The Spirit Level

• Book by Wilkinson and Pickett : The Spirit Level - Why Equallity is Better for Everyone
  • Argued that although income and wealth might lead to better health outcomes in individuals and societies, there is also an additional effect of income equality that leads to better health outcomes, or inequality which leads to worse health outcomes.
  • Argued that inequality has a negative effect on physical and mental health outcomes, but also health indicators such as teenage births, homicide, crime and imprisonment, educational attainment, social mobility etc…
  • They linked inequality to health and social outcomes among both rich countries and among US states. Correlation between states isn't as tight as between countries.
  • Income inequality was measured using the ratio of incomes among the richest compared with the poorest 20% of each country. The index of health and social problems combined data on life expectancy, mental illness, obesity, infant mortality, teenage births, homicides, imprisonment, educational attainment, distrust and social mobility.
• Unequal incomes don't necessarily translate into poorer health in a country, even if a lower income leads to poorer health for an individual.
  • If there is a linear relationship between income and health, then good health among the rich will balance poor health among the poor.
  • The effect of income inequality on health is over and over and above the effect of income on health.

Income and health are not linearly related. Preston curves show that income has a much greater effect on health in countries with low GDP than those with high GDP.

1. Concavity effect

• The shape of the relationship between income and health means that unequal countries will have worse health, even if there is no 'Spirit Level' effect.
• Because income makes more difference to the poor than the rich, transferring income from the poor to the rich (increasing inequality) will increase the mortality risk of the poor more than it reduces the mortality risk of the rich.
• In practice, income distribution rarely looks like this (half of the population have high income and the other half having low income).

2. Composition effect

• Income doesn't tend to follow a normal distributuon.
• Unequal countries have higher proportions of poor people and therefore worse overall health.
• Therefore, unequal countries will have worse health even if health only depends on income levels. This takes into account the people in the society and what income they have, not additional effects of inequality.

• Relates to public spending and resourcing on healthcare, education, social security etc...
• Refers to money spent at a societal level, which is why it is called neo-material.
• In unequal societies, services and facilities tend to be lower quality or less accessible in more deprived areas.
• Argument that contextual effects are created as the population make-up and infrastructural heritage are historical legacies of our industrial, residential and social past. These create concentrations of poverty and residential segregation of particular ethnic groups.
• Mainly used in low and middle income countries.

• Communities (with contexttual effects) are produced by residential segregation of different sorts of people into different areas.
• Mostly areas that were affected by deindustrialisation are the most deprived.

• Position in the status hierarchy affects stress.
• Chronic stress has a number of adverse physical effects and affects health related behaviour.
• Wilkinson and Pickett argue that psycho-social effects reduce the health of everyone in unequal societies. Status anxiety affects the rich as well as the poor.
• This doesn't mean that everyone in a more equal society is healthier than everyone in a less equal society, but they argue that when people in the same social class with the same level of education are compared across societies, those in more equal societies do better.
• Jen et al. (2010) argue that inequality affects health by eroding trust in a society, reducing bridging social capital.
• It is important to note that just because we can see differences in health and mortality outcomes of people in different groups/societies, it doesn't necessarily mean that these are produced by psycho-social effects. They could be produced by other contextual effects e.g. neo-material.

• Wilkinson and Pickett argue that...
  • There is little pure income effect
  • Spending on health and social services are also poorly correlated with health
  • Psycho-social effects have the largest effect

• Too simplistic in its methods.
  • Wilkinson and Pickett argue that it was designed for lay people, hence the simplicity.
• Ignores material pathways from income to health.
  • W&P argue that it isn't material pathways that are important but psycho-social pathways. Also, while material pathways can affect health, they can't affect other societal indicators e.g. those linked to homicide/teenage pregnancy.
• People compare themselves to near equals not those far away from them on a status hierarchy. Therefore, overall inequality measures don't matter - it's just who your neighbours are.
  • Wilkinson and Pickett argue that this might be true, but it doesn't mean that people aren't aware of the rest of the social hierarchy and where they fit into it.
• Does not work for small areas.
• Does not work for poor countries.
• Does not work for international comparisons of self-rated health.

• Close relationship between self-rated health and objective measures of health within countries but not between.
• Dorling and Barford suggest that 'there is less need to fool ypurself that all is well in more equitable countries'.
• May also explain the Suicide Paradox: suicide is more common in countries where murder rates are lower (Durkheim, 1897)

• Both social inequality and health are multidimensional and relational
• Geography, society, identity and social relationships are all important
• The health of a place is the cumulative result of complex historical forces
• There is a strong policy argument for redistribution of income.