Introduction

What policies and values influence inequalities of health of individuals and populations? There are two main interpretations: a “materialist”, and “psycho-social”(Coburn D, 2000). It is suggested that the more a regime is neo-liberal, the bigger are the inequalities in income. The more a society is market oriented, the smaller is the trust and social-cohesion.

It has been known for a long time that there is an inverse proportion between the socio-economic conditions and the state of health of a population. In the majority of industrialised countries health inequality has not been reduced despite the improvement of welfare, as reflected by, among others, life expectancy.

The latest report on health inequality in England (Department of Health, London, 1998) analyses among other things the mortality rate over the last 30 years, through all causes and a series of specific causes, correlating it with six different population groups selected according to kind of work they do.

Figure 1 gives the mortality rate from all causes among the male population of 20-64 years, taken from the years 197072, 1979-83 and 1991-93.

The graph shows that: a) the mortality rates of the six social classes register an order that is inversely proportional to the level of social class; b) clear-cut differences are seen between professionals and technician-managers, who register the lowest mortality rates, specialised and semi-specialised, who occupy a middle position; and the non-specialised who have the highest mortality rates; c) in the space of 20 years the mortality rates diminished in all the classes, but the gap between the richer and poorer classes widened considerably; between the early 70s and 90s the mortality rates fell by 40% in classes I and II, by 30% in classes IIIN, IIIM and IV, and only by 10% in class V.

These growing differences in state of health among the various social groups are also reflected in the specific causes of death: coronary disease, stroke, lung cancer, and suicide among the men, and respiratory diseases, coronary disease and lung cancer among the women. These differences in the mortality rates are reflected in the differences in life expectancy at birth between rich and poor classes: by five years among the men (75 instead of 70), by three years for the women (80 instead of 77).

Similar tendencies are found in the USA where, analysing the state of health (expressed in healthy life expectancy at 30) of various population groups –whites and Afro-Americans with different levels of education –growing inequalities are registered both between the two racial groups, and within themⁱ Crimmings E and Saito Y (2001). (figures 2 and 3).

The “neo-materialist”theory sustains that a society with major income inequalities will have a higher percentage of persons with a low income and, as has been amply demonstrated, that individual income is strongly associated with individual differences in health, the high prevalence of the poor in a society explaining the low levels of health of the population. According to this vision, health inequalities are the result of different accumulation of exposure and experiences that have their roots in the material world. The effects of inequalities of income on health are the consequence of a combination of negative exposure and a lack of individual economic resources associated with a systematic low investment in a whole series of human, physical, health and social infrastructure.

The unequal distribution of income is the result of historical, cultural, political and economic processes. These processes influence the availability of private resources to individuals and determine the nature of public infrastructure for education, health care services, transport, control of the environment, availability of food, quality of housing, rules and regulations in the workplace –in short, everything that makes up the “neo-material matrix”of contemporary life.

Therefore, inequality of income is a manifestation of a package of “neo-material”conditions that influence the health of the population. Strategic investments in neomaterial conditions through a more just and equitable distribution of public and private resources can ensure the greatest impact in reducing inequalities in health and improve public health both in rich and poor countries in the 21^st century, Lynch J.W et al (2000).

Starting from the statement that health in a society is correlated with income, supporters of the “psycho-social”theory offer an interpretation that is profoundly different from the previous one. In those that find themselves on the lower rungs of the social scale, inequalities of income create a set of negative emotions, such as shame and lack of self-respect, which become precarious states of health through psycho-neuro-endocrine mechanisms and health-destroying forms of behaviour.

Wilkinson (2000) suggests that consuming goods for reasons other than satisfying the primary needs serves to satisfy individuals on a social, psycho-social and symbolical level. Consuming goods expresses identity. One’s image is enriched by possession. Buying is a real therapy. Wellbeing is a marker of social status, success and respectability, in the same way as poverty is stigmatised. In work, the highest incomes are associated with lower subordination, greater autonomy and control, and less danger of unemployment.

