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Inequality, Health and WellbeingRichard Wilkinson
Emeritus professor of social epidemiology
Individual differences will explain who falls, but the height of the hurdles will explain how many fall
Walker, R. et al.Poverty in global perspective.
Journal of Social Policy 2013; 42, 215-233
The Effect of Caste Identity on Children's Performance
Caste Unannounced
Caste Announced
0
1
2
3
4
5
6
High Caste
Low Caste
Num
ber o
f maz
es s
olve
d
Source: Hoff K, Pandey P, World Bank Policy Research Working Paper 3351, June 2004
Status differentiation effects cognitive performance
Chart1
5.545.72
6.114.28
High Caste
Low Caste
Sheet1
High Caste5.546.11
Low Caste5.724.28
Sheet2
Sheet3
Life expectancy and GDP per person
www.equalitytrust.org.ukWilkinson & Pickett, The Spirit Level
Life expectancy in rich countries is no longer related to National Income per head
70
71
72
73
74
75
76
77
78
79
80
Local Neighbourhoods(in England & Wales)
Life
exp
ecta
ncy
(yea
rs)
Richest Poorest
Wilkinson & Pickett, The Spirit Level www.equalitytrust.org.uk
Life expectancy is strongly related to income within rich countries
Carol Shively studies macaques in captivity
Social hierarchy in non-human primates
Robert Sapolsky studies baboons in the wild
3.7 3.94.3 4.6
4.8 5.25.3 5.6 5.6 5.6 5.7
6.1 6.26.7 6.8 6.8
7.2
8.5
9.7
4.0
8.07.0
3.4
Japa
nFi
nlan
dNo
rway
Swed
enDe
nmar
kBe
lgiu
mAu
stria
Germ
any
Neth
erla
nds
Spain
Fran
ceCa
nada
Swizt
erla
ndIre
land
Gree
ceIta
lyIs
rael
New
Zeal
and
Aust
ralia UK
Portu
gal
USA
Sing
apor
e
Income gapsHow many times richer are the richest fifth than the poorest fifth?
Wilkinson & Pickett, The Spirit Level www.equalitytrust.org.uk
Inequality...How much richer are the richest 20% in each country than the poorest 20%?
Wilkinson & Pickett, The Spirit Level
Index of: Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness
incl. drug & alcohol
addiction Social mobility
www.equalitytrust.org.uk
Health and social problems are worse in more unequal countries
Inde
x of
hea
lth a
nd s
ocia
l pro
blem
s
Low Income Inequality (Gini) High
UN
ICEF
Inde
x of
Chi
ld W
ellb
eing
Child Wellbeing is lower in more unequal countries
Pickett & Wilkinson, Pediatrics 2015; 135 (1): S39-S47
Death rates of men 25-64yrs & income inequalityUS states and Canadian provinces
Ross, Wolfson, Dunn, Berthelot, Kaplan, Lynch. British Medical Journal 2000;320:898-902
Dea
ths
per 1
00,0
00 p
opn
Income inequality (median share)
http://www.bmj.com/content/vol320/issue7239/images/large/rosn4890.f1.jpeghttp://www.bmj.com/content/vol320/issue7239/images/large/rosn4890.f1.jpeg
www.equalitytrust.org.ukWilkinson & Pickett, The Spirit Level
Mental illness is more common in more unequal societies
www.equalitytrust.org.ukWilkinson & Pickett, The Spirit Level
Imprisonment rates are higher in more unequal countries
Data from Corak (2013), World Bank (2013)
Lancee B, Van de Werfhorst HG. Income inequality and participation: A comparison of 24 European countries. Social Science Research. 2012; 41(5):1166-78.
Participation in local groups and voluntary organisations is lower in more unequal societies.
Civ
ic p
artic
ipat
ion
scor
e
Income inequality (MDMI)
Wilkinson & Pickett, The Spirit Level www.equalitytrust.org.uk
People in more unequal countries trust each other less
0
30
60
90
120
150
180
Income Inequality
Hom
icid
es p
er m
illio
n pe
ople
Low High
Daly M, Wilson M, Vasdev S. Income inequality and homicide rates in Canada and the United States. Can J Crim 2001; 43: 219-36.
