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).

References
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).

Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding

REVIEW Paediatric Respiratory Reviews (2005)

James J. McKenna* and Thomas McDade

Summary There has been much controversy over whether infants should co-sleep or bedshare with an adult caregiver and over whether such practises increase the risk of SIDS or fatal accident. However, despite opposition from medical authorities or the police, many western parents are increasingly adopting night-time infant caregiving patterns that include some co-sleeping, especially by those mothers who choose to breast feed. This review will show that the relationships between infant sleep patterns, infant sleeping arrangements and development both in the short and long term, whether having positive or negative outcomes, is anything but simple and the traditional habit of labelling one sleeping arrangement as being superior to another without an awareness of family, social and ethnic context is not only wrong but possibly harmful. We will show that there are many good reasons to insist that the definitions of different types of co-sleeping and bedsharing be recognised and distinguished. We will examine the conceptual issues related to the biological functions of mother–infant co-sleeping, bedsharing and what
relationship each has to SIDS. At very least, we hope that the studies and data describedin this paper, which show that co-sleeping at least in the form of roomsharing especially with an actively breast feeding mother saves lives, is a powerful reason why the simplistic, scientifically inaccurate and misleading statement ‘never sleep with your baby’ needs to be rescinded, wherever and whenever it is published.
2005 Elsevier Ltd. All rights reserved.
(Exact date of publication not known)
To download pdf of review, Click here (pdf file is 624k)

What We Learn about Babies from Engaging with their Emotions. Vasudevi Reddy and Colwyn Trevarthen

Vasudevi Reddy and Colwyn Trevarthen (2004)

Zero to Three, January 2004, Volume 24, No. 3, 9-15.


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PROMOTING RESILIENCE: Changing Concepts of Parenting and Child Care

Sebastian Kraemer, Consultant Child Psychiatrist
International Journal of Child and Family Welfare 3 :273-287, 1999.
Exact date of publication not known.

The most powerful influence on our capacity to manage life's hurdles is the quality of care we received in childhood, especially the earliest years. Other times and cultures have valued different strengths, so that resilience is not a fixed quality. In the modern world, our greatest fortune is the capacity to know our own minds and understand those of others. This is resilience which is truly flexible; the best condition both for personal mental health and for life in a pluralist and changing society. As the history of attitudes to children demonstrates, we are only at the beginning of a child-centred culture. Resilience based on secure attachment is essentially generous and open minded, and is of little value in an unjust or oppressive society.

Resilience of often used as a term of moral approval. The individual so described has triumphed over adversity. Courage and willpower are invoked. Yet these are moral qualities, while resilience is not. The dictionary definition is helpful: "resilient" = recoiling, springing back, resuming its original shape after bending, stretching, compression etc...buoyant (Oxford Encyclopedic English Dictionary, 1991)

In Latin, 'resilire' means to leap back. This paper argues for a resilience that is genuinely flexible, rather than merely resistant. Until the recent past, survival and success in life were usually attributed to the individual's own determination and courage, especially when he or she had an unpromising start, such as poverty, disability or being the victim of cruelty and abuse. Yet new knowledge of child development is beginning to identify the conditions that promote confidence and courage, even in people who began life with serious disadvantages. Human needs have not changed over the centuries, but the way we now understand them is quite different. To illustrate this point, and before describing recent theoretical and clinical findings, I will briefly chart the changing attitudes to child care since the eighteenth century,

Changing attitudes to children
Until the revolution in health care of the twentieth century, children's lives were far more fragile than today, at the mercy both of lethal diseases and parental whim. Consider the likelihood simply of surviving in 1750:

Deaths per 1000 births of children under 5
England and Wales
1750 750
1865 154
1963 21.8(1)

Two hundred and fifty years ago only one quarter of children made it to their fifth birthdays (Newson & Newson, 1974, p54). Our relatively sophisticated notions of child mental health would have seemed quite irrelevant, even absurd. "Child psychology is a luxury which only a small section of the world's parents can afford to consider" (Newson & Newson, 1974) Simply staying alive was sufficient evidence of resilience; it was not distinguished from survival.

