Unhealthy Societies: The Afflictions of Inequality [Paperback]

Unhealthy Societies: The Afflictions of Inequality, by Richard Wilkinson, is a clear, multifaceted description of research into the patterns of disease, violence, and death between and within societies.

Wilkinson reviews the global patterns of disease and death historically, where the trend is down. Countries which have attained a modest degree of affluence have gone through the `epidemiological transition' where the primary causes of death are no longer infectious, but the `diseases of affluence' the degenerative diseases He then reviews changes between societies, showing that some have large divergence in death rates as a function of income and that others do not. The difference is a function of the spread of income within the society. This pattern applies to the states of the US as well as among nations. . Above a certain level, the prime factors which determine health are relative, not absolute income.

He then cites data on the differences in death rates within societies as a function of income. For example, British civil servants in the lowest income categories have 4 times the rate of death from heart disease as those in the highest income categories. This pattern is shown to apply to homicides, and reading failure as well as a large number of medical conditions.

Another chapter deals with the level of cooperation in human societies in prehistory, versus the atomization and Hobbesian conflict, which is seen as normal and inevitable today. He also reviews studies which show that much of what we call human nature has been shown to be inference from our own behavior and is very sensitive to changes in situation.

He then looks at the societies beyond the epidemiological transition and inquires into the mechanisms by which the poorer folks in society might be afflicted with disease. He concludes that it is due to psychosocial factors and particularly chronic stress. That the lower you go in society, the more fear you have of unemployment and destitution. Also you have less space to live in, less education, and are surrounded by more stressed people. Stressed people have lower self-esteem and for instance are much less likely to be able to give up smoking. Short-term pleasures, such as comfort foods, become harder to refuse. He also relates some studies about the correlations between family discord in childhood and adult health problems, and depression in mothers and children's accident rates. "To feel depressed, cheated, bitter, desperate, vulnerable, frightened, angry, worried about debts or job and housing insecurity; to feel devalued, useless, helpless, uncared for, hopeless, isolated, anxious and a failure: these feelings can dominate people's whole experience of life, colouring their experience of everything else. It is the chronic stress arising from feelings like these which does the damage."

Wilkinson points out with classic British understatement - "If the aim is to improve the welfare [health] of populations, it would be unwise to try to treat the psychosocial symptoms without reducing the underlying scale of relative deprivation." Recovering his voice he adds: "As the powerful logic of the market extends its tentacles ever wider, it is easy to think of economics as a mental illness which leads to the perception of all human behavior as springing from an egotistical desire to maximize consumption." "The public sphere in [healthy and egalitarian] societies seem to be incorporated in social life rather than being abandoned to the negative market relations between self-interested households".

Turning to solutions, he points out that "To want continuous growth in order so solve problems of [unemployment, income insecurity and increased profits] is merely a form of addiction: during the economic highs the problems are temporarily solved only to return in the next recession. The problems which the economic upturns seem to solve need a more fundamental and durable solution which would hold even in the absence of growth." "If we could use a dose of egalitarianism to turn the idea of civilisation into and inclusive rather than an exclusive concept, we would perhaps have an idea of the social conditions for health." "Rather than relying on providing more special needs classes in schools, more prisons and police, more social workers and health services, more counsellors and therapists, we have to tackle at root some of the main causes of the problems with which they attempt to cope. Even if we could afford vast armies of counsellors and community development workers with a small team for every street, there is no reason to think that it is possible to separate the structural causes from their social symptoms." Wilkinson concludes with: "Action does not depend simply on a sense of altruistic concern for the welfare of a minority. The majority cannot enjoy life oblivious to these problems: they affect the quality of life for all of us."

This is a brilliant book, pulling together much data which illuminates the causes of the diseases we experience in our everyday lives. Pediatricians in particular see this and when we are not moralizing, wonder why it is. Wilkinson shows that an egalitarian society where people see each other as partners rather than opponents, as interdependent rather than independent, is healthier and generally wealthier.

Much ink has been used in the last 25 years to talk about the `new' pediatrics. Many pediatricians have expanded their practices beyond the organic diseases to look into the individual stresses and dysfunctions of families seeing them as factors contributing to the diseases we see in our patients. What Wilkinson does is to look beyond the individual stresses to the social stresses. He takes a public health view of stress disease and how it affects us all. In my opinion pediatricians should add this dimension to their work with families and in society. We fail our professional duty if we ignore these pathogens as outside our purview.

Karl W. Hess, M.D., FAAP

He carefully outlines the research that indicates that it is not the wealth of nations that determines health, but rather how this wealth is distributed. He also describes the processes by which economic inequality becomes translated into societal malaise and societal disintegration.

Using many examples from the United States and the United Kingdom, he documents that states and areas that have relatively greater inequality of wealth show greater signs of societal disintegration involving higher crime rates, poorer health, and greater incidence of violence.

Unhealthy Societies: the Afflictions of Inequality suggests that health education and health promotion approaches that ignore broader social issues are doomed to failure. He also suggests that societies that ignore these issues are also destined for increased malaise.

The book should be required reading for health workers, policy and welfare analysts, and government officials and politicians. It should be especially useful as a text in the health and social sciences.

Wilkinson defends his thesis with a mountain of empirical evidence and not a little bit of style. His gift for elegant and persuasive prose makes his complex reasoning seem simple, almost commonsensical. The end result is a truly refreshing rationale for a sort of democratic socialism, one that is neither dogmatic nor ideological, but rather is based on social fact, in the Durkheimian sense.

In Richard Wilkinson we have a rare gift: a social scientist who is careful with his evidence yet is not afraid to take on truly transcendental questions. It's a shame his research isn't more widely read and cited.