Homicide rates are higher in more unequal US states and Canadian provinces
USA states
Canadian provinces
Chart1
158.6200227956
136.6553734085
133.3989753432
128.7166700272
127.774288225
131.6498947648
126.4581603634
112.6480730374
107.9250623775
104.566284719
118.5305572779
108.1828588705
104.8845221654
109.6285026311
107.7536068044
94.6083664474
84.683751948
83.1567003131
65.538845896
65.5869525509
63.673812733
82.8964301803
99.5398321064
112.6456008603
66.1382962694
59.3664702276
56.857568076
50.5273271359
54.3634675933
47.0735748489
48.4945493689
52.2776469299
52.2825810879
56.5479713571
49.2543782229
43.8258126217
39.3482638454
34.6264846114
15.0190103974
27.2416075065
28.1827561813
31.7068210371
21.7723327911
23.4128666994
35.3887661543
38.4305376353
39.1373243559
28.4911137432
33.6261057919
26.9393735331
8.7935328878
17.3995828531
7.2874765973
16.8247998769
19.4348563444
33.1117377058
31.7512100001
25.382727261
22.8355860233
29.6764933112
Low
High
Income Inequality
Homicides per million people
Sheet1
Set 1Set 2Active
Points=50Points=10
xyxy
0.4719782826158.6200227956
0.4667037049136.6553734085
0.4475541778133.3989753432
0.4505041732128.7166700272
0.4505082991127.774288225
0.4376747865131.6498947648
0.43684308126.4581603634
0.4458140923112.6480730374
0.444736209107.9250623775
0.4387698592104.566284719
0.4217420562118.5305572779
0.4236182939108.1828588705
0.423632734104.8845221654
0.4267855862109.6285026311
0.4277702933107.7536068044
0.432588275394.6083664474
0.429702228584.683751948
0.441793087683.1567003131
0.446996837965.538845896
0.451757059165.5869525509
0.425644087763.673812733
0.416039067482.8964301803
0.407665962499.5398321064
0.3989421576112.6456008603
0.389746955266.1382962694
0.395757658159.3664702276
0.403946822256.857568076
0.407026094350.5273271359
0.413600670154.3634675933
0.414975269947.0735748489
0.415701423648.4945493689
0.417027548552.2776469299
0.417515776552.2825810879
0.419938351356.5479713571
0.420946780349.2543782229
0.419994046143.8258126217
0.419891585339.3482638454
0.418935756634.6264846114
0.41377290715.0190103974
0.410911966227.2416075065
0.410785783828.1827561813
0.409793857531.7068210371
0.405931349721.7723327911
0.405069731323.4128666994
0.401111308435.3887661543
0.399022931738.4305376353
0.399019837639.1373243559
0.39467219628.4911137432
0.389889283133.6261057919
0.381007998926.9393735331
0.35728526238.7935328878
0.369575893117.3995828531
0.37145109497.2874765973
0.382639087316.8247998769
0.384458597819.4348563444
0.385619350533.1117377058
0.390873989931.7512100001
0.390169494125.382727261
0.394574891122.8355860233
0.395399381429.6764933112
Sheet2
Sheet3
Cuernavaca, Mexico
Armed Response - Pretoria, South Africa.
Bowles & Jayadev, NYT 2014
Prot
ectiv
e se
rvic
e em
ploy
ees
per 1
0,00
0 w
orke
rs
Societies with wider Income differences need more guard labor
The proportion of guard labor grew with inequality.USA 1979-2000
Inequality (Gini)
Bigger material differences create bigger social distances and increase social class differentiation
24
Literacy Scores of 16-25 year olds by Parents' Education
-1.5
-1
-0.5
0
0.5
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Parents' Education (years)
Lite
racy
sco
re
Sweden
Canada
United States
Source: Willms JD. 1997. Data from OECD Programme for International Student Assessment.
0
10
20
30
40
50
Low High Low High Low High Low High Low HighEngland
England USA
Diabetes Hypertension Cancer Lung disease Heart disease
Self-reported prevalence of illness by education
%
Source: Banks et al. JAMA 2006; 295: 2037-2045
0
5
10
15
Singlemothers
Low HighFather's occupational class
Infa
nt d
eath
s pe
r 10
00 England & WalesSweden
Leon, D. A., D. Vagero, et al. (1992). "Social class differences in infant mortality in Sweden: comparison with England and Wales." Brit Med J 305(6855): 687-91.
The benefits of greater equality are not confined to the poor but extend to all social classes
Infant mortality by class: Sweden compared with England & Wales
Layte R, Whelan CT. Who Feels Inferior? A Test of the Status Anxiety Hypothesis of Social Inequalities in Health. European Sociological Review, 2014.
Status Anxiety across income deciles for high, medium and low inequality countries
Stat
us A
nxie
ty
Income deciles
High inequality
Medium inequalityLow inequality
Countries with:-
0
0.2
0.4
0.6
0.8
1
Other tasks
Tasks with social evaluative threat (uncontrollable)
Cor
tisol
resp
onse
(effe
ct s
ize)
Dickerson SS, Kemeny ME. Acute stressors and cortisol responses. Psychological Bulletin 2004; 130(3): 355-91.
What kind of stress cause the biggest rise in stress hormones?