Marx’s paleo-materialism (as quoted by Marmot and Wilkinson, 2001) also recognised the psycho-social effects of inequality of income: “A house can be large or small. As long as all the surrounding houses remain just as small, that will satisfy all the social needs of living. But if a house is built next to a little house, that house will become tiny until it looks like a hut and those living in it will feel worse and worse, more and more unsatisfied and cramped inside those four walls”The greater the inequalities of income, the greater the phenomena of racism and discrimination of women.

There is a real “culture of inequality”that is more aggressive, less sociable, more violent and more suspicious. Persons with less egalitarian values reveal themselves to be more class-conscious and racist. In support of this thesis Wilkinson gives numerous figures among which the difference in life expectation at birth between blacks in the USA, 66.1 years, and the inhabitants of Costa Rica, 75 years, despite the fact that the former enjoy an average income pro-capite of 26,522 $ as against the 6,410 $ the latter. An income four times higher “buys”a life expectancy of 9 years less.

The explanation for the precarious conditions of health of Afro-Americans is in the psycho-social effects of a relative deprivation, which is accompanied by educational disadvantage, racism, gender discrimination, social and family disintegration, and fear of criminality, more than the direct effects of material conditions (Wilkinson 2000). The distinction between the direct effects of material conditions (malnutrition, cold, air and water pollution) on health and the psycho-socially mediated effects of this deprivation have important political implications. If, in the spirit of neomaterialism, every child is given access to a computer and every family a car, if air and environment pollution is reduced, have we resolved the problem? We do not believe so.

The psycho-social effects of the deprivation that causes insecurity, anxiety, isolation, risky social behaviour, bullying and depression, remain intact. The evidence shows that these factors influence health and that their prevalence is determined by the socio-economic structure of society and by the behaviour of people inside it (Marmot and Wilkinson (2001).

Lynch (2000) provides an analogy. He says that to appreciate how neo-materialist conditions can influence health, it may be useful to take the metaphor of the plane journey. Differences in neo-materialist conditions between first class and economy class can produce inequality in health after a long journey. The first-class passengers, apart from their various advantages, like better food and better service, have more space and a seat that can go into a reclining position. First-class passengers arrive at their destination fresh and reposed, while many of those in the economy class arrive worn out.

According to the psycho-social interpretation this inequality in health is due to negative emotions produced by the perception of a relative disadvantage. According to the neomaterialist interpretation, the economy class passengers are in a worse state of health because they have been in cramped conditions for such a long time, in an uncomfortable seat in which it was impossible to sleep. The fact of seeing the first class passengers in comfortable seats when they go up and down the plane is not the reason for their discontent. The psycho-social interpretation of this inequality in health would be reduced if first class were abolished, or if by means of mass psychotherapy the perception of the relative disadvantage were modified. From the point of view of the neo-materialist, the solution could be found by improving the conditions of the passengers in the economy class.

Naturally, this simplistic metaphor presumes that conditions in first class and economy class are independent –whereas in the real world improvements for those travelling in economy class are opposed by those who can afford to travel first class (Lynch J.W et al, 2001).

There is no doubt that the confrontation between these two visions will continue*.

Causes of inequality: Coburn’s thesis

The thesis of Coburn D (2000) is that we should go back to the causes that produce inequality in the distribution of income. That way we shall discover that neo-liberalism (or the dominion of the market), by weakening or annulling the welfare state, creates both more inequality in incomes and less social cohesion, and a low state of health in the population, or rather a lower state of health than we would expect.

Neo-liberalism, welfare state and inequality

The general principles of neo-liberalism –the “philosophy”of the New Right –are:

1. markets are the best and most efficient assigners of resources in production and distribution;
2. societies are composed of autonomous individuals (producers and consumers) motivated mainly or exclusively by economic and material considerations;
3. competition is the greatest vehicle of innovation.

The essence of neo-liberalism, in its pure form, is a more or less close adherence to the dogma of the market economy and consequently to a society oriented on the market. Even if some neo-liberals claim that there is no direct relation between economic model and type of society, Coburn’s position is that the economy, the state and civil society are actually inextricably interrelated.

