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Iration hotting up torrent

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We can now see that the situation m ay be alm ost the opposite o f that. N ational standards o f health, and o f other im portant outcomes which we shall discuss in later chapters, are substantially determined by the amount o f inequality in a society. Reducing inequality is the best w a y o f doing both.

In the rich countries, it is now the sym bolic importance o f wealth and possessions that matters. W hat purchases say about status and identity is often more im portant than the goods themselves. Put crudely, second-rate goods are assumed to reflect second-rate people.

Possessions are m arkers o f status everywhere, but in poorer societies, where necessities are a much larger part o f consumption, the reasons w hy more equal societies do better m ay have less to do with status issues and more to do with fewer people being denied access to food, clean w ater and shelter.

It is only am ong the very richest countries that health and wellbeing are no longer related to Gross N ational Income per person. In poorer countries it is still essential to raise living standards and it is most im portant among the poorest. In those societies a more equal distribution o f resources will mean fewer people w ill be living in shanty tow ns, with dirty w ater and food insecurity, or trying to scrape a living from inadequate land-holdings. Ralph Waldo Emerson, The Conduct o f Life H o w is it that we are affected as strongly by inequality and our position within society as the data in the last chapter suggest?

Before exploring - as we shall in the next nine chapters - the relations between inequality and a w ide range o f social problem s, including those in our Index o f H ealth and Social Problem s, w e w ant to suggest w h y human beings might be so sensitive to inequality. It is individuals - not the societies themselves - w ho have poor health, are violent or become teenage mothers.

Although individuals do not have an income distribution, they do have a relative income, social status or class position in the wider society. So in this chapter we w ill show the w ays in which our individual sensitivity to the w ider society explains w hy living in more unequal societies might have such profound effects. T o understand our vulnerability to inequality means discussing some o f our com mon psychological characteristics.

T o o often when we speak or w rite about these issues, people misinterpret our purpose. The best w a y o f responding to the harm done by high levels o f inequality w ould be to reduce inequality itself. Rather than requiring anti-anxiety drugs in the w ater supply or mass psychotherapy, w hat is most exciting about the picture we present is that it show s that reducing inequality w ould increase the wellbeing and quality o f life for all o f us.

Far from being inevitable and unstoppable, the sense o f deterioration in social wellbeing and the quality o f social relations in society is reversible. Understanding the effects o f inequality means that w e suddenly have a policy handle on the wellbeing o f w hole societies. Individual psychology and societal inequality relate to each other like lock and key.

One reason w hy the effects of inequality have not been properly understood before is because o f a failure to understand the relationship between them. H ow ever, Je an Tw enge, a psychologist at San Diego State University, has put together impressive evidence that w e really are much more anxious than w e used to be.

By review ing the large number o f studies of anxiety levels in the population carried out at different dates, she has documented very clear trends. She found broadly com parable studies m easuring anxiety levels in the U S A at various times between 1 9 5 2 and 1 9 9 3.

W hat they showed w as a continuous upw ard trend throughout this forty-year period. Her results for men and wom en are shown in Figure 3. Each dot in the graph shows the average level o f anxiety found in a study recorded against the date it w as undertaken.

The rising trend across so m any studies is unm istakable. Data from samples covering 52, individuals. The worsening trend also fits w hat w e kn ow has been happening in related conditions such as depression. There are now large numbers o f studies show ing substantial increases in rates o f depression in developed countries. Some studies have looked at change over the last half century or so by com paring the experience o f one generation with another, while taking care to avoid pitfalls such as an increased awareness leading to more frequent reporting o f depression.

In Britain, for exam ple, depression measured am ong people in their m id-zos w as found to be twice as com mon in a study o f 10 ,0 0 0 or so people born in 19 7 0 as it had been in a sim ilar study carried out earlier o f people in their m id-zos bom in 19 5 8. Am ong adolescents, these have been accom panied by increases in the frequency o f behavioural problem s, including crime, alcohol and drugs.

W e are not suggesting that they were triggered by increased inequality. It is possible, how ever, that the trends between the 19 7 0 s and 19 9 0 s m ay have been aggravated by increased inequality. When com pared over time, in much the same w ay as the trends in anxiety are shown in Figure 3.

So w h at could have been going on? The answ er turns out to be a picture of increasing anxieties about how w e are seen and w hat others think o f us which has, in turn, produced a kind o f defensive attempt to shore up our confidence in the face o f those insecurities. The defence involves a kind o f self-prom oting, insecure egotism which is easily mistaken for high self-esteem. This might seem like a difficult set o f issues to pin dow n, particularly as we are talking about general trends in w hole populations.

