The Problems of Relative Deprivation

Wilkinson, R. G., & Pickett, K. E. (2007). Social Science & Medicine, 65(9), 1965-1978.
The problems of relative deprivation: why some societies do better than others.
Richard G. Wilkinson and Kate E. Pickett
This is a pre-publication copy of the manuscript published as: Wilkinson, R. G., & Pickett, K. E. (2007). The problems of relative deprivation: Why some societies do better than others. Social Science & Medicine, 65(9), 19651978.
The problems of relative deprivation: why some societies do better than others.
ABSTRACT In this paper we present evidence which suggests that key processes of social status differentiation, affecting health and numerous other social outcomes, take place at the societal level. Understanding them seems likely to involve analyses and comparisons of whole societies. Using income inequality as an indicator and determinant of the scale of socioeconomic stratification in a society, we show that many problems associated with relative deprivation are more prevalent in more unequal societies. We summarise previously published evidence suggesting that this may be true of morbidity and mortality, obesity, teenage birth rates, mental illness, homicide, low trust, low social capital, hostility, and racism. To these we add new analyses which suggest that this is also true of poor educational performance among school children, the proportion of the population imprisoned, drug overdose mortality and low social mobility. That ill health and a wide range of other social problems associated with social status within societies are also more common in more unequal societies, may imply that income inequality is central to the creation of the apparently deep-seated social problems associated with poverty, relative deprivation or low social status. We suggest that the degree of material inequality in a society may not only be central to the social forces involved in national patterns of social stratification, but also that many of the problems related to low social status may be amenable to changes in income distribution. If the prevalence of these problems varies so much from society to society according to differences in income distribution, it suggests that the familiar social gradients in health and other outcomes are unlikely to result from social mobility sorting people merely by prior characteristics. Instead, the picture suggests that their frequency in a population is affected by the scale of social stratification which differs substantially from one society to another.
INTRODUCTION A typical approach to examining contextual area effects on health is to start by controlling out the compositional effects of the socioeconomic characteristics of the population in those areas (Diez-Roux, 1998; Merlo, 2003; Pickett & Pearl, 2001). Because individual characteristics usually have the most powerful influence on the local health profile, researchers adjust for them in order to see whether there are residual positive or negative health effects associated with features of the area itself. At the local area level the proportion of people with various socioeconomic characteristics may be primarily a distributional issue how does an area become a deprived area, inhabited by a disproportionate share of poorer, less well educated people, while a neighbouring area attracts better off people (Macintyre, Maciver, & Sooman, 1993; Tunstall, Shaw, & Dorling, 2004)? However, on another level this is not a question about the distribution in physical space of people with given 2
characteristics, it is instead about the social forces which create those characteristics in the first place. What determines the proportions of people in the wider society belonging to different social classes, in different income groups, with different levels of educational qualifications? The answer to a question like that may seem to depend on the outcome of hundreds of different processes covering every aspect of poverty and wealth creation: educational policies and teaching methods, social mobility, cycles of deprivation, the durability of class cultures to name but a few, all involving the complexities and minutiae of interactions between individuals, their social environments, and the wider society. However, in this paper we will show that a wide range of problems associated with relative deprivation, (including ill health, teenage births, violence, low trust, the educational performance of school children, imprisonment, drug abuse and obesity), are all strongly related to one factor societal measures of income distribution. Rather than being left with the infinite complexities of different determinants of peoples standard of health, education, propensities to violence, risks of teenage pregnancy, imprisonment etc., and trying to formulate separate policies which might have an impact on each of these, it may be that there are also some simpler patterns. If the distribution of each of these health and social problems is related to relative deprivation within societies, and also all tend to be more common in more unequal societies, then perhaps this tells us something fundamental about the impact of the processes of social differentiation within the population. In this paper we consider income inequality as both an indicator and a determinant of the scale of social stratification in a society. The range of outcomes which we shall show are statistically related to income distribution suggests that income inequality is related to deep-seated processes of social differentiation. Rather than thinking of populations as made up of basically similar people who by luck or judgement have become attached to different incomes and make up societies with different levels of income inequality, we suggest that the social processes related to income distribution are involved in the deeper ways our personal and class characteristics are constituted (Bourdieu, 1984). As Williams argues, in discussing Bourdieus complex concept of habitus it is the (class-related) habitus whichdetermine(s) not only lifestyles and the chances of successbut