In earlier times, and even today in some parts of the world, children were killed because their parents could not look after them, or simply did not want them (especially if they were girls). Although after a few years they could be put to work, infants and small children were a drain on the family, both in time and effort. Because of this - and perhaps also the dread of losing wanted children - past attitudes to children emphasised the need to control their inherent badness. De Mause (1976) writes about the infant as the receptacle for adult projections of evil. Infants are greedy, impatient and demanding, and they will have to learn not to be. Even in the eighteenth century, while philosophers such as Rousseau(2) were beginning to think about children in gentler ways, advice to parents was harsh: "I insist on conquering the wills of children... the parent who studies to subdue self-will in his children, works together with God in the saving of a soul: the parent who indulges it does the devil's work... break their wills betimes... let a child from a year old be taught to fear the rod and to cry softly... at all events from that age make him do as he is bid if you whip him ten times running to effect it. Let none persuade you that it is cruelty to do this; it is cruelty not to" (Susanna Wesley, cited by Newson and Newson 1974, p56).

The justification for such behaviour, which would now be regarded as frankly abusive, was that children would, if unchecked, stay evil and not get to heaven when they died (even if that day came all too soon). We know from epitaphs and letters written about and to children that they were as loved as they are today. Yet there was no notion of child protection in the home. Even as legislation gradually, and even grudgingly, prevented the exploitation of children in mines and other places of hard labour(3), parenthood was still, officially at least, a matter of instilling respect and obedience. The 'mind' of a child was simply wilful, and was to be trained. Children were not meant to think, but to learn(4). Considering the prevailing attitudes to children we can indeed wonder at their resilience! In spite of the gloomy advice they were given, some parents followed their hearts and cherished their children, but others followed God's will and came up against stubbornness that is quite heroic. "I never cried, I never sulked, I never resented, lamented or repented either my ill doings or their consequences, but accepted them, alike with a philosophical buoyancy of spirit which was the despair of my poor bewildered trainers" (Kemble, 1879). This was Fanny Kemble who, "at four... was given a fool's cap to wear at home, but she danced down the driveway and called passers-by to admire it" (Robertson, 1976).

Even in the twentieth century, within living memory, there were experts on child care and development who warned against the dangers of yielding to children's needs. "Nearly all of us have suffered from over-coddling in our infancy. How does it show? It shows in invalidism... coddling is a dangerous experiment... the fact that our children are always crying and always whining shows the unhappy, unwholesome state they are in. There is a sensible way of treating children. Treat them as though they were young adults. Never hug and kiss them, never let them sit on your lap. If you must, kiss them once on the forehead when they say good night. Shake hands with them in the morning... try it out. In a weeks time you will be utterly ashamed of the mawkish, sentimental way you have been handling it..." (Watson 1928).

Something had changed, however. It was now thought that the early years of a child's life were indeed formative ones, and that it was therefore a public matter how children were brought up. "The neglected toddler in everyone's way is the material which becomes the disgruntled agitator, while the happy contented child is the pillar of the state" said Gwen St Aubyn, in a parenting manual published in 1935 (cited by Humphreys and Gordon 1993). All this was in the context of enormous losses of men in the Great War and in South Africa, and an explicit concern that we needed to replenish stocks of obedient fighting men in case there was another war. Resilience would then be defined in terms of acts of courage on the playing - or battlefield (and its opposite as cowardice; the movement to seek psychological reasons for the effects of trauma gathered ground between the wars).

Note how the task of childrearing is related to the prevailing moral code. In earlier times God's will was the driving force, but by the early twentieth century it was the survival of the nation that mattered most. The most influential expert of those days was Dr Frederic Truby King, originally based in New Zealand, who launched a successful movement to convert mothers to breast feeding. Besides this laudable aim, almost everything else he preached was quite horrific. The key to the Truby King method was to feed your baby by the clock every four hours and never at night. If you gave in to him he would become spoiled and spineless and, by implication, no use as a soldier when he grew up. To toughen them up, babies were to spend much of the day on their own outside in the fresh air, and should not be cuddled or comforted even when in distress. Mothers were not encouraged to play with babies, because it would excite them too much. Fathers had no role except earning money.

