INCOME INEQUALITY, LOWERED SOCIAL COHESION AND THE POORER HEALTH
STATUS OF
POPULATIONS: THE ROLE OF NEO-LIBERALISM
abstract:
There has been a recent upsurge of interest in the relationship
between income inequality and health within nations and between
nations.
It has been argued by Wilkinson and others that, in the advanced
capitalist
countries, higher income inequality leads to lowered social
cohesion which
in turn produces poorer health status. I argue that not enough
attention
has been paid to the social context of income inequality - health
relationships or to the causes of income inequality itself. In
this paper
I contend that there is a particular affinity between neo-liberal
(market-oriented) political doctrines, income inequality and
lowered social
cohesion. Neo-liberalism, it is argued, produces both higher
income
inequality and lowered social cohesion. Part of the effect of
neo-liberalism is due to its undermining of the welfare state.
The rise of
neo-liberalism and the decline of the welfare state are
themselves tied to
globalization and the changing class structures of the advanced
capitalist
societies. More attention should be paid to understanding the
causes of
income inequalities and not just to its effects because income
inequalities
are neither necessary nor inevitable.
Introduction
There has been a recent upsurge of interest in the relationship
between
Socio-Economic Status (SES) and health. Numerous papers in
Social Science
and Medicine, recent special editions of such journals as the
Sociology of
Health and Illness (1998) and The Milbank Quarterly (1998) and a
variety of
books have focused directly or indirectly on the social
determinants of
health generally and on the SES and health status relationship
specifically
(Amick et al. 1995; Blane, Brunner and Wilkinson, 1996; Evans,
Barer and
Marmor, 1994).
It has long been known that there are historically persistent
inverse
relationships between SES and health status within nations. In
most
developed countries health inequalities have not decreased
despite rising
national wealth (as measured by increasing GNP per capita) and
improvements
in longevity. However, recently attention has turned to analysis
of the
relationships between levels of inequality and longevity amongst
the
economically advanced nations rather than only within them. In
his
interesting and provocative book, Unequal Societies (1996), a
central
writer in the area, Richard Wilkinson, proposes that, after
certain
absolute levels of GNP per capita are attained (about $5,000),
the major
determinant of differing levels of health status amongst nations
lies in
their degree of income inequality. Controlling for such factors
as
GNP/cap, the greater a nation's income inequality - the poorer
the average
national health status. That is, it is inequality rather than
wealth that
is important for health.
Wilkinson also cites support for his findings about
inter-national
differences by research on differences in health status among
states in the
United States (Kaplan et al, 1996; Kennedy, Kawachi and
Prothrow-Stith,
1996). The U.S. analyses supports 'the Wilkinson hypothesis' in
indicating
that inter-state differences in health status are more closely
related to
the income inequality of these states than to their average level
of
income.
The mechanisms linking income inequality to general levels of
health or
longevity are rather vague. A focus on absolute levels of income
as
determinants of health does not explain why some 'rich' countries
show
lower levels of health than do some poorer, but more egalitarian,
countries. It has also been frequently pointed out that even the
'within
country' differences in health status show a gradient across high
as well
as low levels of SES. That is, it is not simply those at the low
end of
the SES continuum that are the issue. Even SES groups quite high
in income
and SES show poorer health than those immediately above them.
Attention
has thus turned to the more indirect influence of psycho-social
factors on
health status rather than simply the direct and immediate effects
of
material life circumstances. That is, if indeed relative status
is related
to health up and down the SES hierarchy, then it is likely that
psycho-social factors, and not only absolute material conditions
are a
major influence on health (Wilkinson, 1997a).
Though the psycho-social channels relating inequality to health
status
within countries are rather vague, many observers argue that
those lower on
SES hierarchies show lowered self-esteem, lack of control, more
harmful
emotional reactions, higher stress or the like. But, differences
between
countries cannot be explained simply by reference to 'relative
deprivation'
since comparisons of social status are assumed to be operative
within, but
not between countries. In a fairly speculative vein Wilkinson,
Kawachi and
others (Kawachi and Kennedy, 1997; Kawachi et al, 1997;
Wilkinson, 1996)
have drawn on the work of Putnam (1993) to argue that social
cohesion/trust
is one of the main mechanisms linking the national degree of
income
inequality with health. Putnam had contended that Northern Italy
was more
socially and economically successful than Southern italy because
the North
had developed greater 'social capital' that is, more extensive
social
networks and greater social 'trust' than had the South. Drawing
on these
findings, the 'inequality' theorists generally argue, with some
supporting
evidence, that higher income inequality produces lowered social
cohesion/lower trust which in turn produces lowered health
status. It
might also be claimed, of course, that between country
differences are
explained by the fact that elongated status hierarchies
exacerbate the
status effects noted within countries. Thus, there is a, more or
less
linear, Income Inequality-SC/Trust/ Esteem etc-HStatus linkage.
Wilkinson's findings have been critiqued on methodological
grounds by Judge
(1995 - see also Wilkinson's response) and by Gravelle (1998 also
see
responses). In this paper I do not question the income
inequality-health
status relationship nor will I analyze in any depth the rather
vague use of
the concept of social cohesion. Rather, I initially assume that
income
inequalities amongst nations are related to national levels of
health
status partly through the vehicle of social cohesion/social
disorganization. Though I focus mainly on 'the Wilkinson
Hypothesis' on
between country differences the discussion that follows has
obvious
relevance also for the within country SES-health status
relationship.
David Coburn,
Department of Public Health Sciences
University of Toronto
Toronto
Canada M5S 1A8
Tel: (416) 978-7513
FAX: (416) 978-2087
e-mail: david.coburn@utoronto.ca
28 May, 1999
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None.