also class-related inequalities in health and illness (Williams, 1995) and, as we would argue, also determines class-related inequalities in many other outcomes. The social processes which become structured round income distribution probably also include many of the early childhood influences on social and cognitive development which seem to affect both health and social mobility and are important in social class differentiation (Ben-Shlomo & Kuh, 2002). Our theory is that processes of social status differentiation, including whether a society has a more or less hierarchical class structure, are intimately related to the scale of income distribution. For several reasons we believe, along with others, that these processes are structured primarily at the national level. As Taylor and Flint state, classes have most commonly defined themselves on a state-by-state basis (Taylor & Flint, 2000). Our thinking is not only based on the fact that the distribution of income reflects market incomes (earned and unearned) from the national economy, plus the effects of varying degrees of redistribution resulting from national systems of taxes and benefits; it is also informed by our recent review of the literature on income inequality and health (Wilkinson & Pickett, 2006). We found, as had been noted in previous
studies and commentaries (Franzini, Ribble, & Spears, 2001; Wilkinson, 1997), that population health is most reliably related to income distribution when income differences are measured across nation-states and other large geo-political units. Indeed, the evidence suggested a graded relationship such that small area studies in parishes, neighbourhoods and counties showed either weak or non-existent relationships; studies of states, regions and cities tended to show stronger, more consistent relationships; and studies comparing nation-states showed the strongest and most consistent evidence. This observation is given additional weight by the fact that the same pattern was independently reported in an earlier review of studies looking at the relationship between income inequality and violence (Hsieh & Pugh, 1993). We realize that there has been considerable debate within the disciplines of economic and political geography concerning the spatial scales at which social processes are structured, and the complex ways in which systems operating at different scales interact. However, as Brenner (2001 p.606) points out Whether or not the scalar structuration of a given social process generates sociologically or politically significant outcomes is an empirical question that can only be resolved through context-specific inquiries (Brenner, 2001). We are sensitive to Marstons point that contemporary writing about scale in human geography has failed to comprehend the real complexity behind the social construction of scale (Marston, 2000)and her argument that the emphasis has too often been on the functional agency of the international economy or to national social formations, while other social practices are cordoned off in their respective localities ignoring the fact that even the most privileged social actorsare no less (locally) situated than the workers they seek to command (Marston, Jones, & Woodward, 2005). Nevertheless, the role of nationally constituted social differentiation in relation to health and social outcomes remains an open question, and one that can be empirically examined. Income inequalities in large areas can of course be decomposed into income inequalities within and between their smaller constituent areas (Lobmayer & Wilkinson, 2002). And of course social comparisons with neighbours may sometimes have detectable effects on health. Nevertheless, as Ballas asks, do (people) compare themselves to peer groups in their neighbourhood, city, region, country or possibly to diaspora groups in other countries or with people of whom they know little? There are many other kinds of non-geographical groupsto which we may compare ourselves and with whom we consider ourselves to be of a similar social standing. It is far from clear how reference groups are constituted (Ballas, Dorling, & Shaw, 2007). As we have argued previously, the health of people in a deprived neighbourhood is worse not because of inequalities within that neighbourhood, but because they are deprived in relation to the wider society. To give a particularly dramatic example, consider that in 1996, black American men had a median income of $26,522 and an average life expectancy of only 66.1 years. In comparison, men in Costa Rica had a mean income (at purchasing power parity) of only $6,410, yet their average life expectancy was 75 years (Marmot & Wilkinson, 2001). To call any local level of income an effect of absolute income (or education or deprivation), and to assume that its relation to health is independent of the wider context is to forget that poor areas are poor in relation to the wider society. Rather than ignoring the fabric of peoples lives which, as Marston pointed out are always locally situated (Marston, 2000), we are suggesting that social classes are
constituted in relation to each other partly through what may look like action at a distance through the effects of the population class structure outside ones immediate locality. We start our empirical investigation by summarising previously published evidence suggesting that the societal scale of income inequality is related to morbidity and mortality, obesity, teenage birth rates, mental illness, homicide, low trust, low social capital, hostility, and racism. We then go on to test new hypotheses, that poor educational performance among school children, the proportion of the population imprisoned, drug overdose mortality and low social mobility are also related to greater income inequality. We would emphasise that the issue throughout is not that greater income inequality means simply greater inequality in outcomes localized within societies, but that greater income inequality is associated with a higher prevalence of ill health and social problems in a society as a whole, regardless of its social distribution.
