Sunday, 1 January 2006

Richard Wilkinson - The Impact of Inequality: empirical evidence

[For publication in Renewal – 1st issue of 2006]

What prospects are there of developing a radical political perspective capable of inspiring us with a realistic view of a better society?

The decline of socialist parties, class politics, and any idea that there is an alternative to the market, reflect a loss of confidence in at least some alternatives. Nevertheless, many people continue to believe that inequality is divisive and that its corrosive effects add to the problems associated with relative deprivation. However, in the political battle between contending interests and intuitions, such beliefs have rarely been enough to convince doubters. The issues have seemed too broad to be hammered out with clear evidence and we have been left with nothing to convince doubters but contending ethics and ideologies.

Now, however, that is about to change. For the first time, we have comparable measures of the scale of inequality in different societies and can actually see what effect it has. This new evidence shows, quite simply, that inequality is much the most important explanation of why, despite their extraordinary material success, modern societies are often social failures. It also provides us with the central plank of a political perspective capable of transforming society and the quality of our lives.

What greater equality brings
In societies where income differences between rich and poor are smaller, the statistics show not only that community life is stronger and people are much more likely to trust each other, but also that there is less violence – including substantially lower homicide rates, that health is better and life expectancy is several years longer, that prison populations are smaller, birth rates among teenagers are lower, levels of educational attainment among school children tend to be higher, and lastly, there is more social mobility. In all cases, where income differences are narrower, outcomes are better (Wilkinson 2005).

That’s a lot to lay at the door of inequality, but all these relationships are statistically highly significant and cannot be dismissed as chance findings. Some have already been shown in large numbers of studies – there are over 170 looking at the tendency for health to be better in more equal societies and something like 40 looking at the relation between violence and inequality (Wilkinson & Pickett, in press). As you might expect, inequality makes a larger contribution to some problems than others and is far from being the only factor involved. Inequality seems to explain large differences in average rates of lots of problems; however, where relationships tend to be strongest (explaining perhaps one-third or occasionally half the differences between societies) is with issues like violence, health among working age men, and teenage pregnancies, which show the sharpest class differences and are most closely related to relative deprivation.

None of these findings are based on comparisons with some purely hypothetical utopian society with perfect equality. Far from it. All the data come from comparisons between existing market democracies and sometimes even from comparisons between different regions or provinces within the same country – such as among the 50 states of the USA. What they show is that even small differences in inequality matter. But why? How can inequality be so damaging?

Redistribution, not growth
The first thing to recognise is that we are dealing with the effects of relative, not absolute, deprivation and poverty. Violence, poor health or school failure are not problems which can be solved by economic growth alone – by everyone getting richer without redistribution. Across the richest 25 or 30 countries there is no tendency whatsoever for health to be better among the most affluent rather than the least affluent countries. The same is also true of levels of violence, teenage pregnancy rates, literacy and maths scores among school children, and even obesity rates. We have reached a level of development beyond which further rises in absolute living standards no longer reduce social problems or add to wellbeing.

However, within each country, these problems remain closely associated with income and any other indicator of socioeconomic status. The implication is that what really matters about income is where you are in relation to others in your society, i.e. it is a matter of relative income or social status, not whether the population in one rich country is on average twice as rich as that of another. So for example, why the USA has the highest homicide rates, the highest teenage pregnancy rates, the highest rates of imprisonment, and comes about 26th in the international league table of life expectancy, is because it also has the biggest income differences. In contrast, countries like Japan, Sweden and Norway, although not as rich as the US, all have smaller income differences and do well on all these measures. Even among the 50 states of the USA, those with smaller income differences perform as well as more egalitarian countries on most of these measures.

If – as researchers – we had been working on violence, or teenage pregnancies, or the educational performance of school children, this might have seemed more obvious from the start. But for those of us trying to explain “health inequalities” (the five or ten year differences in average life expectancy between social classes) it seemed very likely that they were the direct result of differences in material living standards such as poor housing, diet and perhaps air pollution. Other, essentially behavioural, social problems obviously needed psychosocial explanations, but health initially seemed a predominantly physical phenomenon requiring physical explanations.

What first aroused suspicions that the health differences were not simply a reflection of the direct effects of material circumstances was that health inequalities were not just inequalities between the poor and the rest of society. Instead, there is a health gradient running right across society, from the bottom to the top. Life expectancy decreases at every step down the social ladder, so even those who are comfortably off tend to have shorter lives than those who are very well off. So even leaving out the homeless, the unemployed, and those on benefits, and looking – as one very important study did – just at office based Civil Servants in secure jobs, it turns out that those in the Executive grades have substantially poorer health than more senior Administrative staff working in the same offices (Marmot 2004). The material privations of having a house with a smaller lawn to mow, or one less car, hardly seemed plausible explanations for these difference.

