Marek Kohn

Review of Richard Wilkinson's The Impact of Inequality: How to Make Sick Societies Healthier


This review first appeared in Prospect magazine, September 2005. 

Richard Wilkinson’s latest book tells us what we already know, and that is why we need it. We know that oppressive, unequal relationships are bad, and that broadly voluntary, roughly equal relationships are good; and if we think about it we recognise that this is true for societies as well as for personal relations. Yet we take these for truisms rather than fundamental truths upon which our lives and society should be based.

Wilkinson’s project, pursued for over 25 years, is to show that these are scientific truths. The effects of inequality are counted above all in deaths. Easy to define, reliably reported, and unarguably grave, deaths make high-quality data. The foundations of the worldview presented by Wilkinson, who is Professor of Social Epidemiology at Nottingham University’s Medical School, are the correlations he finds between death rates and inequality, measured by income. As well as overall mortality statistics, there are particularly strong associations between inequality and homicide – regarded by many criminologists, according to Wilkinson, as “the most well-established relation between  homicide and any environmental factor”. The sickness to which his subtitle refers is to be understood in the broadest of senses.

It extends into areas described by less absolute measures, such as degrees of trust or hostility, which are also worse where inequality is greater. Inequality is the enemy of social cohesiveness, or social capital. What this relationship demonstrates, writes Wilkinson, “is that societies that tolerate the injustices of great inequality will almost inescapably suffer their social consequences: they will be unfriendly and violent societies, recognized more for their hostility than their hospitality”. These remarks are characteristic of Wilkinson’s way of writing, in their construction from moral and empathic language, and in their roots in empirical observation. The combination is also evident in the phrase he likes to use to describe the project on which he and others in various countries are engaged: “the science of social justice”.

His most prominent colleague is Michael Marmot, of University College London, who has led the studies which pioneered the field. Conventional wisdom views inequality in affluent societies as a residual issue: the persistence of a smallish minority whose relative poverty is accompanied by a concentration of social ills and menaces. Inequality among the remainder is not considered a problem. Even though this covers most of the range, from modest security to fantastic luxury, it is felt that all are “haves”, and that is that. Marmot’s team produced the graphs that show otherwise. Surveying Whitehall civil servants, they found that the lowest grades were about four times more likely to die during a given period than the highest. They were not impoverished, though, and they were not an underclass distinct from the rest. There was a steady gradient in death rates down the hierarchy of rank. Professional and executive grades were twice as likely to die as their bosses. Though the price of inequality is not paid equally, it is paid by almost all.

The obvious suspects, such as smoking and poor diet, were examined and found to account for only about a third of the effect. Most of the gradient was evidently being generated by the hierarchy itself. And it became apparent in a range of measures of health, from heart and gastrointestinal disease to depression and back pain. Inequality not only appears to be worse for health than smoking, but seems to be at the root of much of our illness and misery.

Findings like these are complemented by studies which imply that healthy social relations make for a healthy body. When American volunteers were exposed to cold viruses, the ones who had recently been involved in a greater variety of social relationships – with friends, relations, colleagues or fellow members of clubs and other associations – caught fewer colds than those whose networks of involvement were less rich. (The study checked for antibodies, excluding the possibility that the protective effect of social involvement arose from being exposed to more viruses and thereby developing immunity.) Among the Whitehall civil servants, studies also found that having a wide circle of friends and acquaintances, and seeing them regularly, was good for health. The effect seem to flow not from the ability to call on others at times of crisis, but rather from a background sense of social security.

This could be seen as the confidence that one could turn to others if the need arose, but that would be to underestimate the rewards of relationship. Life is an accumulation of moments in which a person is affirmed or rejected in encounters with others; a succession of pulses of happiness or hurt, with everything hanging in the balance between them. A person for whom a passing insult or a casual jibe means nothing is truly happy. At the extremes, on the streets, the slightest hint of disrespect may provoke a deadly reaction. Richard Wilkinson quotes forceful examples from prisons and the increasingly hostile culture of what used to be neighbourhoods. He also writes with unashamed candour about the everyday inner fear of humiliation, the constant anxiety that others regard us as ugly or stupid or boring. In wealthy countries, where nobody starves any longer, the approval of others is the currency that really matters.