RECENT EVIDENCE LINKING INEQUALITY TO SOCIAL OUTCOMES. Health Morbidity and mortality In a recent review of 168 analyses of the relationship between income inequality and population health we found that a large majority of studies reported that more egalitarian societies tend to be healthier (Wilkinson & Pickett, 2006). Studies of small areas such as parishes and census tracts were the only major exceptions to this pattern. We found 104 studies of health in which income inequality was measured across whole nations, states, regions or cities areas large enough for income inequality to be indicative of the overall scale of social differentiation and social hierarchy in those societies (Wilkinson & Pickett, 2006). After adjustment for various control variables (including ones which could be either mediating or confounding variables), 81 of the 104 studies (78%) found all or some of the health variables they measured were significantly related to inequality. Before adjustment the proportion supporting this relationship was higher still. As well as a large number of international comparisons of developed and developing countries, evidence confirming this pattern also came from studies of regions, states, and cities in a number of different countries including Canada, Chile, China, Ecuador, Italy, Russia, Taiwan, UK, and USA. In contrast, studies which measured inequality and health in smaller areas (counties, tracts and parishes) produced more equivocal results. Obesity In a study of obesity rates (BMI >30) in 21 of the richest countries we reported that rates were higher in more unequal societies (Pickett, Kelly, Brunner, Lobstein, & Wilkinson, 2005). These relationships were statistically significant for obesity among both men and women, but noticeably stronger among women. The same study also showed that greater inequality was associated with higher total calorie intake. The relation between obesity and inequality was attenuated, but remained significant, even after adjusting for calorie consumption.
Teenage birth rates Whether for biological or social reasons, teenage births are often considered a problem with health and social consequences for both mothers and children. The teenage birth rate was reported to be closely related to income inequality both internationally among 21 rich countries and among the 50 states of the USA (Gold, Kawachi, Kennedy, Lynch, & Connell, 2001; Gold, Kennedy, Connell, & Kawachi, 2002; Pickett, Mookherjee, & Wilkinson, 2005). Mental Illness Using surveys of random samples of the population, the World Health Organization (WHO) recently produced comparable estimates of the prevalence of mental illness for eight developed countries six in Western Europe plus Japan and the USA (Demyttenaere, Bruffaerts, Posada-Villa, Gasquet, Kovess, Lepine et al., 2004). We found statistically significant correlations between income inequality and the prevalence of both serious and any mental illness (Pickett, James, & Wilkinson, 2006). We have since confirmed this correlation (r=0.79, p=0.002) in an expanded dataset, including data from a further WHO survey for New Zealand, and non-WHO population based prevalence estimates for Australia, Canada and the UK (Figure 1). However, we found no evidence of such a relation among the 50 states of the USA.
The Quality of Social Relations Many people have intuited that inequality is socially divisive and corrosive of human relations. Writing of the United States in the first half of the 19th Century, de Tocqueville emphasised his belief that the strength of the associational and civic life to which he drew attention was based (with the crucial exception of slavery) on what he called the equality of conditions (de Tocqueville, 2000). Numerous analyses including homicide, trust, social capital, hostility and racism, suggest that the quality of social relations in a society is poorer where there is more inequality (Wilkinson, 2005). Homicide A large body of evidence suggests that there is a robust relationship between greater inequality and higher homicide rates. All 24 studies of inequality and homicide rates in large areas (whole countries, regions, states or cities) reported significant relationships (Wilkinson & Pickett, 2006). An earlier review also reported a robust relationship which, like health, was stronger when the areas measured were larger rather than smaller (Hsieh & Pugh, 1993). Trust There have been a number of analyses of the relation between inequality and various measures of the quality of social relations, including trust and social capital. As summarised elsewhere (Wilkinson, 2005), these results are consistent with the findings on violence, and suggest that the quality of social relations is poorer in more unequal societies. An international analysis of data from 38 countries (Uslaner, 2002) as well as an analysis among the 50 states of the USA (Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997) have shown substantially lower levels of trust where income differences are bigger. In the less unequal states only 10 or 15 percent felt they could not trust others; this rose to 35 or 40 percent in the more unequal states. The differences related to inequality internationally were just as large.