Chronic stress
What added weight to these doubts was when statistical research began to show the importance to health of all sorts of psychological and social factors. Friendship, sense of control, and good early childhood experience were all found to be highly protective, while things like hostility, anxiety, and major difficulties, were damaging. At the same time biologists were gradually identifying the many pathways through which chronic stress makes us more vulnerable to disease – and not just to one or two diseases. The emerging picture shows that stress increases our vulnerability to so many diseases that it has been likened to more rapid ageing.

The evidence of the effects of psychosocial risk factors, working through the biology of chronic stress, raised the possibility that health inequalities reflected not just the effects of the purely physical hazards to which people were exposed, but also the psychological and emotional impact of living in those circumstances.

Very soon this picture received powerful confirmation from studies of non-human primates (Sapolsky 2004). Although among humans you cannot unambiguously separate out the effects of social status from better material conditions, among animals you can. Studies in which social status among macaque monkeys was experimentally manipulated by moving animals between groups while ensuring material conditions and diets were kept the same, showed that the stress of low social status produced physiological effects similar to those associated with low status in humans. Since then, studies of other non-human primates species have shown that the stress effects of social status vary as the dominance hierarchy and the quality of social relations changes.

Three components of this picture were then in place. We had evidence a.) that it was relative income within countries that mattered (rather than differences in living standards between countries); b.) that there were powerful psychosocial risk factors for disease; and c.) evidence from animal studies that social status itself – working through stress as it clearly did in the animal studies – could be a major influence on health. Together, these transformed the statistical evidence showing more equal societies were healthier from looking like a peculiar oddity, into a confirmation of what we should perhaps have expected all along.

Social relations and hierarchy
The growing awareness of the importance of the social environment to health raised the question of whether the quality of social relations differed between more, and less, equal societies. When analysed, data from a number of different sources left no room for doubt: people in more unequal societies trust each other less, they are less likely to be involved in community life, and rates of violence are higher. All suggest that inequality damages the quality of social relations. Indeed, this must be one of the most important ways inequality affects the quality of life for all of us. In the most unequal of the 50 states of the USA, 35 or 40 percent of the population feel they cannot trust other people, compared to perhaps only 10 percent in the more equal states. The international differences are at least as large. Measures of social capital and the extent to which people are involved in local community life also confirm the socially corrosive effects of inequality. Given the dysfunctional response to hurricane Katrina, it is interesting to note that New Orleans is amongst the most unequal cities in the USA.

These patterns are again reminiscent of the effects of greater inequalities among monkeys and apes: social relations tend to be more stressful in species which have stronger social hierarchies than they are in more egalitarian species. Among humans, it seems likely that the bigger the income and status differences, the more important social position and competition for status becomes.

Although not obvious at the beginning of this research, it is now clear that income inequality tells us about how hierarchical societies are and about the scale of class differentiation within them. The limited comparable data on social mobility in different countries shows that more unequal countries have, as you might expect, less social mobility. Rather than being the “land of opportunity”, the United States is the land of least opportunity, with unusually low rates of social mobility. Similarly, social mobility has diminished in Britain as income inequalities have risen. And whether as a result of social, or market, forces, it also looks as if increased income inequality leads to greater residential segregation of rich and poor in both Britain and the US. Bigger differences seem to mean less mixing – both socially and geographically.

With such profound effects on society and health, it would be surprising if inequality did not also exacerbate most of the problems associated with relative deprivation. Indeed, as we expected, we found that greater inequality is associated with higher rates of imprisonment, poorer literacy and maths scores, increased obesity, more violence, and higher teenage pregnancies rates.

Inequality and social anxiety
But how does inequality really get to us? Why are we so sensitive to it? Some pointers to the mechanisms involved are provided by the psychosocial risk factors for health. Foremost amongst these, as we saw earlier, are three intensely social factors: low social status, weak friendship networks, and poor quality of early childhood experience. Given that we know these work through chronic stress, what the research seems to be telling us is that these are the most pervasive sources of chronic stress in affluent societies. That is an important point to keep in mind.

However, thinking more about these three sources of chronic stress, we can see an underlying story. There is little doubt that insecurities we may carry with us from a difficult early childhood can be exacerbated by the insecurities of low social status. Neither helps confidence or make you feel valued. Friends come into the picture because they provide positive feedback: they enjoy your company, laugh at your jokes, seek your advice, etc.. In contrast, not having friends, feeling excluded, and thinking people avoid sitting next to you, fills most of us with self-doubt. We worry about being unattractive, boring, unintelligent, socially inept, and so on. Perhaps the underlying message is that the most widespread and potent kind of stress in modern societies centres on our anxieties about how others see us, on our self-doubts and social insecurities. As social beings, we continuously monitor how others respond to us, so much so that it is sometimes as if we experienced ourselves through each other’s eyes. Shame and embarrassment have been called the social emotions as they shape our behaviour to meet acceptable standards and spare us from the stomach-tightening we feel when we have made fools of ourselves in front of others.

