseases of affluence are very largely diseases of later life.
One other piece of evidence confirms that the reason why the curves in Figures 1.1 and 1.2 level off is because countries have reached a threshold of material living standards after which the benefits of further economic growth are less substantial. It is that the diseases which used to be called the ‘diseases of affluence’ became the diseases of the poor in affluent societies. Diseases like heart disease, stroke and obesity used to be more common among the rich. Heart disease was regarded as a businessman’s disease and it used to be the rich who were fat and the poor who were thin. But from about the 1950s onwards, in one developed country after another, these patterns reversed. Diseases which had been most common among the better-off in each society reversed their social distribution to become more common among the poor.
THE ENVIRONMENTAL LIMITS TO GROWTH
At the same time as the rich countries reach the end of the real benefits of economic growth, we have also had to recognize the problems of global warming and the environmental limits to growth. The dramatic reductions in carbon emissions needed to prevent runaway climate change and rises in sea levels may mean that even present levels of consumption are unsustainable particularly if living standards in the poorer, developing, world are to rise as they need to. In Chapter 15 we shall discuss the ways in which the perspective outlined in this book fits in with policies designed to reduce global warming.
INCOME DIFFERENCES WITHIN AND BETWEEN SOCIETIES
We are the first generation to have to find new answers to the question of how we can make further improvements to the real quality of human life. What should we turn to if not to economic growth? One of the most powerful clues to the answer to this question comes from the fact that we are affected very differently by the income differences within our own society from the way we are affected by the differences in average income between one rich society and another.
In Chapters 4-12 we focus on a series of health and social problems like violence, mental illness, teenage births and educational failure, which within each country are all more common among the poor than the rich. As a result, it often looks as if the effect of higher incomes and living standards is to lift people out of these problems. However, when we make comparisons between different societies, we find that these social problems have little or no relation to levels of average incomes in a society.
Take health as an example. Instead of looking at life expectancy across both rich and poor countries as in Figure 1.1, look just at the richest countries. Figure 1.3 shows just the rich countries and confirms that among them some countries can be almost twice as rich as others without any benefit to life expectancy. Yet within any of them death rates are closely and systematically related to income.
Figure 1.3 Life expectancy is unrelated to differences in average income between rich countries.
Figure 1.4 shows the relation between death rates and income levels within the USA. The death rates are for people in zip code areas classified by the typical household income of the area in which they live. On the right are the richer zip code areas with lower death rates, and on the left are the poorer ones with higher death rates. Although we use American data to illustrate this, similar health gradients, of varying steepness, run across almost every society. Higher incomes are related to lower death rates at every level in society.
Figure 1.4 Death rates are closely related to differences in income within societies.
Note that this is not simply a matter of the poor having worse health than everyone else. What is so striking about Figure 1.4 is how regular the health gradient is right across society it is a qradient which affects us all.
Within each country, people’s health and happiness are related to their incomes. Richer people tend, on average, to be healthier and happier than poorer people in the same society. But comparing rich countries it makes no difference whether on average people in one society are almost twice as rich as people in another.
What sense can we make of this paradox that differences in average income or living standards between whole populations or countries don’t matter at all, but income differences within those same populations matter very much indeed? There are two plausible explanations. One is that what matters in rich countries may not be your actual income level and living standard, but how you compare with other people in the same society. Perhaps average standards don’t matter and what does is simply whether you are doing better or worse than other people, where you come in the social pecking order.
The other possibility is that the social gradient in health shown in Figure 1.4 results not from the effects of relative income or social status on health, but from the effects of social mobility, sorting the healthy from the unhealthy. Perhaps the healthy tend to move up the social ladder and the unhealthy end up at the bottom.
This issue will be resolved in the next chapter. We shall see whether compressing, or stretching out, the income differences in a society matters. Do more and less equal societies suffer the same overall burden of health and social problems?
2 Poverty or inequality?
“Poverty is not a certain small amount of goods, nor is it just a relation between means and ends; above all it is a relation between people. Poverty is a social status It has grown as an invidious distinction between classes”
Marshall Sahlins, Stone Age Economics
HOW MUCH INEQUALITY?
In the last chapter we saw that economic growth and increases in average incomes have ceased to contribute much to wellbeing in the rich countries. But we also saw that within societies health and social problems remain strongly associated with incomes. In this chapter we will see whether the amount of income inequality in a society makes any difference.
Figure 2.1 How much richer are the richest 20 per cent than the poorest 20 per cent in each country?
Figure 2.1 shows how the size of income differences varies from one developed country to another. At the top are the most equal countries and at the bottom are the most unequal. The length of the horizontal bars shows how much richer the richest 20 per cent of the population is in each country compared to the poorest 20 per cent.
