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Keith Rankin: The Health Costs of Inequality

Keith Rankin's Thursday Column
The Health Costs of Inequality
2 March 2000

Yesterday the Herald's editorial writer criticised Jim Anderton's regional development plan - announced on 29 February. The Herald sees Anderton's approach as a trade-off between efficiency (or "competitiveness" which is not always the same thing) and "internal equity - or equal relative poverty". ("Equal relative poverty" here means that we are all poor relative to the populations of the countries we trade with.)

It would be useful if more politicians and newspaper editors could read Richard Wilkinson's 1996 book Unhealthy Societies; the Afflictions of Inequality. After trawling through much of the world's public health literature and health statistics, Wilkinson (a British economic historian) concluded that life expectancy and other health outcomes show a strong and direct functional relationship with internal (but not international) relative poverty. Neither diet, absolute income, nor the quality of medical services have much impact on death rates. Where poor diets or bad habits (eg smoking) could be shown to play some role in inducing premature death, there were strong indications that it was the stresses of relative poverty that played a major role in inducing people to overeat, to smoke, or to otherwise take foolish risks with their lives.

Societies with longevity have (i) a relatively equal income distribution, and (ii) a high degree of social cohesion; "social capital" if you will. A society that wishes to have a happy, healthy and prosperous population is a society that makes the reduction of income inequality its number one economic policy objective.

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Not only would a society that had the political will to distribute income equitably have fewer social or medical problems. Such a society would also have faster economic growth. Wilkinson cites a number of studies that reveal much more than a correlation between equity and growth; they reveal that more equity causes more growth. The Herald is quite wrong to argue - as many economists do - that equity can only be bought by having less economic growth.

Wilkinson shows that all except the poorest few countries have made huge gains in life expectancy during the 20th century. The gains are not caused by rises in nations' GNPs (gross national product). Rather the improvements have been due to a kind of "qualitative" economic growth that has diffused around the world. Almost all countries have benefited from this kind of globalisation of civilisation, regardless of their economic performances as defined by levels of GNP per person.

Many poor countries in 1990 had higher life expectancies than many rich countries in 1960. Although sensitive to the passage of time, life expectancy differs little between poorer countries and richer countries. For any particular year, a nation's inequality was the only reliable predictor of its average life expectancy. A nation in which only the top few percent of the population experienced economic growth would show a slower rate of life expectancy gain than a nation in which no social groups experienced economic growth.

Wilkinson explained his research findings through a kind of norm-referencing process that individuals use to interpret their own lives. People who believe that they are failing with respect to the perceived norms of their society are much more likely to die of cancer or coronary disease or infectious diseases or (of course) suicide than are people who rate themselves as successful. Homo sapiens is an inherently social species, and health outcomes are governed by what Wilkinson calls "psychosocial" processes. Indeed, we evolved through economic systems based on mutual cooperation and gift exchange, not through systems based on private property, impersonal market forces and the conflict.

Put bluntly, stress kills. And inequality is the major source of stress. While Wilkinson concludes that inequality imposes stress on the rich as well as on the poor, he notes that the so-called "diseases of affluence" (eg cancers, heart attacks) are diseases in the main of the relatively poor who live in relatively affluent countries.

I recently read that Japanese immigrants in North America have significantly higher rates of prostate cancer than do Japanese in Japan. I understand that this is also true for breast cancer. It is usually taken to be that the change from a Japanese to an American diet has caused the higher cancer rates. Wilkinson's research offers an alternative explanation; namely that Japanese migrants get more cancers because they are migrants. Not only is migration a highly stressful process, the lesser degree of social standing in the new country compared to one's country of birth means that an immigrant is more likely to feel excluded. (In the Industrial Revolution, rural to urban migration was undertaken on a massive scale. Cities became death traps. Similar migration is happening within China today. New arrivals in cities always have higher death rates than the established urban populace.)

According to a feature article in the Sunday Star-Times of 20 February, five midwives aged under 50 employed at Auckland's National Women's Hospital have died of cancer in recent years. Eight others have been diagnosed with cancer. Down the road at Middlemore, the midwives are cancer-free. There appears to be no plausible cause for the NWH cancers other than "stress" or "coincidence". Wilkinson's findings favour stress over coincidence. Most probably there is something wrong with the workplace culture at NWH, or at least the culture as it affects midwives.

At the level of the nation, he sees the excessive numbers of deaths in America and Britain (and by implication New Zealand, which is cited as a country with record inequality growth in recent years) compared to say Sweden and Japan as being due to the Anglo-Saxon culture of market pre-eminence; a culture of winners and losers, a culture of exclusion. It follows from his reasoning that where undermining cultures exist in specific communities or workplaces, then those communities will have particularly poor health outcomes. After all, stress is the process of being undermined.

It is entirely appropriate that economic and social policy should be integrated. Reductions in inequality need to become the major policy goal in any society that suffers from too many people being prevented from living according to the perceived norms of their society. Relative equality is not only an end in itself, however. It is also a powerful means to achieve economic performance targets that neoliberal politicians and bureaucrats advocate but rarely deliver.

Wellbeing follows when the social "horse" is placed before the economic "cart". Jim Anderton should be applauded for his pursuit of economic development as a social process.

© 2000 Keith Rankin

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