The Dominance Behavioural System
Johnson SL, Leedom LJ, Muhtadie L. The Dominance Behavioral System and Psychopathology.
Psychological Bulletin, 2012; 138(4): 692-743.
Findings:-
Anxiety and depression are related to subordination, to submissiveness and to the desire to avoid subordination.
Mania and narcissistic traits are related to inflated self-perceptions of power.
Externalizing disorders, mania proneness, and narcissistic traits are related to heightened dominance motivation and behaviour.
Messias E, Eaton WW, et al. . Economic grand rounds: Income inequality and depression across the United States: an ecological study." Psychiatric Services, 2011; 62(7): 710-2.
Depression is more common in more unequal statesPe
rcen
t of p
opul
atio
n de
pres
sed
in p
ast 2
wee
ks
Income Inequality (Gini)
Burns JK, et al.. Int J Soc Psychiatry, 2013; 60(2), 18596.
Income inequality and schizophrenia
Loughnan S, et al. Economic Inequality is linked to biased self-perception. Psychological Science, 2011; 22: 1254
Self enhancement increases in more unequal societies
Two recent studies show that inequality increases conspicuous consumption and
consumerism
People in more unequal areas of the USA are more likely to buy high status cars
Data from internet searches shows that people in more unequal states are more likely to search for status goods
Iacoviello M. Household Debt and Income Inequality, 19632003. Journal of Money, Credit and Banking 2008;40(5):929-65.
Household Debt and Income Inequality USA
Gains of the past are being undone
Taylor-Robinson D, Whitehead M, Barr B. BMJ 2015
Changes in death ratesof pensioners aged over 85 by local authority 2011-12
Loopstra R, et al.. Austerity and old-age mortality in England: a longitudinal cross-local
area analysis, 20072013.Journal of the Royal Society of Medicine2016;109.3: 109-116.
Fig 1 Infant mortality rate (95% confidence interval) by socioeconomic classification, 2008-15.
David Taylor-Robinson, and Ben Barr BMJ 2017;357:bmj.j2258
2017 by British Medical Journal Publishing Group
Belfield C, Cribb J, Hood A, Joyce R. Living Standards, Poverty and Inequality in the UK: 2015. (Institiute for Fiscal Studies, 2015).
Trends in Income inequality Gini and 90:10 ratio. Institute For Fiscal Studies, BHC, GB.
USA
UKGermany
IrelandAustralia
SwedenNetherlands
Percent of all income going to top 1% 1930-2014
Source: World Top Incomes Database
% o
f inc
ome
rece
ived
by
riche
st 1
%
Colin Gordons analysis of Historical Statistics for the US, unionstats.com, Piketty and Saez 2003, and World Top Incomes Database. Economic Policy Institute, Washington DC.
Trade Unions membership (% workforce) and Share of Income going to top 10% (USA, 1918-2008)
40
Mishel L, Sabadish N. Economic Policy Institute Brief #331. Washington, May 2012
Changing ratio of CEO pay to average pay of production & non-supervisory workers in top 350 US companies
Between 1979-2007 the income of the:-Top 0.1% increased by 362%Top 1% increased by 156%Bottom 90% increased by17%
Companies paying CEOs above the median performed less well than those paying below the median
Marshall R, Lee L. Are CEOs paid for performance? MSCI 2016
10yr performance of 429 large publicly quoted companies
Cum
ulat
ive
shar
ehol
der r
etur
ns
What can be done?
Taxes & benefits
Stop tax avoidance
End tax havens
Make taxation progressive again
Income differences before tax
Increase economic democracy -employee ownership etc
Strengthen trade unions
Economic democracy:-
turns companies from being pieces of property into communities
reduces pay ratios within companies transforms the experience of work redistributes wealth & reduces unearned income improves productivity makes companies more environmentally &
socially responsible
Boards can include employee, community and consumer representatives
45
The Effects of Income inequality
EVIDENCE OF CAUSALITYPickett KE, Wilkinson RG. Income inequality and health: a causal review. Social Science & Medicine 2015;128: 316-26
THEORY & PSYCHOSOCIAL PROCESSESWilkinson RG, Pickett KE. The enemy between us: The psychological and social costs of inequality.European Journal of Social Psychology, 2017; 47, 11-24. http://dx.doi.org/10.1002/ejsp.2275
CREATING THE SOCIETY WE WANTWilkinson RG, Pickett KE. A Convenient Truth: A Better Society for Us and the Planet. Fabian Society, London 2014. http://www.fabians.org.uk/publications/a-convenient-truth/
http://dx.doi.org/10.1002/ejsp.2275
Local Authority Budget cuts 2010-11 to 2014-15 and premature mortality
Taylor-Robinson D et al. BMJ 2013; 347: bmj.f4208
Premature mortality rate (
The index of health inequality measures the proportion of illness that correlates with income status. Source: Hertzman C. American Scientist, 2001; 89 (6): 538-45
Life expectancy is worse where health inequalities are larger
Doorslaer E. et al. J Health Economics 1997; 16: 93-112
Health inequalities are larger where income differences are larger
OECD (2015), "In It Together", http://www.oecd.org/social/in-it-together-why-less-inequality-benefits-all-9789264235120-en.htm.