Social Capital Measures of the strength of associational and community life have also been reported to be related to income inequality. Putnam reported a strong cross-sectional relation between income inequality and his index of the strength of the civic community in the 20 regions of Italy (Putnam, 1993), and a similar relation between inequality and his index of social capital among the states of the USA (Putnam, 2000). Putnam also mentions a striking similarity in the trends in inequality and social capital during the 20th century. Until the late 1960s income differences narrowed and social capital strengthened, but around 1965-70 both reversed direction: income differences widened and social capital weakened. Hostility and racism The last indicators that greater inequality is accompanied by less good social relations come from US data on hostility scores and racism. Williams measured hostility scores in random samples of the population in 10 US cities (Williams, Feaganes, & Barefoot, 1995). The average score for each city was significantly related to its income inequality (Wilkinson, 2005). In a separate study, Kennedy et al found that people held more racist attitudes and beliefs in US states where income differences were large (Kennedy, Kawachi, Lochner, Jones, & Prothrow-Stith, 1997).
NEW ANALYSES In the light of these findings we decided to see if there were relations between inequality and other social problems associated with relative deprivation. The outcomes we were able to look at were limited by the availability of comparable data but, in addition to the outcomes discussed above, we now report analyses of the relationship between income inequality and the educational performance of school children, prison populations, drug overdose mortality, and social mobility.
Data Sources and Results To improve comparability, we limited the international analyses to countries among the richest 50 (by Gross National Income per capita at purchasing power parities) in 2002. To avoid tax havens, we excluded countries with populations of less than three million. Income distribution data were available for 24 countries which met these criteria: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Israel, Italy, Japan, The Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and the United States. Data on income inequality came from the Human Development Indicators (HDI), 2003; reporting dates vary slightly from country to country but are within the period 1992 1998 (United Nations Development Program, 2003). For Germany we used an average of the HDI figures given in the 2002, 2003 and 2004 reports as the figure for 2003 was anomalous. For consistency with our other recent publications, income inequality was measured as the ratio of the total annual income received by the richest 20% of the population to the total annual income received by the poorest 20% of the population. This ratio ranged from 3.4 in Japan, the most equal country, to 9.7 in Singapore, the most unequal.
To supplement the international analyses, where data were available we also analysed relationships with income inequality among the 50 United States and the District of Columbia (DC). Rather than calculating our own measure, we used the Gini coefficient of the inequality of family income for 1999 as provided by the US Census Bureau (U.S. Census Bureau, 2004). (The Gini coefficient varies between 1, indicating maximum inequality, and 0, indicating total equality (Allison, 1978)) Educational performance To see if the educational performance of school children was related to inequality internationally, we used estimates of the combined maths and literacy scores for 15year olds taken from the Programme for International Student Assessment 2003 (OECD Programme for International Student Assessment, 2004). These data were available for 19 countries and the distribution of educational performance in relation to income inequality is shown in Figure 2. The correlation coefficient was r = -0.50, pvalue = 0.029. To check if a similar relationship existed among the 50 states (& DC) of the USA, we combined maths and reading performance scores for 8th graders (about 14 years old) from the US Department of Education, National Center for Education Statistics for 2003. (US Department of Education, 2004a, , 2004b) The scores were significantly lower in states with wider income differences: r = -0.69, p-value < 0.01. DC was an outlier but the association remained highly significant when it was excluded. We also found a statistically significant tendency for the proportion of children not completing high school to be greater in more unequal states. The correlation coefficient was r = 0.66, p-value < 0.01. Imprisonment Figures on the proportion of the population imprisoned in different countries come from the United Nations Survey on Crime Trends and the Operations of Criminal Justice Systems (United Nations Crime and Justice Information Network, 2000). Relating these to income inequality we found a correlation of r = 0.69 p-value<0.01. The data are shown in Figure 3. Because the USA is an outlier, we also checked the association when it was excluded; the correlation then rose to r = 0.75, p-value <0.01. With Singapore also excluded the correlation was r = 0.60, p-value <0.01. Again, we looked at the same association among the 50 states (& DC) of the USA. Figures for imprisonment in 1997-8 were taken from the US Department of Justice, Bureau of Justice Statistics (US Department of Justice). The correlation coefficient relating imprisonment rates to income inequality was r = 0.77 (p-value<0.01). DC was an extreme outlier in this relationship; with much the highest level of income inequality and an imprisonment rate of 1,566 per 100,000 - more than twice that of Louisiana, the next highest. With DC excluded, the correlation was attenuated to r = 0.56 but remained statistically significant (p-value <0.01). The data (with DC excluded to facilitate scaling) are shown in Figure 4, which also shows which states retain and which have abolished the death penalty. Abolition appears to be more common in the more egalitarian states. Drug Overdose Mortality