Middle class mothers were particularly taken by this method, in the expectation that they could produce perfect children, but it was heartbreaking. Only a decade later, but with a world war in between, Benjamin Spock published the first edition of Baby and Child Care. It was a liberation from the harshness of prewar methods, and sold millions of copies. Spock advised mothers to trust their own judgement about what the baby needs. He did not say that one could let children do anything that they liked. "Children are proud to think that they can be truly useful and will rise to the challenge. This can begin very young. A baby of 9 months shouldn't be allowed to get the impression that it's alright to pull mother's hair or bite her cheek but that he owes her respect...." (Spock, 1968). In the meantime John Bowlby, who with Donald Winnicott and Emanuel Miller had protested in a letter to the British Medical Journal at the evacuation of children during war time(5) , had began work on what was to become attachment theory. He was, inevitably, preoccupied with the effect of separation, because it so often happened and was easily measured. But by the time his bestselling book Child Care and the Growth of Love (1953) was published he was talking about the nature of the intimate relationship between baby and caregiver - usually, but not necessarily, the mother.

"...all the cuddling and playing, the intimacies of suckling by which a child learns the comfort of his mother's body, the rituals of washing and dressing by which through her pride and tenderness towards his little limbs he learns the value of his own.. " (Bowlby 1953 p18).

This is the beginning of an entirely different approach to the study of children, in which they are not simply a bundle of desires and needs but are essentially engaged in a relationship with a caregiver. "There is no such thing as an infant" said Donald Winnicott(6) . In the following half century it has of course become much clearer that attachments may be formed with a small number of significant caregivers besides mothers. Within a generation of the publication of these texts, parenthood in Britain and other Western countries has changed. There is now greater recognition that infants are not simply selfish, but sociable, and need the company of a few responsible and committed adults for much of their waking lives. Published advice to parents emphasises this understanding, but it tends to evaporate rapidly under economic pressures. As a result of progressive reforms over the past 180 years children have of course become less useful economically. In terms of cost they may be regarded only as a burden. They need to be educated, clothed, and cared for, all of which are expensive. Public policy in some modern states does not reflect the knowledge gained during the last twenty years. While children may be better protected than they were, they are not necessarily better cared for.

Changing concepts of resilience: from passive acceptance to active involvement.
In earlier times, when war was uppermost in the minds of governments, we needed obedient children who were prepared to die for their country when they grew up. Their training would therefore be unreflective and unquestioning. You did what you were told at home and at school the teacher was always right. Trust and generosity were not useful attributes, neither in peace nor in war. Indeed, children caught up in conflict may well be better off if they know how to steal, and even kill. Although there may be 'honour among thieves', in modern states where there is great poverty, deprivation and danger resilience depends on little more than stubbornness and guile. Children who manage to keep out of trouble in high risk neighbourhoods, for example, seem to have needed rather harsh parental discipline to do so: "amongst disadvantaged children living in dangerous environments, favorable outcomes have been found to be associated with restrictive and authoritarian family patterns rather than with democratic ones" (Luthar 1993).

There is no point in being ill if there is no one to care for you. In a peaceful modern state where childhood (and dependency) is respected, being ill is part of life and is catered for (as in the European Union Parental Leave Directive), but in a survival economy the danger of being a burden to parents and peers is obvious. In such a world resilience is really no more than keeping out of danger. Compulsive self reliance (Bowlby, 1981) may well be admired by employers and by parents who have little concern for their charges, but it is not healthy, nor a sign of resilience. Being able to look after yourself means knowing when you can't.

Family relationships, too, require skills if people are to stay together, but modern expectations of intimate relationships are far more ambitious and demanding than they were. Although marriage for love has been acknowledged for centuries, it is only in the twentieth that it has (at least in the western world) become the primary reason. In the past it was more often a business arrangement than a romantic one (Richards 1995). Couples stayed together because they had to. The interdependence of married couples was far greater, and of course women had far fewer exits than they now have. Was this resilience, or simply lack of choice? Nowadays we would regard couples who manage to stay together as both lucky and emotionally resourceful. They have the capacity to weather the inevitable storms, to deal with conflict without being destroyed by it.

At school, although rote learning is still required for some exams, modern teachers are trained to encourage curiosity, thoughtfulness and even originality in their pupils, and the emphasis on coursework through the school year reflects that. In the past this attitude was more the exception than the rule.