But let us look briefly at the evidence which has accum ulated since the self-esteem movement o f the 19 8 0 s, which show s w hat has been happening. O ver the years, m any research groups looking at individual differences in self-esteem at a point in time rather than at trends in population averages over time began to notice tw o categories o f people w ho came out with high scores. In one category, high self-esteem went w ith positive outcomes and w as associated with happiness, confidence, being able to accept criticism , an ability to m ake friends, and so on.

They were people w ho showed tendencies to violence, to racism, w ho were insensitive to others and were bad at personal relationships. The other seemed to be prim arily defensive and involved a denial o f weaknesses, a kind o f internal attempt to talk oneself up and maintain a positive sense o f oneself in the face of threats to self-esteem.

It w as and is therefore fragile, like whistling in the dark, and reacts badly to criticism. People with insecure high self-esteem tend to be insensitive to others and to show an excessive preoccupation with themselves, with success, and with their image and appearance in the eyes o f others.

D uring the com paratively short time over which data are available to com pare trends in narcissism w ithout getting it m ixed up with real self-esteem, Tw enge has show n a rising trend. She found that by zoo 6, two-thirds o f Am erican college students scored above w hat had been the average narcissism score in 19 8 2.

The recognition that w h at w e have seen is the rise o f an insecure narcissism - particularly am ong young people - rather than a rise in genuine self-esteem now seems w idely accepted. There are now good pointers to the main sources o f stress in modern societies. M uch o f the research has been focused on a central stress hormone called cortisol which can be easily measured in saliva or blood.

There have now been numerous experiments in which volunteers have been invited to come into a laboratory to have their salivary cortisol levels measured while being exposed to some situation or task designed to be stressful.

Social evaluative threats were those which created the possibility for loss o f esteem. They typically involved the presence o f an evaluative audience in the experiment, a potential for negative social com parison such as scoring w orse than someone else, or having your perform ance videoed or recorded, so creating the potential for later evaluation.

The finding that social evaluative threats are the stressors which get to us most pow erfully fits w ell w ith the evidence o f rising anxiety accom panied by a narcissistic defence o f an insecure self-image. A quite separate strand o f health research corroborates and fills out this picture. One o f the most im portant recent developments in our understanding o f the factors exerting a m ajor influence on health in rich countries has been the recognition of the importance o f psychological stress.

But w hat matters to us in this chapter is that the most powerful sources o f stress affecting health seem to fall into three intensely social categories: low social status, lack o f friends, and stress in early life. All have been shown, in m any well-controlled studies, to be seriously detrimental to health and longevity.

M uch the most plausible interpretation o f w hy these keep cropping up as m arkers for stress in modern societies is that they all affect - or reflect - the extent to which w e do or do not feel at ease and confident with each other.

Insecurities which can come from a stressful early life have some similarities with the insecurities which can come from low social status, and each can exacerbate the effects o f the other. Friendship has a protective effect because w e feel more secure and at ease with friends.

Friends make you feel appreciated, they find you good com pany, enjoy your conversation - they like you. If, in contrast, w e lack friends and feel avoided by others, then few o f us are thick-skinned enough not to fall prey to self-doubts, to worries that people find us unattractive and boring, that they think w e are stupid or socially inept.

H o w people see you matters. W hile it is o f course possible to be upper-class and still feel totally inadequate, or to be lower-class and full o f confidence, in general the further up the social ladder you are, the more help the w orld seems to give you in keeping the self-doubts at bay. If the social hierarchy is seen - as it often is - as if it were a ranking o f the human race by ability, then the outw ard signs o f success or failure the better jobs, higher incomes, education, housing, car and clothes all make a difference.

T o do well for yourself or to be successful is alm ost synonym ous with m oving up the social ladder. H igher status alm ost alw ays carries connotations o f being better, superior, more successful and more able. Social com parisons increasingly show you in a positive light - whether they are com parisons o f wealth, education, job status, where you live, holidays, or any other markers o f success.

By playing on our fears o f being seen as o f less w orth, advertisers m ay even contribute to the level of violence in a society. It w as Thom as Scheff, emeritus professor o f sociology at the University o f C alifornia, Santa B arbara, w ho said that shame was the social em otion.

Shame and its opposite, pride, are rooted in the processes through which w e internalize how w e imagine others see us. N o r o f course does it stop in childhood: our sensitivity to shame continues to provide the basis for conform ity throughout adult life. People often find even the smallest infringement o f social norms in the presence o f others causes so much em barrassm ent that they are left wishing they could just disappear, or that the ground w ould sw allow them up.

