If you plot a graph of the wealth of nations against the health of their citizens, it is clear that, up to a point, the more you spend the better the health outcomes. But if you then analyse the health of the rich countries that cluster at the top of the graph, where extra spending has ceased to buy significant gains in health, something very interesting emerges. The more equal the society, the better the health of its citizens. And not just their health: on a wide range of social measurements equal societies score better. In contrast, societies where a small percentage of people hold most of the wealth, everyone, rich or poor, is less healthy, less comfortable and less fulfilled. In UK, one of the least equal countries, we have never been so anxious about being happy.
‘The Spirit Level’, written by two British epidemiologists, examines the phenomenon in detail, plotting physical and mental health, teenage pregnancy rates, children’s educational performance, community violence and levels of trust against the level of inequality in 23 countries of the rich world, and also against the level of inequality in the states of the USA. In almost every case, the problems are worse, often much worse, in unequal societies. There is no evidence that this is due to confounding factors: inequality appears to be at the root of many of the social ills which occupy news headlines.
Intuitively, the idea seems right. Gang warfare and the demand for respect which fuels it are responses to inequality. The rich may try to isolate themselves in gated communities, but electronic barriers, security guards and razor wire cannot entirely eliminate the fear and anxiety which must gnaw away at their enjoyment and their health. The cost of managing the problems of inequality suck money from the services which should be promoting equality: responding to the democratically expressed wish of its citizens to control antisocial behaviour, the government of California now spends more on prisons than on education.
The society most people dream of living in is an equal one – everyone in the village drinking in the same pub and sharing the pleasures of the summer fete. Though humans quarrel over resources, we also co-operate, and the pleasure we get from group activities is demonstrated way beyond the football field and the orchestra. There is a balance between our hierarchical and our co-operative natures
The ideas in ‘The Spirit Level’ are not new. I first came across them in a BMJ editorial in 1996, It was a ‘eureka moment’, and I still have on file the series of articles under the title’ socioeconomic determinants of health’, edited by ‘Spirit Level’ author Richard Wilkinson, which followed. And in 2008, the report by Michael Marmot, chair of WHO commission on social determinants in Health, declared ‘social injustice is killing people on a grand scale’.
So, since equality is good for us all, what can be done to promote it? Ironically, war fosters equality. Faced with an external threat, we all pull together. But there are other ways of generating equal societies, and it doesn’t matter how the equality is achieved. Both Japan and Sweden score well on equality. In Japan, there is a narrow range of incomes, while Sweden has a much wider disparity between incomes but a progressive taxation system which redistributes wealth. Even inside the USA the same is found: New Hampshire and Vermont both score highly on equality, but in New Hampshire income is evenly distributed while in Vermont it is redistributed through tax.
“There is no such thing as society: there are individual men and women, and there are families.” said Margaret Thatcher, setting the tone which accompanied the growth of inequality in this country. But in reality we are all in the same boat, and on the same planet, and not just our happiness but our survival depend on us pulling together. How can we persuade our politicians and those who soar in the financial stratosphere earning hundreds of times more than most of the rest of us, that equality is good for all of us, poor or rich? Put another way, how can we start to reaccumulate the social capital that we have thrown away over the past twenty years?
Well, there is an election coming up. The government has responded to economic collapse by trying everything it can think of to stimulate economic growth. The opposition is pursuing the same solution. But where is the evidence that economic growth is going to mend our ‘broken society’? There seems to be no voice speaking out for using the collapse to forge a different strategy. No-one is pointing out to the wealthy that it is in their interest, not just that of the poor, to review the way companies are run and the level of rewards of those who currently command stratospheric incomes. The easy way for a government to be seen to be doing something is to slap on a sticking plaster, and that is what most politicians are proposing. But these problems are gaping wounds, and exhortations to eat green vegetables, lectures on the dangers of obesity and posters about knife crime don’t change society. So when the election candidates come knocking on your door, ask them what they plan to do for equality. And check http://www.equalitytrust.org.uk/ to see what you can do.
The Spirit Level Richard Wilkinson and Kate Pickett 2009 Penguin 978-0-141-03236-8
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…