Resilience is not, after all, simply a matter of survival or even of 'toughness', but one of flexibility. Looking at it this way questions also the easy assumption that men are by nature more resilient than women. They are of course usually physically stronger, but this refers only to muscle power. In general the male is less resilient than the female. From the very beginning boys are at a disadvantage. They are more likely to be be spontaneously aborted, to be born with chromosomal abnormalities and congenital deformities and to suffer brain damage before and during birth (O'Dowd & Jewell, 1998), are generally more demanding and fussy as babies (Haviland & Malatesta 1981)7, to have seizure disorders at all ages, and are at greater risk of a whole host of disorders of development, such as autism and related problems, dyslexia and hyperactivity, and from the damaging effects of postnatal depression in their mothers (Murray and Cooper 1997)(8). "At every developmental stage, the male is less mature than the female" (Gualtieri & Hicks, 1985, p428). Later on boys are more likely to have conduct disorders, to get into trouble with the law and more likely to kill themselves, or others (Lewis & Slogget,1988). In Britain the national publication of school test results shows how consistently superior girls are in literacy and other subjects that imply, or require, social skills. Overall their performance at GCSE level (public examination at 16 years) is about 10% better. Boys are not significantly better at anything, except in sports, and non-linguistic abstract skills such as maths and science. It is possible that one of the factors making mid-adolescence harder for boys is the intensity of their sexual drive. In girls this tends to peak later, after the exams are over. Fewer young men than women are now going to university, and more are unemployed. Men are more vulnerable to the damaging effects of unemployment. In adulthood most of the diseases that kill are more frequent, or come earlier, in men, so that on average women live the longest lives.

Parenting for resilience
How does care promote resilience? Some people still assume, like the old parenting manuals, that one is weakened ("spoiled") by care and attention. This seems to be proved by people who, in spite of deprivation and abuse in early life, can escape from the apparently inevitable fate of repeating the lives of their parents, and thrive as adults and parents themselves. Overcoming early hardship is, on this view, entirely a matter of personal determination. Yet, though temperament and intelligence certainly make a difference, will power is not simply inborn, and there is a great deal of clinical evidence to show just how powerful the past can be (eg Byng-Hall, 1995). In spite of our best efforts we often turn out to have many of our parents' least admired qualities. Heroic attempts, much exploited in popular narrative, to 'put it all behind you' are often doomed, as greater works of literature often reveal. The work of Fonagy and others (1994) has shown that those who manage to survive abuse and neglect achieve this not by putting early experience out of their minds but, on the contrary, by being able to remember, reflect and make sense of it(9). The resilient individual is one who can understand what has happened to him, and this of course requires understanding of what happened to others too, particularly his caregivers. Such individuals are able to break the cycle of sorrow, and bring up their children more successfully than their parents did them. Sometimes it is necessary to forgive one's parents, especially when it becomes clear what kind of upbringing they themselves had. The capacity to "put oneself in the other's shoes" is an essential condition of resilience in a modern pluralistic society. But where does this come from?

Optimal parenting
It seems on the surface to be an entirely moral matter. Parents usually want children to have 'good manners' which means, amongst other things, putting the needs of others before their own. But this is not a skill that can be conjured up in adolescence or adulthood when required, unless the seeds have been sown earlier on. The normal, and best, way of acquiring it is in infancy. This may cause surprise as it is often assumed that there is nothing you can teach babies about other people's states of mind until they can talk and think for themselves. But infants are profoundly social beings, and are just as much in need of conversation as they are of food and warmth. It is in fact quite difficult to meet a baby without trying to talk to him and touch him(10). We are, like other mammals, drawn into intense social contact with small and apparently helpless creatures. The conversation between an adult and the baby she (or he) is caring for is quite familiar. The adult speaks in a high tone, and tells the baby about himself: "that's nice, isn't it", "ooh, listen to that tummy rumbling", "here it is", "you are a grumpy boy", "no you can't have that", and so on. Most attached caregivers will sing to their babies. This, if it is consistent and continuous, is the basis of a secure attachment. The caregiver follows the infant, often in a playful way, helping him to make sense of his own states of mind and body. Babies come to expect patterns of responses from their principal caregiver, almost always the mother, so that strangers, however skilled, are unlikely to be able to take over without difficulty (Beebe, 1992). Note that, as well as understanding what the child is about, such care also includes limiting his behaviour. 'Containment' creates boundaries for both thought and action (Miller et al 1989).