Confirming this picture are the findings from a review of over 200 experiments in which cortisol, a central stress hormone, was measured among volunteers while they were subjected to various stressors such as loud noises, mathematical problem solving, public speaking etc.. The aim of the review was to find out what kinds of stressors led most reliably to a rise in cortisol. The authors concluded that we are most sensitive to “Tasks that included social-evaluative threat (such as threats to self-esteem or social status), in which others could negatively judge performance.” They went on to suggest “Humans are driven to preserve the social self and are vigilant to threats that may jeopardize their social esteem or status.”

Several of the great sociological thinkers have suggested that this is the gateway through which we are socialised and our behaviour controlled within acceptable norms. It appears that it is also how society gets under the skin to affect health.

The development of individualism and the break up of settled, life-long, communities must have increased our vulnerability to these social evaluation anxieties: we try continuously to put on a public face and create a good impression. There is no difficulty in seeing how our sensitivity to “social evaluative threats” would be involved in everything from embarrassment and loss of face in a personal context, to issues to do with low social status in the wider society. Interestingly, the literature on violence points out how often issues of respect and loss of face provide the triggers to violence. The reason why violence is more common were there is more inequality is not only because inequality increases status competition, but also because people deprived of the markers of status (incomes, jobs, houses, cars, etc) are naturally particularly sensitive to how they are seen.

Similar processes are involved in the social gradient in children’s educational performance. A recent study for the World Bank showed that children in India from high and low castes performed equally well when asked to solve a series of puzzles – as long as they were unaware of the caste differences between them; but when made aware of the differences, the performance of children from low castes was substantially reduced.

We can see then that increased social hierarchy and inequality substantially raises the stakes and anxieties about personal worth. We all want to feel valued and appreciated, but a society which makes large numbers of people feel they are looked down on, regarded as inferior, stupid and failures, not only causes huge suffering and wastage, but also incurs the costs of antisocial reactions to the structures which demean them.

Inequality, consumption, and the environment
This analysis has one more major implication. It concerns the threat to the environment from the ever expanding scale of economic activity. We have already mentioned that, despite its urgency in poorer countries, there is little evidence that continued economic growth brings any real increases in wellbeing to the populations of the rich developed countries. As Gross National Income per head rises we no longer see rises in measures of happiness or economic welfare, and although longevity continues to increase, those increases are unrelated to national rates of economic growth.

However, although economic growth brings few real benefits and poses a serious environmental threat, most people want increased wealth more than almost anything else. Given the concern with status, and the use of consumption to express status, much of the desire for higher incomes is of course a desire for the advantages and position enjoyed by the better off in our own societies. Several economists have provided detailed evidence suggesting that status competition is a very important driver behind the desire for ever higher levels of consumption (Frank 1999). Indeed, as income differences widened in the US, it looks as if they increased the pressure to consume: aspirational incomes and debt went up, while savings went down. Advertisers, endless suggesting that products enhance attractiveness, sophistication and exclusivity, are very aware of our social insecurities. They know that we hope – consciously or not – that our purchases will shore-up our self image and social identity.

If what we want is an income which improves our standing and social attractiveness in relation to others, then it is simply not legitimate to treat our individual desires for higher incomes as if together they amounted to a societal desire for economic growth.

Consumerism is driven substantially by social neuroses and insecurities fanned by inequality and increased competition for status. Rather than a sign of our rampant materialism, our insatiable capacity to consume is an indication (aptly labelled “retail therapy”) that we use our purchases as a source of comfort – as in “eating for comfort” – and to provide a sense of wellbeing which we cannot get from society. Our possessions make us feel like more substantial people in each others eyes. As such, our apparent materialism is actually an expression of what a highly social species we are.

Without a reduction in inequality, the individualism of the market becomes dysfunctional. If we are to avoid further damage to the natural environment we must first improve the real social quality of our lives. That means reducing inequality and the resort to consumption as a substitute source of comfort.

Richard Wilkinson is professor of social epidemiology at the University of Nottingham Medical School and author of: The Impact of Inequality: how to make sick societies healthier (Routledge 2005).

Frank R. Luxury Fever: Why money fails to satisfy in an era of success. Free Press, N.Y. 1999.
Marmot MG. The Status Syndrome. Bloomsbury, London 2004
Sapolsky RM. Why zebras don't get ulcers. A guide to stress, stress-related disease and coping. WH Freeman, N.Y. 3rd edition 2004.
Wilkinson RG. The Impact of Inequality: how to make sick societies healthier. Routledge, 2005.
Wilkinson RG, Pickett KE. Income inequality and health: a review and explanation of the evidence. Social Science and Medicine 2006 (in press).