Age-adjusted mortality rates for deaths from accidental narcotic and hallucinogen poisoning (ICD-10 Code X42) were taken for US states (& DC) from the Center for Disease Control and Preventions Compressed Mortality Files for the years 1999-2002 (Center for Disease Control and Prevention). The correlation with state income inequality was r = 0.61 (p-value<0.01). As for education and imprisonment (above), DC was an outlier, but the association remained statistically significant when it was excluded. It appears that there are no reliable international data on drug related deaths (Advisory Council on the Misuse of Drugs, 2000). Social Mobility International data on intergenerational social mobility are available for a few countries from a study by Blanden and colleagues (Blanden, Gregg, & Machin, 2005). Social mobility was measured by estimating the correlation between fathers and sons incomes (when sons were close to age 30) and calculated from large, representative cohort studies in each of eight countries. Higher correlations between fathers and sons incomes therefore indicate less social mobility. Despite having data for only eight countries, the relationship between intergenerational social mobility and income inequality was statistically significant (r = 0.93, p-value < 0.01). The relationship is shown in Figure 5: among these eight countries bigger income differences are associated with lower social mobility. When the USA and UK are excluded as possible outliers, the correlation remains close (r = 0.60) but with only six data points is not statistically significant.
DISCUSSION The evidence outlined here, consistent as it is across outcomes and setting, goes some way to establishing the simple but important point that numerous social problems associated with relative deprivation from ill health to poorer educational performance are more common in more unequal societies. For comparability with earlier work the new analyses presented in this paper used Pearson correlation coefficients which assume normal distributions and linearity. However, we found that the use of non-parametric Spearman rank correlations produced broadly similar results and in no instance affected statistical inference. We also checked to see if the international results were robust to the use not only of the ratio of the top to bottom 20 percent of incomes, but also to the ratio of the top and bottom 10 percent and to the Gini coefficient. In all cases the measure of inequality made no substantive difference to the results. Whilst causal inference from observational studies, particularly from ecological studies, is inherently problematic, this body of evidence meets epidemiological guidelines for assessing causality (Gordis, 2004; Hill, 1965). Previous studies of associations between income inequality and health have shown that these are strong relationships and that they exhibit a dose-response form; as inequality increases so does poor health (Wilkinson & Pickett, 2006). Findings at the scale of nations and states (but not more local areas) have been well replicated (Subramanian & Kawachi, 2004; Wilkinson & Pickett, 2006), and the biology of chronic stress provides a plausible biological explanation of the findings (Sapolsky, 2005). As well as several time series analyses (Marmot & Bobak, 2000; Wilkinson, 1992), there are also examples of societies such as Britain during the two World Wars and the formerly centrally planned societies
undergoing transition to market economies (Wilkinson, 1996) showing that changes in income inequality are followed by changes in health outcomes. What our new evidence adds is coherence and specificity: if relative deprivation links income inequality to poor health then we would expect to find, as we do, that other social problems linked to relative deprivation are also associated with income inequality but are not associated with absolute levels of income as such. This picture suggests that more unequal societies are socially dysfunctional in many different ways. It is striking that a group of more egalitarian countries (usually including Japan, Sweden, Norway and often other Scandinavian countries) perform well on a variety of outcomes, and a similar group of more unequal countries (including the USA, Portugal and often the UK) tend to have poorer outcomes. We find it hard to think of other possible explanations apart from inequality for these patterns. Although there are clearly numerous similarities between the US and Britain, the same cannot be said of the US and Portugal or Singapore which also tend to perform badly. Singapore and the US are ethnically diverse, but Portugal has a more homogeneous population like Finland or Japan. Japan and the US are service-based economies, while Singapore and Finland have a heavier manufacturing base. Despite performing well on almost all outcomes, Sweden and Japan show marked contrasts in the position of women in society and in their participation in