For most of human history such moments have been of no more interest than any other domestic activity to any but the participants. That's just what people (almost always mothers) do with children. But it is now known just how important these interactions are, and how important that they go on daily throughout the early years. Infants cannot manage on their own, not just because they cannot feed, clothe and clean themselves, but because they cannot think without anyone there to help. They must first practice with another person, preferably with someone who loves them. When this goes well it is touching, but in many respects unremarkable. Hence the lack of historical and scientific interest in the process. When it goes wrong, even in quite subtle ways, we now know that the result can be quite damaging. Work with mothers who are depressed, for example, shows how the mismatch between the child's social offerings and the mother's gloomy responses leads to the child eventually 'giving up'. It is very painful to watch this on the video recordings that have been made for research purposes, but like the work of James Robertson (1952) that preceded it by forty years it is unforgettable(11). Besides frankly abusive or negligent care, other examples of misattunement can arise if the baby is too placid or too active for his particular caregiver. The former can contribute to failure to thrive (Skuse et al, 1994) while the latter may lead to hyperactivity (Stiefel, 1997). Babies can also remind their mothers of their own mothers. When this is an unhappy memory, the child will be experienced as a persecutor, with damaging consequences ('ghosts in the nursery', Fraiberg et al 1975). None of this is to blame parents, but to identify the sort of attentiveness that is required to bring up a baby. Most people can manage it, but a significant minority find the task difficult, even overwhelming, often because their own early care was lacking in similar ways. For all caregivers, though the rewards may be profound, looking after children is demanding and exhausting.

Many researchers and clinicians have tried to pin down the ingredients of a successful parent-infant conversation. Metaphors from the performing arts are often used to describe it (Trevarthen 1979). The infant and the caregiver are said to be in a dance; but who is in the lead? It is the infant who leads, while the adult responds, naming the child's efforts. His agency is acknowledged. Trevarthen emphasises babies' capacity to create theatre, to tease and make mischief with their caregivers. Another term to describe this relationship is the musical notion of 'attunement', which also implies close attentiveness to the other (Stern 1985). Follow-up studies of children who consistently have such care show that they are themselves more attentive and in tune with others. In order to understand one must first have been understood. Along with this goes greater curiosity about the world around, including wondering about how people think, why they do what they do, and so on. This is essentially a generous state of mind in which the child is open to new ideas and experiences.

Besides these cognitive and emotional developments there are also biological ones. The stability of body systems, such as those regulating hormones, temperature, blood pressure, is dependent to some extent on the quality of care (Hofer 1995), as is the optimum development of the central nervous system, which is necessary for the capacity to regulate affects and the the capacity to pay attention, and to think. "The growth [of the baby's brain] literally requires brain-brain interaction and occurs in the context of a positive affective relationship between mother and infant" (Schore, 1997, p1). Conversely: 'prolonged negative states are too toxic for infants' [and]..disrupt 'state regulation' (p15).

A securely attached child is more stable neurologically, physiologically, emotionally and intellectually, but this does not mean that everything is tightly regulated. Resilience is the capacity to get back in balance after being pushed out of it, to tolerate greater challenges without breaking down. Clearly this is most easily acquired in early infancy (and probably even before birth) but not everyone has such a lucky start.

Resilience through disadvantage
As we have seen, consistent, attentive and confident care is a powerful predictor of later resilience, but the term also implies qualities that may emerge in spite of deprivation or abuse. People who overcome serious disadvantage usually credit one or more supportive people in their lives, such as schoolteachers, friends or sexual partners who respect them and in whom they can confide. Others owe their resilience to belonging to a community. This may be a neighbourhood, a group of friends or an association of colleagues with common interests, a school or college, the armed services, or a faith.

There is always, as both modern research (Quinton et al, 1993) and traditional wisdom has it, a tendency towards either virtuous or vicious cycles: "good or bad fortune usually comes to those who have more of the one than the other" (La Rochefoucauld, 1665). Yet to some extent all of these turn up by chance. It is almost a tautology to say that resilience depends on luck. In the first place there are inherited(12) qualities of temperament, looks and intelligence (and the absence of genetic disadvantages), but none of them is much use if they are not cultivated in the child's upbringing. This too is a matter of luck. We do not choose our parents, yet the way they care for us is strongly determined by their own experiences a generation earlier (Steele, et al 1996).