Neo-liberals are not particularly worried about inequality: if the market is the best and most efficient assigner of resources they are inclined to accept any consequences deriving from the market. The welfare state interferes with the normal working of the market, for which reason neoliberals are opposed to any intervention that might damage the work of the “invisible hand”. Neo-liberals also affirm that inequality is the necessary sub-product of the proper working of the economy, which is “right”because it responds to the principle that if someone enters the market, someone else must leave it. So actions by the state to correct “distortions”in the market are not only inefficient and useless, but also unjust, “not ethical”.

The welfare state was born in liberal states to correct the inequality produced by the market, removing certain sectors of social life such as education and health from market criteria. So both health, through the effects of the welfare state on the social determinants of health, and health services, through the institution of various forms of national health care service, are closely connected to the existence of the welfare state. It is a question for debate whether the effects of the welfare state are direct and material or indirect and psycho-social –“re-distributional policies are important materially and psycho-socially”. “High levels of social expenditure and taxing, as a proportion of the GNP, are associated with longer life expectancy, lower maternal mortality and a lower percentage of infants born small”.

Through globalisation, neo-liberalism has affected in various degrees all economies of the world. There is a clear proof that it is associated with rapid and growing inequality. This is more obvious in countries that have adopted more radical neo-liberal policies. We can therefore maintain that markets produce inequality in income and that neoliberalism opposes measures that tend to re-distribute income.

In summary, the more a system is neo-liberal and oriented on the market, the greater is the inequality in incomes.

Neo-liberalism, inequality and social cohesion

There are many arguments to support the thesis that neoliberal doctrines are contrary to social cohesion. While in the previous liberal theory the state was seen as at least partially representative of the general interests of society, in the neo-liberal view it must have the lowest profile possible. It is well known that the neo-liberal vision is individualistic rather than collectivist or communal. There is a clear-cut distinction between the collectivist or communal conception, which includes the notion that some goods can be put into common use, and that of the market.

So the first act of neo-liberal governments has been to privatise state organisations and functions, considered common goods. Privatisation actually means making individual property those functions that previously belonged to the state as expressions of society, or those goods that previously were considered as belonging to all (the environment, land, fishing, etc.)

The concept of “citizenship”connected to owning certain rights, social and political, is an inclusive concept. Universal measures of citizenship, aimed at everyone, mean that we are all members of the same society and we all benefit from it to the same degree. Neo-liberal programmes are on the other hand aimed specially at particular population groups and may be defined exclusive, in that they tend to privatise the negative effects of the market. The implication of “special”programmes is that it is families or individuals that represent a problem and not the structure of opportunities within society. Neo-liberals generally consider everything belonging to the public sphere as something that would deserve to be privatised, the result of this being the tendency to valorise all private goods and denigrate all public goods.

Given the absence of any feeling of community, neoliberals try to resolve the problems of society by invoking individualistic market-based solutions. Hence the communities protected by nets and gates and the use of private police are the response to criminality, private insurances the reply to growing health care needs in a population that is becoming older and older. There is a constant emphasis on private transport rather than public, private schools rather than public, private health assistance rather than public. The reduction of the role of the state means reduction of public expenditure, which is why neoliberals are strongly in favour of reducing taxes. Fewer taxes means less capacity on the part of the government to redistribute income and so the privatisation of risks and opportunities within society.

Privatisation and lack of ties (non contractual) between citizens means a general growth of scepticism and mutual mistrust. If everyone is allowed to seek their own selfish interest –as neo-liberalism preaches –there are many reasons for the general suspicion about other people’s intentions. The consequences of all this may be a growing emphasis on individual enrichment at the expense of general and collective goals, scorn for public institutions and no support for those organisations through which collective ideals are expressed, kept alive or reproduced. Moreover, as markets are efficient (and just) distributors of resources, economic and social problems must be attributed to individual failures. If the markets give people what they deserve, it is likely that the general attitude will be to blame and punish those who are in difficulty, rather than helping them. So those who receive welfare are considered good for nothings, parasites and welfare bums.

While we say that neo-liberalism produces a reduced sense of community, we might also say that the spread of neoliberalism is in itself an indicator of the decline of the sense of social solidarity within society. The political growth of neo-liberalism goes in step with a more individualistic vision of society and perhaps reflects the decline of the notion “we are all in the same boat”. It is not only neoliberal policies that are undermining the social infrastructures that support social cohesion, but these neoliberal movements are in part the cause of this decline.