Income Inequality 1995-2012
Carol Shively studies macaques in captivity
Social hierarchy in non-human primates
Robert Sapolsky studies baboons in the wild
Plasma fibrinogen by employment gradeamong Civil Servants, Whitehall II.
Brunner E, Davey Smith G, Marmot M, et al. Lancet 1996; 347: 1008-1013
(Adjusted for age, ethnic origin and womens menopausal status)
Womens preference for more masculinized faces is stronger in more unequal societies
Brooks R, Scott IM, et al. Proceedings of the Royal Society, B, 2011; 278: 810 12
56
Psychosocial risk factors for ill health
Low social status
Weak social connections
Stress in early life (pre- & post-natal)
The Jekyll & Hyde of Public Health?
Friendship in contrast, is based on reciprocity, mutuality, social obligations, sharing and a recognition of each others needs.
Social status (dominance hierarchies, pecking orders) are orderings based on power, coercion and privileged access to resources regardless of the needs of others.
Companion Spanish: Compaero; French: Copain
from the Latin Con (with) and Pan (bread)
- someone with whom you eat bread
Marshall Sahlins, Stone Age Economics (1974)
Gifts make friends and friends make gifts
Brands owned by the big ten food multinationals
Oxfam and ww.behindthebrands.org
Kondo et al, BMJ, 2009; 339: b4471
Inequality and mortality over time: multilevel cohort studies
Time lags between changes in inequality and changes in health
Zheng H. Do people die from income inequality of a decade ago? Social Science & Medicine 2012;75(1):36-45.
Lillard DR, Burkhauser RV, Hahn MH, Wilkins R. Does early-life income inequality predict self-reported health in later life? Evidence from the United States. Social Science & Medicine 2015;128(0):347-55.
Charles Cooley (1864-1929)
Many people of balanced mind and congenial activity scarcely know that they care what others think of them, and will deny, perhaps with indignation, that such care is an important factor in what they are and do. But this is an illusion. If failure or disgrace arrives, if one suddenly finds that the faces of men show coldness or contempt instead of the kindliness and deference that he is used to, he will perceive from the shock, the fear, the sense of being outcast and helpless, that he was living in the minds of others without knowing it, just as we daily walk the solid ground without thinking how it bears us up.
Human Nature and the Social Order. 1902, p.207
Alan Bennett, Untold Stories, Faber/Profile, 2005
(My parents) putdownmost of their imagined shortcomings to their not having been educated, education (was) to them a passport to everything they lacked: self-confidence, social ease and above all the ability to be like other people.Put simply and as they themselves would have put it, both my parents were shy, a shortcoming they thought of as an affliction while at the same time enshrining it as a virtue.I assured them, falsely, that everybody felt much as they did but that social ease was something that could and should be faked.Well, you can do that, Dad would say, you've been educated, adding how often he felt he had nothing to contribute. I'm boring, I think. I can't understand why anybody likes us. I wonder sometimes whether they do, really.
School bullying is much more common in countries with bigger income differences.11-year-olds in 37 countries (r = .62)
Elgar FJ. et al. School bullying, homicide and income inequality. International Journal of Public Health 58, 237-245, 2013.
Income inequality (Gini)
% o
f 11y
r old
s w
ho b
ullie
d ot
hers
tw
o or
mor
e tim
es p
er m
onth
66
Teenage Birth Rates are Higher in More Unequal Rich Countries
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
Credit Lyonnais Securities Asia. Bloomberg Businessweek
Rank total shareholder return in relation to CEO pay rankamong Australias largest 200 companies
Stoc
k re
turn
rank
CEO pay rank
Slide Number 1Slide Number 2Slide Number 3Slide Number 4Status differentiation effects cognitive performanceSlide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Health and social problems are worse in more unequal countriesSlide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Gains of the past are being undoneSlide Number 36Slide Number 37Slide Number 38Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51Slide Number 52Slide Number 53Plasma fibrinogen by employment gradeamong Civil Servants, Whitehall II.Slide Number 55Slide Number 56Slide Number 57Slide Number 58Slide Number 59Slide Number 60Inequality and mortality over time: multilevel cohort studiesSlide Number 62Slide Number 63Slide Number 64School bullying is much more common in countries with bigger income differences.11-year-olds in 37 countries (r = .62)Slide Number 66Slide Number 67Slide Number 68