Although the D ickerson and Kem eny study found that it was exposure to social evaluative threats which most reliably raised levels o f stress horm ones, that does not tell us how frequently people suffer from such anxieties. A re they a very com mon part o f everyday life, or only occasional? An answ er to that question comes from the health research show ing that low social status, lack o f friends, and a difficult early childhood are the most im portant m arkers o f psychosocial stress in modern societies.

If our interpretation o f these three factors is right, it suggests that these kinds o f social anxiety and insecurity are the most com m on sources of stress in modern societies. W hy does the social evaluative threat seem so great? A plausible explanation is the break-up o f the settled communities o f the past.

People used to gro w up know ing, and being know n by, m any o f the same people all their lives. Although geographical m obility had been increasing for several generations, the last half century has seen a particularly rapid rise. A t the beginning o f this period it w as still com m on for people - in rural and urban areas alike - never to have travelled much beyond the boundaries o f their immediate city or village com munity.

M arried brothers and sisters, parents and grandparents, tended to remain living nearby and the com m unity consisted of people w ho had often known each other for much o f their lives. Fam iliar faces have been replaced by a constant flux o f strangers. A s a result, w ho we are, identity itself, is endlessly open to question.

A nd at the core o f our interactions with strangers is our concern at the social judgements and evaluations they might m ake: h ow do they rate us, did w e give a good account o f ourselves? It is w ell know n that these problems are particularly difficult for adolescents. W hile their sense o f themselves is most uncertain, they have to cope in schools o f a thousand or more o f their peers.

It is hardly surprising that peer pressure becomes such a pow erful force in their lives, that so m any are dissatisfied with w hat they look like, or succumb to depression and self-harm. Rather than being entirely separate spheres, how much status and wealth people achieve - from unskilled low -paid w o rk to success, money and pre-eminence - affects not only their sense o f themselves, but also how positively they are seen even by friends and fam ily.

Our need to feel valued and capable human beings means w e crave positive feedback and often react w ith anger even to implied criticism. Social status carries the strongest messages o f superiority and inferiority, and social m obility is w idely seen as a process by which people are sorted by ability. Instead o f accepting each other as equals on the basis o f our com m on humanity as w e might in m ore equal settings, getting the measure o f each other becomes more im portant as status differences widen.

Between strangers it m ay often be the dom inant feature. If inequalities are bigger, so that some people seem to count for alm ost everything and others for practically nothing, where each one o f us is placed becomes more im portant. Greater inequality is likely to be accom panied by increased status com petition and increased status anxiety. It is not sim ply that where the stakes are higher each o f us w orries more about where he or she comes.

It is also that w e are likely to pay more attention to social status in how w e assess each other. Surveys have found that when choosing prospective m arriage partners, people in more unequal countries put less em phasis on rom antic considerations and more on criteria such as financial prospects, status and am bition, than do people in less unequal societies. In Jap an , people choose a much more self-deprecating and self-critical w a y o f presenting themselves, which contrasts sharply with the much more self-enhancing style in the U S A.

While Am ericans are more likely to attribute individual successes to their ow n abilities and their failures to external factors, the Japanese tend to do just the opposite. This Japanese pattern w as also found in T aiw an and China. Rather than getting too caught up in psychological term inology, w e w ould do well to see these patterns as differences in how far people value personal modesty, preferring to maintain social bonds by not using their successes to build themselves up as more able than others.

A s greater inequality increases status com petition and social evaluative threat, egos have to be propped up by self-promoting and self-enhancing strategies. M odesty easily becomes a casualty of inequality: we become outw ardly tougher and harder in the face o f greater exposure to social evaluation anxieties, but inw ardly - as the literature on narcissism suggests - probably more vulnerable, less able to take criticism , less good at personal relationships and less able to recognize our own faults.

The slogan focused attention on the dimensions o f social relations which matter most if w e are to create a better society and m ake a difference to the real quality o f our lives. It w as liberty from the feudal shackles o f inferiority. We raise the same issues when w e talk about com munity, social cohesion or solidarity. Their importance to human wellbeing is demonstrated repeatedly in research which show s how beneficial friendship and involvem ent in com munity life is to health.

N o t only do large inequalities produce all the problems associated w ith social differences and the divisive class prejudices which go w ith them, but, as later chapters show , it also w eakens com m unity life, reduces trust, and increases violence. I easily perceived the enormous influence that this primary fact exercises on the workings of the society. A m andatory evacuation order was issued for the city the day before the storm hit, but by that time most public transport had shut down and fuel and rental cars were unavailable.

