Unknown Knowns: The
Relationship between Inequality and Health
Conference paper: Medicine and the
Body Politic, Centre for Applied
Philosophy, Politics and Ethics, University of Brighton, 22 September
The view that social inequality may have a harmful effect on health,
independent from any effects caused by absolute poverty, is supported
by a substantial body of theory and data. Leading exponents of this
view have been involved in consultations surrounding policy formation
in Britain, where the government has declared the reduction of health
inequalities to be a priority. Their research is well known in expert
and policy circles, but the idea that inequality has a causal effect on
illness has not been widely acknowledged. Policy appears to remain
focussed on the idea of individual choice, despite empirical evidence
suggesting that health outcomes are heavily influenced by social
It is generally agreed that health inequalities are to be regretted and
should be reduced.1 The British government has
declared their reduction
to be a policy priority. Yet this concern is not supported by
robust accounts of why health inequalities are wrong per se, or
analyses of the relationship between health and other forms of
inequality. The contrast is the more striking for the fact that just
such an account and analysis have emerged from studies of health among
civil servants in ‘Whitehall’, where the government’s policies
The ‘Whitehall studies’ began in the 1970s, are
ongoing, and have collected data relating to around 30,000 individuals.
Their central finding is of a ‘social gradient’ in mortality, in which
death rates increase as the hierarchy of occupational grades is
descended. In the first study, men in the lowest grades were found to
be three times more likely to die of coronary heart disease that men in
the highest (‘administrative’) grades.2 Less
than half of this
elevated risk could be explained by conventional major risk factors
such as smoking, cholesterol levels, blood pressure or lack of
exercise. After controlling for such factors, those at professional or
executive grades remained nearly twice as likely as administrators to
die of coronary heart disease, while the lowest grades still ran a risk
more than two and a half times as high.3
All of these were office workers, and none could be
considered impoverished. All those at subordinate grades were more
likely to die than those at the top of the hierarchy; and the bulk of
their increased risk could not have been reduced by changing their
behaviour, in the sense that this is conventionally understood in the
context of health. Their health inequalities seemed to arise from the
social hierarchy itself.
The implications of such findings have subsequently
been elaborated into a theory about the psychologically-mediated
effects of social relations upon both individual and social health,
drawing upon a range of sources that includes international data on
income inequality, research into social capital, and primate
physiology.4 It is argued that the adverse
effects on individuals
may be caused by the prolonged activation of physiological responses
that are beneficial in brief emergencies. These processes re-order
bodily priorities so as to maximise the body’s capacity to respond to a
sudden challenge, reallocating resources away from activities, such as
tissue repair, that can be suspended for a brief duration but are
essential in the long term. Social relations experienced as oppressive
are likely to generate such responses; the more unequal social
relations are, the more likely they are to be experienced as
oppressive. The Whitehall studies have focussed upon individuals’ lack
of control over work, which they have found to increase the risk of
Other researchers, notably Richard Wilkinson of the
Nottingham, have broadened this ‘psychosocial’ perspective to include
considerations that are not specifically medical but speak to the idea
of health in its most extensive sense. Inequality is found to inhibit
trust and to exacerbate violence. For many criminologists, Wilkinson
observes, the relationship between inequality and homicide is “the most
well-established relation between homicide and any environmental
factor”.6 In this vision the individual is
the body’s fate may be more profoundly influenced by social position
than by genetic constitution or conscious choices.
The psychosocial account has been vigorously
contested within its own discipline. Critics have concentrated upon
analyses which depict consistent, negative relationships in different
parts of the world between income inequality and health. They have
reinterpreted the data to conclude that though such relationships may
be apparent in the United States, these are not universal.7
reservations are not only empirical, however. They include concerns
about the political implications of the theory. Noting the psychosocial
emphasis upon “aspects of personal psychological functioning such as
trust, respect, and support”, John Lynch and colleagues consider that
“It is hard to understand how this emphasis ... would serve as a basis
for a public policy agenda to reduce health inequalities.” Instead they
recommend a “more equitable distribution of public and private
resources”.8 From their ‘neo-materialist’
inequalities persist in the absence of want simply because the more
money people have, the more resources they can buy for their comfort
and health. As the health economist Robert Evans observes, hiring a
nanny or flying first class are highly effective means of coping with
For psychosocial theorists like the principal
Whitehall researcher, Michael Marmot, the explanatory power of money is
limited. Its basic significance lies in its relationship to status.