paid employment. In addition, Japan in contrast to Sweden has low rates of single parenthood and divorce. Even their pathways to greater equality of incomes differ substantially: Sweden depends primarily on redistribution through taxes and benefits while Japan has smaller differences in earnings even before taxes and benefits. Sweden has one of the strongest welfare systems, while Japan devotes an unusually small proportion of its National Income to public social expenditure. Not even unemployment rates fit the pattern: Finland has an unemployment rate of 8.4%, much closer to Portugals 7.6% than to Japans 4.4%, which is more like Singapores 3.1% (Central Intelligence Agency, 2006). Interpretation Human beings have lived in every kind of society, ranging from the most egalitarian foraging societies of prehistory to the most tyrannical hierarchies (Boehm, 1993; Erdal & Whiten, 1996). Modern societies almost certainly continue to differ in how hierarchical and socially differentiated they are. The development of comparable measures of income inequality seems at last to have given us a rough indication of the extent of social differentiation from one society to another, and so a new approach to a vital arena for social research. Despite having data for only eight countries, the apparent tendency for societies with wider income differences to have less social mobility, seems to confirm the relation between income inequality and social stratification. Bigger income differences seem to solidify the social structure and decrease the chances of social mobility. In effect, equal opportunity is a more distant prospect where there are greater inequalities of outcome. Reinforcing this impression is the fact that while income differences widened in Britain and the United States, social mobility slowed (Blanden, Gregg, & Machin, 2005) and, as if greater social distances were translated into greater geographical distances, residential segregation of rich and poor increased (Berube, 2005; Kawachi, 2002; Mayer, 2001).
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As if to confirm that the link between income inequality and these outcomes is indeed mediated by changes in the burden of relative deprivation, there are indications that the outcomes most strongly related to deprivation and showing steeper social gradients within societies, are also those most closely related to income inequality. For example, the relation between population mortality rates and income distribution is typically strongest among men of working age; this is also the age and sex group in which the social class gradient in health tends to be steepest. Similarly, just as income inequality is more closely related to the population prevalence of obesity among women than men, so too is the social gradient in obesity more marked among women than men (Molarius, Seidell, Sans, Tuomilehto, & Kuulasmaa, 2000). Violence and teenage births also seem to be examples of problems which are particularly strongly related to both relative deprivation and to income inequality (Health Development Agency, 2003; Wilson & Daly, 1997). These observations seem to confirm the simplest interpretation: that the reason why greater inequality is associated with a higher prevalence of these problems is that they are partly responses to the burden of relative deprivation, and inequality increases that burden. The relation between inequality and a range of health and social problems may also contribute to the debate around theories of social selection versus social causation in the production of social gradients in these problems, see for example: (Claussen, Smits, Naess, & Davey Smith, 2005; Dohrenwend, Levav, Shrout, Schwartz, Naveh, Link et al., 1992; Goldman, 1994; Hudson, 2005; McMunn, Bartley, Hardy, & Kuh, 2006; Ritsher, Warner, Johnson, & Dohrenwend, 2001). According to social selection theory, social gradients may reflect a tendency for social mobility to discriminate between the healthy and the unhealthy, so that the healthiest and most capable people move up the social ladder and end up with the highest incomes, while the least healthy end up at the bottom of the income distribution. Alternatively, social gradients in health might result from the way peoples health risks are shaped by less favourable social and material circumstances. If we can demonstrate a strong relationship between national levels of income inequality and a range of social problems, beyond health, we might gain a new perspective on the problem of social selection versus social causation, in relation to health. If we observe more homicides or a higher prevalence of obesity, in more unequal societies, it is unlikely that having a higher level of violence or a greater proportion of heavy people has caused income distributions to be wider. It is instead much more likely that causation runs the other way wider income differences leading to more violence and more obesity. And if greater economic inequality in a society is associated with more of most of the problems associated with relative deprivation, then this strongly suggests the operation of powerful processes of social causation for health as well. This does not mean that social mobility does not also act selectively: it may in turn select according to how people have been shaped by greater inequality. This is particularly plausible in relation to the long-term effects of circumstances in early life. As well as sharing roots in relative deprivation, many social problems including poor health may also involve similar causal processes involving psychosocial pathways related to chronic stress. The relative contributions to the link between inequality and population health of psychosocially mediated, or of the direct, unmediated, effects of material factors, have been disputed (Lynch, Smith, Kaplan, & House, 2000; Marmot & Wilkinson, 2001). However, many of the social problems which seem to be related to income inequality are inherently behavioural and provide evidence that income inequality has psychosocial effects. Indeed, if low social status increases chronic stress,