Within countries such as Japan and some of the Scandinavian countries at the top of the chart, the richest 20 per cent are less than four times as rich as the poorest 20 per cent. At the bottom of the chart are countries in which these differences are at least twice as big, including two in which the richest 20 per cent get about nine times as much as the poorest. Among the most unequal are Singapore, USA, Portugal and the United Kingdom. (The figures are for household income, after taxes and benefits, adjusted for the number of people in each household.)
There are lots of ways of measuring income inequality and they are all so closely related to each other that it doesn’t usually make much difference which you use. Instead of the top and bottom 20 per cent, we could compare the top and bottom 10 or 30 per cent. Or we could have looked at the proportion of all incomes which go to the poorer half of the population. Typically, the poorest half of the population get something like 20 or 25 per cent of all incomes and the richest half get the remaining 75 or 80 per cent.
Other more sophisticated measures include one called the Gini coefficient. It measures inequality across the whole society rather than simply comparing the extremes. If all income went to one person (maximum inequality) and everyone else got nothing, the Gini coefficient would be equal to 1. If income was shared equally and everyone got exactly the same (perfect equality), the Gini would equal 0. The lower its value, the more equal a society is. The most common values tend to be between 0.3 and 0.5. Another measure of inequality is called the Robin Hood Index because it tells you what proportion of a society’s income would have to be taken from the rich and given to the poor to get complete equality.
To avoid being accused of picking and choosing our measures, our approach in this book has been to take measures provided by official agencies rather than calculating our own. We use the ratio of the income received by the top to the bottom 20 per cent whenever we are comparing inequality in different countries: it is easy to understand and it is one of the measures provided ready-made by the United Nations. When comparing inequality in US states, we use the Gini coefficient: it is the most common measure, it is favoured by economists and it is available from the US Census Bureau. In many academic research papers we and others have used two different inequality measures in order to show that the choice of measures rarely has a significant effect on results.
DOES THE AMOUNT OF INEQUALITY MAKE A DIFFERENCE?
Having got to the end of what economic growth can do for the quality of life and facing the problems of environmental damage, what difference do the inequalities shown in Figure 2.1 make?
It has been known for some years that poor health and violence are more common in more unequal societies. However, in the course of our research we became aware that almost all problems which are more common at the bottom of the social ladder are more common in more unequal societies. It is not just ill-health and violence, but also, as we will show in later chapters, a host of other social problems. Almost all of them contribute to the widespread concern that modern societies are, despite their affluence, social failures.
To see whether these problems were more common in more unequal countries, we collected internationally comparable data on health and as many social problems as we could find reliable figures for.
The list we ended up with included:
- level of trust
- mental illness (including drug and alcohol addiction)
- life expectancy and infant mortality
- children’s educational performance
- teenage births
- imprisonment rates
- social mobility (not available for US states)
Occasionally what appear to be relationships between different things may arise spuriously or by chance. In order to be confident that our findings were sound we also collected data for the same health and social problems or as near as we could get to the same for each of the fifty states of the USA. This allowed us to check whether or not problems were consistently related to inequality in these two independent settings. As Lyndon Johnson said, ‘America is not merely a nation, but a nation of nations.’
To present the overall picture, we have combined all the health and social problem data for each country, and separately for each US state, to form an Index of Heaith and Social Problems for each country and US state. Each item in the indexes carries the same weight so, for example, the score for mental health has as much influence on a society’s overall score as the homicide rate or the teenage birth rate. The result is an index showing how common all these health and social problems are in each country and each US state. Things such as life expectancy are reverse scored, so that on every measure higher scores reflect worse outcomes. When looking at the Figures, the higher the score on the Index of Health and Social Problems, the worse things are. (For information on how we selected countries shown in the graphs we present in this book, please see the Appendix.)
Figure 2.2 Health and social problems are closely related to inequality among rich countries.
We start by showing, in Figure 2.2, that there is a very strong tendency for ill-health and social problems to occur less frequently in the more equal countries. With increasing inequality (to the right on the horizontal axis), the higher is the score on our Index of Health and Social Problems. Health and social problems are indeed more common in countries with bigger income inequalities. The two are extraordinarily closely related, chance alone would almost never produce a scatter in which countries lined up like this.
Figure 2.3 Health and social problems are only weakly related to national average income among rich countries.