The damaging effects of early loss or abuse can be overcome, provided the lucky break somehow makes up for the conversations that were missed. Another way of putting this is that some friendships (Pahl, 1996), whether individual or as part of a community, give one a second chance for mutual affection and reflection, and the opportunity to test these even when conflict arises, as it inevitably does in close relationships. While research shows that "the caregiver's capacity to reflect on mental states in describing their own childhood predicts [their] child's security of attachment" (Fonagy, 1999, in press), we have to rely on clinical knowledge to find out where this comes from. If the ordinary caregiver-baby conversations were absent or inadequate how are reflective skills obtained? Sometimes it becomes clear that quite badly abused children had a few months or years of devoted care in infancy, which we can suppose provided a kind of 'immunity' to later harm. Because people do not remember the earliest months of life this may only emerge after lengthy psychotherapeutic work. In other cases it is evident that the individual was not wanted from the beginning, or was simply too demanding for the caregivers. Some such people finish up as the loneliest adults, unable to sustain close relationships of any kind. Others are more resilient. In my clinical work I ask adolescent and adult patients who in their lives do they feel cared most about them. The answers are often surprising, even to the patient, who may not have identified their champion to anyone before. A fifteen year old girl who was often beaten in childhood and is now in care speaks of her cousin, ten years older than her, who would often rescue her from her parents' rows and abuse. A woman who had suffered years of sexual abuse told me of an older brother who she felt understood her plight as the family scapegoat. She also remembered her maternal grandfather with affection, while her mother (his daughter) is beneath contempt for failing to believe her disclosures of abuse. A middle aged alcoholic man, now a grandfather, who has stayed dry for ten years spoke of an uncle who took an in interest in him and "showed me things". The mother of his children left long ago and he had to care for them alone. He feels he has failed his daughter and her baby, but has done well with his youngest, a son. A woman in her mid-thirties has successfully brought up two girls, while their father is in prison. She cannot recall any love or support until adult life, when she met a nurse in the psychiatric ward where she was a patient. This led her into psychotherapy. How did she keep going until then? "Anger". All show something of Fanny Kemble's stubbornness. They are argumentative. They have not given up the hope that someone will respond, if only to fight back. It is hard to resist the conclusion that all of them were born with something of this spirit, but there is more to it than that.

The social context
This kind of resilience is admirable. As I understand it, I can admire these individuals because someone, however briefly, admired them before. In spite of everything, they were lucky (and one of the primary tasks of psychotherapy is to find that quality in the client or patient, however sad, bad or mad they may appear. This has nothing to do with being reassuring (Kraemer, 1994)). A social policy that sets out to promote resilience has to increase the chances of every child to be admired, whether by parents or other relatives, or by childminders, nannies and teachers. This means greater support and training for the increasing army of childcare professionals, who spend far more time with their charges than a generation ago. This is a trend that is unlikely to be stopped, though there are signs that some parents are beginning to wonder whether wall-to-wall work to pay for wall-to-wall childcare is so rewarding after all. It would be far better if both fathers and mothers had more time to care for their children in the earliest years, but this will require a change of culture in which such care is valued, and paid for out of public funds, as it already is in many European countries. All EU member states are now obliged to allow parental leave for up to three months to be taken at any time during the child's early years. Although this is paid in Belgium, Denmark, Germany, France, Italy, Luxembourg, Austria, Finland and Sweden the British government has refused to consider payment. In effect this reduces the measure to the promise that a worker can keep his or her job during three months unpaid leave, if they can afford it. Few mothers will take this up, and even fewer fathers. Having small children is expensive. Even when it is paid, the takeup of parental leave takes many years to get established, but the benefits in terms of the quality of children's attachments to both parents, and the corresponding reduction in the social costs of poor attachment will pay for the provision within a generation (Wilkinson 1997).