The underlying processes, however, are likely to be primordial. They can be seen in other primates, whose health and well-being also depend upon their relations with each other. The higher a rhesus monkey ranks in the hierarchy it occupies, the less likely it is to develop atherosclerosis, the furring of the arteries that underlies heart disease. Take the highest ranking monkeys from a number of groups and put them together in a new group: they will sort themselves out into a new order, and each monkey’s chance of developing atherosclerosis depends on where it ends up in the new hierarchy. Subordination is a condition of permanent threat. Animals respond to threat by going into fight-or-flight mode, in which non-essential bodily activities are minimised. If this condition is prolonged, the animal’s body will not be properly maintained, its immune system will be inhibited, and it will suffer the corrosive effects of prolonged exposure to stress hormones.

That is the rhesus monkey condition, but is it the human condition too? The same physiological processes clearly operate, and they can be seen to operate in the dominance hierarchies that humans are so adept at creating. Unlike rhesus monkeys, however, humans are not obliged to live in dominance hierarchies. It is possible that the ancestral human condition was egalitarian. Hunter-gatherer societies tend to operate ‘counter-dominance’ systems, in which individuals are cut down to size by their fellows if they attempt to dominate the group. Now that dominance hierarchies predominate in human organisation, individuals struggle frenetically to succeed in them; but as Wilkinson puts it, to reason from this that people should remain in hierarchies is like “saying that because a drowning man struggles to keep his head above water, he needs to be kept in water”.

This image illustrates how radically anti-materialist Wilkinson’s thinking is. The struggle for status in a world of status symbols is a genuine struggle, against misery, illness and premature death, even though it takes place in a sea of luxuries. It really isn’t the money, or the things; it’s what they do for our relations with others.

At the same time, the main thrust of Wilkinson’s research has focussed on income inequalities, and this has provided an opportunity for critics who believe that the important thing about material wealth is its material effect. They have challenged the data relating income inequality to ill-health: the effect now appears extensive rather than universal. They have also advanced a “neo-materialist” alternative explanation, arguing that people need expensive goods such as cars and computers in order to thrive in an affluent society. “Psychosocial’ explanations smack to them of therapy culture and palliative politics: don’t change the conditions in which the poor live, just change the way they feel about it. Redistribute wealth, say critics like John Lynch and George Davey Smith, not feelings.

Wilkinson’s egalitarian vision plainly implies that the conditions of life must be adjusted in order to alter how people feel about them, but he is at pains to remain within the possible. His own favoured means of promoting equality sidesteps the state and concentrates on the workplace, where he sees great potential in the development of employee ownership. He also points out that the data, showing significant differences in health and social well-being among market democracies, demonstrate the benefits of equality even within the existing range of political settlements. But they also raise many questions yet to be explored, such as the extent to which, and how, the oppressive effects of hierarchy can be ameliorated by the way hierarchical relationships are conducted.

 Whereas the neo-materialists have made their objections explicit, recalling the old days when the concrete left was at loggerheads with those of their comrades whose priorities were not economic, the resistance of the wider intellectual culture has been subtler. These ideas have scarcely been suppressed. Wilkinson has published two other summary expositions in the past ten years; Michael Marmot issued an account aimed at a general audience (Status Syndrome, Bloomsbury) last year. People in the policy trade and the opinion business are familiar with the propositions – but these still come as a revelation even to well-informed members of the public.

The Labour government has identified health inequalities as a problem to be addressed. It received a report by Sir Donald Acheson on the subject to which Wilkinson made submissions and which was overseen by a group that included Marmot. But the government’s understanding of the problem excludes any acknowledgement that social inequality may itself cause health inequalities. John Reid, the Health Secretary, placed the onus firmly on the disadvantaged in a speech last year, making plain the government’s view that the solution required people to choose to change their behaviour.

The science of social justice thus finds itself in the position of a man at a crowded bar who gets a nod from the bartender but can’t get served, because the other customers are more appealing and assertive. Slavoj Zizek’s extension of Donald Rumsfeld’s widely, though unjustifiedly, mocked remarks about what is known and unknown seems pertinent here. The Slovenian philosopher proposed a category of “unknown knowns”: things we don’t know we know. The reason we don’t know that we know things is that they conflict with more powerful ideas, and so we see them but fail to recognise them. The idea that inequality is a sign of economic health and social vigour is too compelling to permit serious engagement with the idea that inequality is anti-social and a cause of illness. We need to be told what we know, instinctively, about what makes a good society. Wilkinson’s book tells us, and shows us that our social instincts have become a science.

Richard G. Wilkinson, The Impact of Inequality: How to Make Sick Societies Healthier, Routledge, London, 2005