A t least 1,8 3 6 people were killed by the hurricane, and another 70 0 people were missing and unaccounted for. There were numerous arrests and shoot-outs throughout the week follow ing the hurricane. This response to the chaos in N ew O rleans led to widespread criticism and condem nation within the U S. M an y alleged that the lack o f trust between law enforcement and m ilitary forces on the one hand and the m ostly poor, black citizens o f N ew O rleans on the other, reflected deeper issues o f race and class.

These troops kn ow h ow to shoot and kill and I expect they w ill. A lexis de Tocqueville travelled throughout the United States in 1 8 3 1. And de Tocqueville points out the w ays in which Am ericans support one another in times o f trouble: Should some unforeseen accident occur on the public highway, people run from all sides to help the victim; should some family fall foul of an unexpected disaster, a thousand strangers willingly open their purses.

But does inequality corrode trust and divide people - government from citizens, rich from poor, m inority from m ajority? This chapter show s that the quality of social relations deteriorates in less equal societies. Inequality, not surprisingly, is a pow erful social divider, perhaps because w e all tend to use differences in living standards as markers o f status differences. We tend to choose our friends from am ong our near equals and have little to do with those much richer or much poorer.

O ur position in the social hierarchy affects w ho we see as part of the in-group and w ho as out-group - us and them - so affecting our ability to identify w ith and empathize w ith other people. De Tocqueville understood this point. A lifelong opponent o f slavery, he w rote about the exclusion o f both African-Am ericans and N ative Am ericans from the liberty and equality enjoyed by other Am ericans.

E arly socialists and others believed that m aterial inequality w as an obstacle to a w ider human harm ony, to a universal human brotherhood, sisterhood or com radeship. The data w e present in this chapter suggest that this intuition w as sound: inequality is divisive, and even small differences seem to make an im portant difference. Income inequality Figure 4. Data available for only forty-one US states.

These relationships are strong enough th at w e can be confident that they are not due to chance. Th e international data on trust in Figure 4. People trust each other m ost in the Scan din avian countries and the N eth erlan d s; Sw eden has the highest levels o f trust, w ith 66 per cent o f people feeling that they can trust others. T h e lo w est level o f trust is seen in Portu gal, w h ere on ly 10 per cent o f the popu lation believe that others can be trusted. So just w ithin these rich, m arket dem ocracies, there are m ore than six fo ld differences in levels o f trust, and, as the graph sh ow s, high levels o f trust are linked to lo w levels o f inequality.

The data on trust w ithin the U S A , sh ow n in Figure 4. W ithin the U S A , there are fourfold differences in trust between states. N orth D akota has a level o f trust similar to that o f Sweden - 67 per cent feel they can trust other people - whereas in M ississippi only 1 7 per cent o f the population believe that people can be trusted. Ju st as with the international data, low levels o f trust among the United States are related to high inequality. The im portant message in these graphs o f trust and inequality is that they indicate how different life must feel to people living in these different societies.

Imagine living somewhere where 90 per cent o f the population mistrusts one another and w hat that must mean for the quality o f everyday life - the interactions between people at w ork, on the street, in shops, in schools. In N o rw ay it is not unusual to see cafes with tables and chairs on the pavem ent and blankets left out for people to use if they feel chilly while having a coffee. N o b o d y w orries about customers or passers-by stealing the blankets. M an y people feel nostalgic for time past, when they could leave their doors unlocked, and trusted that a lost w allet w ould be handed in.

O f all large U S cities, N ew O rleans is one o f the most unequal. This w as the background to the tensions and mistrust in the scenes o f chaos after H urricane Katrina that we described above. In the U S A , trust has fallen from a high o f 60 per cent in i96 0, to a lo w o f less than 40 per cent by Z Which comes first? In terms of the distribution of wealth and income, America in the s and s was more egalitarian than it had been in more than a century.

Record highs in equality and social capital coincided. Conversely, the last third of the twentieth century was a time of growing inequality and eroding social capital. The timing of the two trends is striking: Sometime around 19 6 5 -7 0 America reversed course and started becoming both less just economically and less well connected socially and politically, p.

Using a wealth o f data from different sources, he show s that people w ho trust others are optimists, with a strong sense o f control over their lives. The kind o f parenting that people receive also affects their trust o f other people. The numbers on the graph show for each year 19 6 0 -9 8 the relation between the level o f trust and inequality in that year. Changes in inequality and trust go together over the years. With greater inequality, people are less caring o f one another, there is less m utuality in relationships, people have to fend for themselves and get w hat they can - so, inevitably, there is less trust.