To emphasize that the prevalence of poor health and social problems in whole societies really is related to inequality rather than to average living standards, we show in Figure 2.3 the same index of health and social problems but this time in relation to average incomes (National Income per person). It shows that there is no similarly clear trend towards better outcomes in richer countries. This confirms what we saw in Figures 1.1 and 1.2 in the first chapter. However, as well as knowing that health and social problems are more common among the less well-off within each society (as shown in Figure 1.4), we now know that the overall burden of these problems is much higher in more unequal societies.
To check whether these results are not just some odd fluke, let us see whether similar patterns also occur when we look at the fifty states of the USA. We were able to find data on almost exactly the same health and social problems for US states as we used in our international index.
Figure 2.4 Health and social problems are related to inequality in US states.
Figure 2.4 shows that the Index of Health and Social Problems is strongly related to the amount of inequality in each state, while Figure 2.5 shows that there is no clear relation between it and average income levels.
Figure 2.5 Health and social problems are only weakly related to average income in US states.
The evidence from the USA confirms the international picture. The position of the US in the international graph (Figure 2.2) shows that the high average income level in the US as a whole does nothing to reduce its health and social problems relative to other countries.
We should note that part of the reason why our index combining data for ten different health and social problems is so closely related to inequality is that combining them tends to emphasize what they have in common and downplays what they do not. In Chapters 4-12 we will examine whether each problem taken on its own is related to inequality and will discuss the various reasons why they might be caused by inequality.
This evidence cannot be dismissed as some statistical trick done with smoke and mirrors. What the close fit shown in Figure 2.2 suggests is that a common element related to the prevalence of all these health and social problems is indeed the amount of inequality in each country. All the data come from the most reputable sources from the World Bank, the World Health Organization, the United Nations and the Organization for Economic Cooperation and Development (OECD), and others.
Could these relationships be the result of some unrepresentative selection of problems? To answer this we also used the ‘Index of child wellbeing in rich countries’ compiled by the United Nations Children’s Fund (UNICEF). It combines forty different indicators covering many different aspects of child wellbeing. (We removed the measure of child relative poverty from it because it is, by definition, closely related to inequality.)
Figurer 2.6 The UNICEF index of child wellbeing in rich countries is related to inequality.
Figure 2.6 shows that child wellbeing is strongly related to inequality, and Figure 2.7 shows that it is not at all related to average income in each country.
Figure 2.7 The UNICEF index of child wellbeing is not related to Gross National Income per head in rich countries.
As we mentioned at the end of the last chapter, there are perhaps two widespread assumptions as to why people nearer the bottom of society suffer more problems. Either the circumstances people live in cause their problems, or people end up nearer the bottom of society because they are prone to problems which drag them down. The evidence we have seen in this chapter puts these issues in a new light.
Let’s first consider the view that society is a great sorting system with people moving up or down the social ladder according to their personal characteristics and vulnerabilities. While things such as having poor health, doing badly at school or having a baby when still a teenager all load the dice against your chances of getting up the social ladder, sorting alone does nothing to explain why more unequal societies have more of all these problems than less unequal ones. Social mobility may partly explain whether problems congregate at the bottom, but not why more unequal societies have more problems overall.
The view that social problems are caused directly by poor material conditions such as bad housing, poor diets, lack of educational opportunities and so on implies that richer developed societies would do better than the others. But this is a long way from the truth: some of the richest countries do worst.
It is remarkable that these measures of health and social problems in the two different settings, and of child wellbeing among rich countries, all tell so much the same story.
The problems in rich countries are not caused by the society not being rich enough (or even by being too rich) but by the scale of material differences between people within each society being too big. What matters is where we stand in relation to others in our own society.
Of course a small proportion of the least well-off people even in the richest countries sometimes find themselves without enough money for food. However, surveys of the 12.6 per cent of Americans living below the federal poverty line (an absolute income level rather than a relative standard such as half the average income) show that 80 per cent of them have airconditioning, almost 75 per cent own at least one car or truck and around 33 per cent have a computer, a dishwasher or a second car.
What this means is that when people lack money for essentials such as food, it is usually a reflection of the strength of their desire to live up to the prevailing standards. You may, for instance, feel it more important to maintain appearances by spending on clothes while stinting on food. We knew of a young man who was unemployed and had spent a month’s income on a new mobile phone because he said girls ignored people who hadn’t got the right stuff. As Adam Smith emphasized, it is important to be able to present oneself creditably in society without the shame and stigma of apparent poverty.
However, just as the gradient in health ran right across society from top to bottom, the pressures of inequality and of wanting to keep up are not confined to a small minority who are poor. Instead, the effects are as we shall see widespread in the population.
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The Spirit Level. Why equality is better for everyone
by Richard Wilkinson and Kate Pickett
get it at Amazon.com