In a nutshell the more a society is oriented on the market, the greater is social fragmentation and the weaker is social trust and cohesion.

The effects of globalisation

Coburn 2000 states that it is important to give an explanation for the mechanisms at the base of the growth of neo-liberalism and how these influence the growing inequality in socio-economic conditions. For this purpose he uses Ross and Trachte’s analysis (Ross and Trachte (2000).

The growing globalisation of financial and industrial capital has reduced the power of national, regional and local authorities and has brought about a break in the balance of power between working class and capital, which in the past had developed welfare policies aimed at the re-distribution of income. Economic globalisation is leading to a new phase of capitalism in which the power of business is increasing and the autonomy of states is declining: the result is the excessive power of market doctrines and policies and the increase in inequality.

The decline in the power of the working class in respect to that of “global”capital is characterised by the dominion of neo-liberal policies and ideologies, the attack on the welfare state, the predomination of company interests in the market. All this is associated with a smaller capacity to contract welfare measures and inevitably produces greater income inequality, less social cohesion, and directly or indirectly a worse state of health for the population.

The arguments describe a unique relation between neoliberalism, inequality of income, social fragmentation and declining state of health of the population. This raises the problem of a more profound analysis of the various hypotheses that link the inequality of income and state of health. The discussion should focus on the wider social, political and economical factors that have so far been widely ignored in the literature regarding inequality in the socio-economic state and state of health. Inequality is not a necessary condition produced by extra-human forces. The degree of this inequality is clearly influenced by international, national and local policies, which are subject to change. We can ignore these processes or try to understand them and start changing them.

Conclusions

Coburn’s article, published in Social Science & Medicine, stirred up an intense debate in the pages of the review, in which there were also articles by Wilkinson RG (2000) and Lynch JW (2000). The latter accepted Coburn’s thesis and re-elaborated the neo-materialist interpretation of the inequality of income and health, as shown in figure 4.

Alvin R. Tarlov, of the University of Houston, Texas, USA, commenting on Coburn’s article, writes: “Coburn’s conceptual framework goes beyond previous work on the inequality of income and beyond previous considerations on class that were invoked to explain health gradients. He goes beyond the various macro-social explanations that have been presented from time to time, such as regressive taxation, the diminished power of the working class, the instability of occupation, the lack of faith in the state, and so on. His hypothesis is particularly attractive because it unifies a dozen variables that have been examined inside a coherent set of interrelated factors. His thesis is compatible with certain figures that have emerged in the UK in the last 30 years, which show the growing influence of social factors on the health of the population”.

This tendency coincides with the widening gap in the distribution of income in the last 50 years, and also coincides with the progressive shift towards the dominion of the market in business, in national governments, and in social organisation in the whole world. Coburn’s thesis seems plausible enough, but it is far from being proven. To test this hypothesis, new measures and new studies are needed. In the economy, in finance, in politics and in international government, some attention should be given to the possibility of introducing an additional variable, that is health, when dealing with the balance of efficiency-equity in a global economy in such rapid evolution.

Social factors can be competently determined through the disciplines of epidemiology and sociology. Slowly but surely the methods and theories of other intellectual disciplines, including economics, political sciences and anthropology, are showing interest in the search for explanations for the phenomena of the differences and concepts of public strategies to preserve and reinforce human health in this explosive period of social change. Coburn’s thesis shows how useful the concepts of political science and economic philosophy can be for an understanding of the complexity of the differences in socioeconomic conditions and health (Tarlov AR, 2000).

References

* The varying views on this subject can be found in: “British Medical Journal “(Vol 324, 5 January); Mackenbach JP., Income inequality and population health; analysis of pooled data from two cohort studies; Shibuya K et al, Individual income, income distribution, and self rated health in Japan: cross sectional analysis of nationally representative sample; Sturm R et al, Relations of income inequality and family income to chronic medical conditions and mental health disorders: a national survey in USA.

Copyright 2003 - Department of Health Sciences of Uganda Martyrs University