Meanwhile the trend continues. More parents are employing others to look after their preschool children. Rather than protest (in vain) about this it is better to use the moment to press for better trained and more professional childcare, so that those children whose parents are already overwhelmed have a earlier chance of making links outside the home. From family centres to therapeutic communities there is, potentially, a whole range of skilled care that has hardly any status at all in our rich modern societies (Kraemer, 1999). Fewer young people in Britain, for example, are choosing the caring professions, because they see low pay and high stress. (They go for computing and marketing instead.) In any case residential and day care staff have the least training, and the most demanding jobs. Registration of childminders is resisted by the UK government because it might remove thousands of perfectly capable people (mostly women) from the work force for lack of formal training qualifications. Yet in spite of a National Childcare Strategy to improve quality of care, looking after children is still regarded as a low-key domestic task that anyone can do, like house cleaning.

Modelled on the famous HeadStart programme in the USA, the Sure Start and Early Excellence schemes now proceeding in Britain are milestones in child policy. Yet there is a real danger that while the greatest effort will (rightly) be put into supporting families most at risk, other families may be left to the vagaries of the child care market. UK Government policy is to be socially inclusive, but it remains to be seen how this can be achieved without a massive political shift in attitudes towards children and parenting, which have up to now been effectively privatised. In effect the British class system, which privileges a small elite in private schools, putting the state system at a constant disadvantage, is likely to be built into the child's development in early care too. Comprehensive provision at any age must be so good that the private, so-called 'independent', alternative is put out of business.

A further problem is that child care is almost exclusively regarded as a job only for women. The Equal Opportunities Commission reports that 97% of those wishing to train for child care (precisely the same proportion as are aiming for hairdressing) are women. These opportunities pay significantly less than the jobs that attract boys, such as information technology and engineering. ('Girls fail to bridge gender gap on jobs', Guardian 9.4.99) Moss (1997) calls for a generic training in the care of children, similar to the profession of pedagogue found in many European countries (Jones 1994).

Resilience in the modern age
In a world in which individuality is acknowledged, even celebrated, resilience is best understood as the experience of agency (Rutter 1993): that what you do or say makes a difference, that it is worthwhile making plans for your life; that you are not simply a helpless victim of forces entirely beyond your control. Those who feel so powerless are more likely to become victims of scapegoating in their families or bullying by their peers. People who feel that they can make some changes in their lives if they need to are less likely to become ill (Blane et al 1996). The paradox is that such individuality can only be fostered in a good society. In very detailed cross-national comparisons Wilkinson (1996) has demonstrated the ill effects of social inequality. In a society with steep differences between the rich and poor everyone is less secure, the rich because they can see what might happen to them if they lose their place, through unemployment, illness or accident, the poor because they lack money, which makes them overestimate the protection that wealth provides. Unequal societies promote a more aggressive and selfish culture. In more equal societies, anxieties at both ends of the social scale are reduced and mortality and morbidity is lower overall. They also tend to be more prosperous (Glyn & Miliband, 1994). Social equality is good for business, too. In the United Kingdom, inequality increased during the Thatcher years. The proportion of the population on less than half average income was below 10% throughout the 1970s, but had increased to over 20% by 1985.

Children are still relatively powerless. They can shout and argue more loudly than they used to. They have 'ChildLine' and liberal minded teachers. But they are even more confined to their homes than a generation ago, for fear of collision with cars and bullying or abuse by strangers. It is no longer thought safe for a child under 10 to travel to school alone, for example. And they are still at the mercy of our adult terror of helplessness. Public (and private) discussions about children tend to veer from the sentimental to the negligent. When we talk about children we talk about everyone, yet there is, especially amongst politicians and journalists, a subtle but pervasive contempt for children, often disguised with condescending words, as if they were a different species. (The term "kids" for children sometimes conveys this). Quite apart from the scandalous levels of poverty in one of the richest countries in the world ('Two in five children born poor' UK Government figures, reported in The Guardian, 29.3.99) there are still far too many neglected children, at all levels of society. They may look as if they don't need anyone to help, but that is because they think that no one is bothered (Winnicott 1958). The streetwise young person wears a facade, but it can be a very impressive one. Such people can find their way into political power. After sexism and racism, we still have to confront 'childism'.

The millennium is an opportunity for a real shift in our political centre of gravity. If it means anything at all, it is the anniversary of the birth of a baby whose parents were in difficulty. In mentioning this I am not proposing a return to a supposed religious golden age, but a leap forward to an honestly child-centred one.