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this would provide fertile ground suggesting why so many health and behavioural problems seem rooted in relative deprivation and show similar social gradients and relationships with income inequality. Researchers have frequently assumed that if income differences are important, this implies the importance of processes of social comparison. A long tradition of sociological theory, stretching back to Marxs assumptions about the importance of the larger social framework (Bergesen & Bata, 2002) and Durkheims notion of social facts (Berkman, Glass, Brissette, & Seeman, 2000; Schwartz & Diez-Roux, 2001), has emphasized the ways in which individuals are shaped by the social environment, yet empirical investigation of the scales and pathways that underpin social comparisons is lacking. Following Runciman (1966), such comparisons are often thought to take place primarily at the local level, although there is some recognition that those who are spatial neighbours are not always social neighbours (Mitchell, Gleave, Bartley, Wiggins, & Joshi, 2000). But if income inequality is related to health more closely when the units of analysis are whole societies than when they are smaller areas, this implies that we are dealing with effects of relativities across a much larger scale. Dunn and colleagues recently reported relationships between health and various measures of socioeconomic status in a Canadian survey (Dunn, Veenstra, & Ross, 2006). They found that self-rated health was predicted by whether or not people felt they were better or worse off than the average Canadian. They also calculated how peoples actual incomes compared in relation to incomes in their neighbourhood and in their province. Although statistically significant for both, the correlations with health were stronger when peoples incomes were related to province-level income than they were when related to neighbourhood income. The less local provincial reference point was more salient than the neighbourhood reference point. This fits with what we would expect, based on our review of studies of income inequality and health (Wilkinson & Pickett, 2006). Because of the tendency to expect reference points for income to be local, people frequently refer to actual levels of monetary income as absolute income. But within a single nation it is of course impossible to tell whether relationships between health and income arise because of the absolute material standards of living which any given level of income buys, or because of where it places you in the national status hierarchy. Only when we compare income in different societies, as in our comparison of black Americans and Costa Ricans above, or when we look at life expectancy and Gross National Income per capita among the richest countries, do we see how weak the relation between absolute income levels and population health may be. Yet it is still not uncommon to refer to associations between the mean income and health for small areas as indicating effects of absolute income, rather than the effects of how the local population fits into the scale of national relativities whether the area is deprived or not in relation to the standards of the rest of society. What we are suggesting may look like action at a distance. Relativities and comparisons beyond the local seem more important than purely local ones. This looks less implausible if we are thinking of income distribution as a determinant of processes of social class differentiation rather than simply in terms of income comparisons. As we said above, the range of health and social problems which seem to be related to income distribution, and the fact that they are also related to relative deprivation, suggests that the salience of income distribution involves something much deeper than comparisons of income. When income distribution first appeared on the public health agenda, there
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was a tendency to assume that, if it was related to health at all, it must reflect some additional and previously unknown causal process. But it now seems much more likely that it is telling us more about the nature of the factors driving the familiar social class differences in health. What matters is perhaps that the associations between inequality and the prevalence of different outcomes are telling us more about the causal processes rooted in social differentiation. If, in addition, income distribution is really telling us about more general processes of social class differentiation, then it may be mistaken to analyse its effects after adjusting for other factors closely related to class, such as education. An indication of the range of the processes which may be set in motion by greater social differentiation comes from the data shown in figures 3 and 4 on imprisonment. Analyses of the increase in prison populations in Britain and the United States during the later 20th century, when income differences were widening, suggest