Wilkinson - Impact of Inequality: How to Make Sick Societies Healthier

Table of Contents

Also by Richard G. Wilkinson

To the future of my children, George and Ann, in the hope that real social and political progress will enable them and future generations to live in more egalitarian and environmentally sound societies.

As this book is primarily a work of synthesis, I am indebted to a large number of people whose work has provided the pieces of the jigsaw puzzle I have attempted to fit together. Although there have been numerous discussions and some arguments about how they fit together, what has struck me throughout the thirty years I have been thinking about these issues is peoples profound sense of commitment to their work, to its social purposes, and to concepts of social justice that have motivated the long hours of painstaking research work. Rarely, if ever, have disagreements been about trivial or unworthy issues. As a result, and despite usually working alone, I have felt part of a wider community bound together not only by a commitment to research on health inequalities and the determinants of health and well-being in the population, but also by the issues of social justice they raise. I therefore feel a deep sense of gratitude to a network of supportive friends and colleagues, and to a few whose interpretations have made them formidable rivals.

Despite the danger that such a long list of names will lead to an expectation that it will end and Uncle Tom Cobbley and all, I would like to express my special thanks to the following for the way they havein different combinationsaffected my thinking, set admirably high standards in research, shown me kindness and support, and done the research on which I draw: Mel Bartley, Lisa Berkman, Stephen Bezruchka, David Blane, Mildred Blaxter, Martin Bobak, Eric Brunner, Simon Charlesworth, Helena Cronin, George Davey Smith, Angus Deaton, David Donnison, Danny Dorling, Jim Dunn, David Erdal, Sarah Fan, Luisa Franzini, Paul Gilbert, Pam Gillies, David Halpern, Clyde Hertzman, Ichiro Kawachi, Shona Kelly, Bruce Kennedy, Margareta Kristenson, Barbara Krimgold, Di Kuh, Anton Kunst, Peter Lobmayer, David Lowe, Johan Mackenbach, Michael Marmot, Sally McIntyre, Kate Pickett, Chris Power, Pauline Rosenau, Nancy Ross, Robert Sapolsky, Mary Shaw, Aubrey Sheiham, Carol Shively, Johannes Siegrist, Alvin Tarlov, Roberto de Vogli, Mike Wadsworth, Patrick West, David Williams, Michael Wolfson, and Alison Ziller. The world would be a poorer place without them and the contributions they have made to the development of a new field that brings the benefit of scientific investigation to bear on one of the key issues of social justice facing modern societies.

Over the years I have been supported financially by both the Economic and Social Research Council and the Medical Research Council in Britain, by several charitiesincluding the Baring Foundation and the Paul Hamlyn Foundationand, most recently, by the University of Nottingham. Without the universitys (and my departmental colleagues) forbearance, I would never have completed this volume.

Affluent Societies

Within each of the developed countries, including the United States, average life expectancy is five, ten, or even fifteen years shorter for people living in the poorest areas compared to those in the richest. This huge loss of life, reflecting the very different social and economic circumstances in which people live, stands as a stark abuse of human rights. Although we tend to assume that class differences have been diminishing in modern societies, during the last few decades the health differences between classes have increased. They reveal such a gulf between the lives and experience of rich and poor, well educated and less well educated, and, through the same social and economic stratification, different racial or ethnic groups, that they call into question the humanity, morality, and values of modern societies.

This book is not a guide to the dos and donts of healthy behavior. Instead, it uses the research on these health differences to explore the effects social and economic inequality have on us as individuals and on whole societies. An understanding of such gross effects of social stratification takes us to a deeper understanding of the societies we live in. Because health standards are most powerfully determined by social factors, it takes us to the roots of the social malaise affecting many of the richest societies and suggests the kind of changes that are likely to increase not only the length of life but, much more importantly, the subjective social quality of life for all of us.

With the provision of sewers and clean water supplies, the public health movement of the nineteenth century led to a transformation of the physical environment in our cities. Our growing understanding of the social determinants of health in modern societies has the potential to usher in another, more fundamental transformation in the quality of our lives. By identifying what it is about the social structure that does the damage, we initiate a program of reform that will allow future generations, with the benefit of hindsight, to see how disfigured our societies and social relations really were.

A family photo taken almost ninety years ago shows my mother as a baby sitting on her grandmothers knee. My mother, now also age ninety, is still alive; her grandmother, on whose knee she was sitting, was born in 1826. (In case that sounds as if it stretches the time limits on female reproductive capability, I should point out that the connection between them is through my mothers father.) Eighteen twenty-six was three years before Stephensons Rocket, the primitive steam engine that, pulling a load at thirteen miles an hour, won its historic victory by demonstrating the potential of mechanical over animal power. These two overlapping lives stretch from the dawn of mechanical power to a world in which air travel has shrunk what were once long and dangerous voyages by sail to a few hours; they stretch from before the first integrated national postal service to modern global electronic communications. They also stretch over equally large social and political changes: from when slavery was still widespread and public executions and floggings were common even for minor crimes to the present, when in all the more progressive developed countries (including all members of the European Union but excluding the United States) all forms of corporal and capital punishment are banned, and teachers and sometimes even parents are not allowed to slap children.

Despite the extraordinary speed of change, the economic growth rates that drove so much of this forward would now be regarded as little better than stagnation. Throughout the worlds first industrial revolution, which took place in Britain, economic growth rates rarely exceeded 1 percent a year. Growth rates now have to be at least three times that to be regarded as respectable, and a few countries grow ten times as fast. Remarkable though the extraordinary transformations of the recent past are, the pace of change is accelerating.

To match this, our thinking has to be radical. From a time when it took a generation or two for what was beyond imagination to become reality, we now find that what was unthinkable in our early adulthood becomes reality before the end of our lives. This means that we have to think ahead on the grand scale, grasping the essential dynamics of the forces that are driving our society forward, asking not only where they are taking us but where we want to go, what we can do to avoid the worst pitfalls, and how we can steer our societies toward happier outcomes.