Conclusion
Most people would agree with this statement that "..healthy, happy, and self-reliant adolescents and young adults are the products of stable homes in which both parents give a great deal of time and attention to the children" (Bowlby, 1988, p2), yet it is not often stated so openly. Some might even cringe at Bolwby's simple faith in good parenting, as if we were wiser now, and knew that the reality is always different. It is not. The majority of children are brought up this way, but the majority of social and psychological problems arise in families that are not like this. Paradoxically, one of the serious political obstacles to promoting secure attachments is the fear of causing offence to parents who fail their children. Attachment theory, precisely because it delineates so clearly the conditions for healthy development, has always run into criticism from those who assume it holds parents responsible for everything that happens to a child. Parenting is indeed an immense responsibility, far greater than most people entering it can possibly know, but the purpose of this paper is not to blame parents but to show that pain and loss need not be passed mindlessly from one generation to the next. Blaming parents is in any case futile, both clinically and politically. The moral development of children is not, as was formerly believed, dependent simply on obedience to adult authority, though that is often necessary on the way. It requires years of negotiations between caregivers and children, beginning with the apparently simple conversations we have with our babies. Parents should play the major part in this, but they cannot do it alone. Childminders, nannies, teachers, and others all need the reflective skills that make all the difference between power which is abused, and authority which is necessary.

It is no good arguing for resilience based on secure attachment if we do not also argue for a society that welcomes it. In a world in which trust is possible, in which ordinary life is not constantly undermined by threats of instability, loss, oppression, or worse, the securely attached individual has greater freedom of social action, at home, at school, and later in adult relationships, both with intimates and with colleagues. But there is little value in having a generous and open mind if life is primarily a struggle for survival, where there are few or no trusted neighbours, and where it is better not to think about other people's states of mind. If you have to steal from others to survive, for example, it is a hindrance to be bothered about their feelings. Thoughtfulness is not useful in a thoughtless culture.

"Enabling and facilitating social competence, self-esteem and secure attachments is likely to create the conditions for a post-industrial society where relationships are based on mutual recognition and respect rather than on fear and deference" (Svanberg, 1998)

Dr Sebastian Kraemer
Child & Family Department
Tavistock Clinic
120 Belsize Lane
London NW3 5BA

NOTES

1 in the African country of Niger, death rates of children under 5 are 318 per 1000, ie at the levels of 18th Century England. (1996 figures, The Guardian (London) 11.5.98)

2 Jean Jacques Rousseau published Emile or On Education in 1762. "..watch your scholar [child] well before you say a word to him; first leave the germ of his character free to show itself, do not constrain him in anything, the better to see his as he really is".

3 the Earl of Shaftesbury (Anthony Ashley Cooper 1801-1885) did a great deal to protect children from abuse, but his motives were as much political as humanitarian. He was afraid that such children, if not rescued, would become revolutionaries when they grew up (Hendrick, 1994)

4 Charles Darwin and Mrs Gaskell were honourable exceptions, but his sensitive observations of his own infant were published in the learned philosophical journal Mind (II, 1877, 286-294), and her diary was not published (Gaskell, E.C. My diary; the early years of my daughter Marianne, privately printed, London, 1923).

5 a similar letter to The Times was not published (Van Dijken, 1998)

6 This statement was never published, but Winnicott recalls that he said it in a scientific meeting of the British Psycho-analytical Society in about 1940.

7 It is also interesting to note that parents tend to imitate boy babies more than they do girl babies, (Trevarthen et al. 1999) suggesting that parents might have to work harder with boys.

8 They are also more obviously affected by parental conflict, but this may be evidence of resilience, since some of their sisters, who "cope" at the time, are probably at greater risk of depression later on, when they themselves become parents.

9 Many survivors of the Nazi holocaust were obliged to keep quiet about their stories, because no one wanted to hear them (Haas 1996). This was not in the end helpful. As is well known, survival from such horrors is on its own not enough, and some of these victims later took their own lives.

10 English is a difficult language for this kind of writing. "her" would do just as well, but not both together.

11 Murray and colleagues' recordings are not publicly available, to protect the subjects of the study, but many professionals have seen them and the impact should, in time, be as influential as the Robertsons' work in changing attitudes to the care of small children.

12 The mother's nutrition before her baby's birth is also a crucial determinant of the offspring's lifelong health (Barker 1992)

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