that the greater part of the increase resulted from more punitive sentencing rather than from increases in crime (Mauer, 2001). A relation between wider income differences and more punitive attitudes to crime is suggested in Figure 4 which shows, cross-sectionally, that more unequal states are more likely to retain the death penalty. Greater inequality and bigger social distances may then be accompanied by hardening of social attitudes. The remaining question is of course how one knows ones class or social status in the wider society. The answer is likely to involve a knowledge of where one fits into many different relativities, all substantially influenced by income. A person may assess these relativities in relation to those she was at school with, where her school fitted into the social hierarchy, the income and social standing of her parents, the social connotations of her house and the part of town in which she lives, her educational achievements, place in the job hierarchy, and her knowledge gained through the media of the lives of the elite, the rich and powerful, the celebrities, and so on. Somehow we all learn the degrees of superiority and inferiority in our society and know where we stand. As Emerson said, Tis very certain that each man carries in his eye the exact indication of his rank in the immense scale of men, and we are always learning to read it (Emerson, 1883).
Conclusions It is often assumed that the desire to raise national standards of performance in fields such as education and health is a quite separate problem from the desire to reduce health and educational inequalities within a society. However, perhaps the most important implication of the relationships with inequality shown here is that the achievement of higher national standards of performance may be substantially dependent on reducing inequalities in each country. As well as improving health, reducing inequality may also raise the educational performance of school children, increase trust, while decreasing violence and teenage births. The associations we have seen between income inequality and a range of health and social problems are far from trivial. Even ignoring extreme examples, there are ten-fold differences in homicide rates between more and less equal countries and US states, sixfold differences in teenage birth rates, six-fold differences in the prevalence of obesity, four-fold differences in how much people feel they can trust each other, five- or tenfold differences in imprisonment rates and, mainly as a result of deaths at younger ages,
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three years difference in the average length of life. These issues go to the heart of problems which beset our societies and are constantly in the news. They attract strings of policy initiatives designed to tackle each of these issues separately: policies to reduce overcrowded prisons, to reduce violence or teenage births, to raise childrens educational performance and so on as if there was no connection between them. Although Britain is said to be ahead of continental Europe in developing and implementing policies to reduce socio-economic inequalities in health (Mackenbach, 2006b), so far they have met with little success (Department of Health, 2005; Mackenbach, 2006a). Perhaps that is because they have focussed less on decreasing the burden of relative deprivation than on attempts to reduce its effects on health. It is difficult to stop relative deprivation having its familiar effects on health. However, if ill health is just one of the many social problems related to relative deprivation which are less common in more egalitarian countries, then there are likely to be substantial and widespread benefits of tackling the underlying inequality itself. Indeed, if inequality has psychosocial effects, perhaps involving chronic stress and the aversive effects of low social status, then it is possible that some of the health and social problems marked by social gradients share roots in chronic stress. Rather than providing ever more prisons, doctors, health promoters, social workers, educational psychologists and drug rehabilitation units, in expensive and at best only partially effective attempts to offset the problems of relative deprivation, it may be cheaper and more rewarding to tackle the underlying inequalities themselves. The differences in inequality we have been looking at are, after all, not differences between an impractical perfect equality and practical reality. Instead, they seem to show the importance of the existing differences in inequality which occur now between developed market democracies or between US states, and which can only be revealed through comparative analysis at the scale of whole societies.
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FIGURE LEGENDS Figure 1 Prevalence in mental illness in relation to income inequality among rich countries Figure 2 Educational achievement in relation to income inequality among rich countries Figure 3 Imprisonment in relation to income inequality among rich countries Figure 4 Imprisonment in relation to income inequality among the 50 US states and DC, also indicating states with and without the death penalty Figure 5 Intergenerational social mobility in relation to income inequality among rich countries
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Wilkinson, R. G., & Pickett, K. E. (2007). Social Science & Medicine, 65(9), 1965-1978.

Richard G. Wilkinson and Kate E. Pickett

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