Marmot points to Swedish research in which men with doctorates were
found to have half the mortality of men who had completed more than
three years of higher education, qualifying in professions such as law
and medicine, but had not obtained Ph.Ds. The difference in mortality
remained even after income and other factors were taken into
Such empirical objections are accompanied, like
those of the neo-materialists, by an undercurrent of socio-political
concern. For Wilkinson, materialism is part of the problem. Declaring
that “despite their extraordinary material success, modern societies
are often social failures”, he claims that the empirical evidence
us with the central plank of a political perspective capable not only
of transforming society and the quality of our lives, but also of
reigning in the consumerism which increasingly threatens the
environment.”11 This is not just a theory but
a sociopolitical and
moral critique. For Wilkinson, it is “the science of social justice”. 12
Marmot and Wilkinson have been involved in the
process of policy
formation. 13 Yet their perspective remains
unfamiliar in wider
public discourse, and invisible in government policy pronouncements.
The crucial missing term is that of the gradient, a phenomenon in which
health inequalities are experienced at almost all levels of society,
albeit diminishing with increasing affluence. Instead, the problem is
posed as that of a social residuum. In the foreword to the Department
of Health’s publication Tackling
Inequalities: A Programme for
Action, the Prime Minister, Tony Blair, presented the goal of
project as the improvement of the health of “the most disadvantaged in
The government’s project turns upon the rhetoric of
‘choice’. In the words of the then Secretary of State for Health, John
Reid, it is “about ensuring that everyone has an opportunity to choose
health by working with people to tackle the conditions that constrict
their choice”. The extent to which these conditions will be tackled is
indicated by the extent of the consultation: “to the food industry and
retailers, the media and advertisers, schools and communities, as well
as individuals and health professionals”.15 It
appears that the
strategy is to moderate commercial pressures and to promote ‘healthy’
community values. From Wilkinson’s perspective, however, the potential
benefits would be limited. Not only is lasting behavioural change hard
to achieve, he has argued, but only about a quarter of the differences
in heart disease deaths in the original Whitehall study population
could be attributed to factors controllable by changes in behaviour. 16
By referring to social conditions without defining
them, official public health discourse suggests more than its
strategies are prepared to address. The possibility that social
inequality might in itself be a cause of health inequality remains at
the periphery of public discourse as a whole. At the same time the
understandings in which it is embedded are present in a paradoxical
sense, acknowledged as ideals but discounted as sentimental and denied
in practice. As Wilkinson has pointed out, the psychosocial perspective
is a reminder of “just those dimensions of the social environment
people have always thought crucial to the real quality of life”.17
They are “’unknown knowns, things we don't know that we know”, to
borrow a useful phrase coined by the philosopher Slavoj Zizek,
continuing a train of thought begun by the US defence secretary Donald
Rumsfeld.18 Such knowledge is unconscious
because it is
problematic. It implies that intuitive egalitarianism may be
of Health n.d.
2 Marmot et al. 1978.
3 Wilkinson 1996, 65.
4 Marmot 2004; Wilkinson 1996, 2005.
5 Bosma et al. 1997
6 Wilkinson 2005, 50.
7 Lynch et al. 2004.
8 Lynch et al. 2000.
9 Evans 2002.
10 Marmot 2004, 77-9.
11 Wilkinson 2006.
12 Speaking at launch of Marmot 2004,
quoted with permission in Kohn 2005.
13 Acheson 1998.
14 Department of Health 2003.
15 Reid 2004.
16 Wilkinson 1996, 64.
17 Wilkinson 2005, 30.
18 Zizek 2005.
Acheson, D. (chair) 1998, Independent
into Inequalities in Health, Stationery Office, London.
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disease in Whitehall II (prospective cohort) study, British Medical Journal 314,
Department of Health, n.d., Health
Department of Health, 2003,
Health Inequalities: A Programme for Action.
Evans, R,. 2002, Interpreting and
addressing Inequalities in health: from Black to Acheson to Blair to …?
Office of Health Economics, London.
Kohn, M., 2005, review
of Wilkinson 2005, Prospect
Lynch, J.W., et al., 2000, Income
inequality and mortality: importance to health of individual income,
psychosocial environment, or material conditions’, British Medical Journal 320,1200–4.
Lynch, J.W., et al., 2004, Is income inequality a determinant of
population health? Part 1. A systematic review. Milbank Quarterly 82, 5-99.
Marmot, M.G. et al., 1978, Employment grade and coronary heart disease
in British civil servants, Journal
of Epidemiology and Community Health 32, 244-249.
Marmot, M., 2004, Status Syndrome,
Reid, J. (speech) 2004, Choosing
- closing the gap on inequalities.
Wilkinson, R.G., 1996, Unhealthy
Societies, Routledge, London.
Wilkinson, R.G., 2005, The Impact of
Inequality, Routledge, London.
Wilkinson, R.G., 2006, The impact of inequality: empirical evidence,
Scottish Centre for Research on Social Justice/Scottish Executive
Social Justice and Public Policy in Scotland Seminar, University of
Stirling, 22 February.
Zizek, S., 2005, The empty wheelbarrow, Guardian 19 February.