M istrust and inequality reinforce each other. A s de Tocqueville pointed out, w e are less likely to empathize with those not seen as equals; material differences serve to divide us socially. Uslaner show s that, in the U S A , people w ho trust others are more likely to donate time and money to helping other people.

They are also supportive o f the legal order. H igh levels o f trust mean that people feel secure, they have less to w o rry about, they see others as co-operative rather than competitive. A number o f convincing studies in the USA have linked trust to health - people with high levels o f trust live longer. Trust w as also crucial for survival in the Chicago heatwave o f 19 9 5.

In equally poor H ispanic neighbourhoods, characterized by high levels o f trust and active com munity life, the risk o f death was much lower. But the vehicles themselves have names that evoke images o f hunters and outdoorsm en - O utlander, Pathfinder, Cherokee, W rangler, etc. Others evoke an even tougher image, o f soldiers and w arriors, with names like Trooper, D efender, Shogun, R aider and Com m ander. N o t only did the popularity o f S U V s suggest a preoccupation with looking tough, it also reflected grow ing mistrust, and the need to feel safe from others.

When w e put this to the test, we found that just as levels o f trust and social relations are affected by inequality, so too is the status o f wom en. Nevertheless, there is a tendency that cannot be put dow n to chance, for fewer wom en to vote or hold political office, for wom en to earn less, and fewer wom en to complete college degrees in more unequal states. O nly N o rw ay , Sweden, Denm ark and the Netherlands meet that target - indeed, they are generous beyond w hat the United N ations expects - and, as we show in Figure 4.

Jap an and the U K might be seen as outliers on this graph. One factor is the strength o f the relationship, which is shown by the steepness o f the lines in Figures 4. People in Sweden are much more likely to trust each other than people in Portugal. A ny alternative explanation w ould need to be just as strong, and in our ow n statistical models we find that neither poverty nor average standards o f living can explain our findings.

We also see a consistent association among both the United States and the developed countries. Earlier w e described how Uslaner and Rothstein used a statistical model to show the ordering of inequality and trust: inequality affects trust, not the other w ay round. In sum m ary, we can think o f trust as an im portant m arker o f the w ays in which greater material equality can help to create a cohesive, co-operative com munity, to the benefit o f all.

Mental health and drug use It is no measure of health to be well adjusted to a profoundly sick society. A m illion British children - one in ten between the ages o f 5 and 1 6 - are estimated to be mentally ill. In the U S A , 6 per cent o f children have been diagnosed with Attention Deficit H yperactivity D isorder, a behavioural syndrome characterized by serious distractibility, im pulsivity and restlessness. Everyone's on an anti-depressant!

To be mentally healthy you must value and accept yourself. It is also im portant to note that although people w ith mental illness sometimes have changes in the levels o f certain chemicals in their brains, nobody has show n that these are causes o f depression, rather than changes caused by depression.

Can w e really com pare levels o f mental illness in different countries? But this began to get easier in the 19 8 0 s, when researchers developed diagnostic interviews - sets o f questions that could be asked by non-psychiatrists and non-psychologists, allow ing researchers to measure on a large scale the numbers o f people meeting diagnostic criteria for different mental illnessess.

In 19 9 8 , the W orld H ealth O rganization set up the W orld M ental Health Survey Consortium in an attempt to estimate the numbers o f people w ith mental illness in different countries, the severity o f their illness and patterns o f treatment. Ju st as we saw w ith levels of trust in the previous chapter, there are big differences in the proportion o f people with mental illness from 8 per cent to 26 per cent between countries.

In Germ any, Italy, Ja p a n and Spain, fewer than 1 in 1 0 people had been mentally ill within the previous year; in A ustralia, C anada, N e w Z ealan d and the U K the numbers are more than 1 in 5 people; and in the U S A , as we described above, more than 1 in 4.

We saw in Chapter 3 h ow anxiety has been increasing in developed countries in recent decades. A nxiety disorders represent the largest sub-group o f mental illness in all our countries. Indeed, the percentage o f all mental illnesses that are anxiety disorders is itself significantly higher in more unequal countries. U nfortunately, there are no international sources o f com parable data on the mental health o f children and adolescents.

Turning now to our other test-bed, the fifty states o f the U S A , we discovered something rather surprising. Alone am ong the numerous health and social problem s we exam ine in this book, we found no relationship between adult male mental illness and income inequality among the U S states. State-specific estimates o f mental illness are collected both by the United States Behavioral R isk Factor Surveillance Study and by the N ational Survey on D rug Use and Health, but the lack of a relationship between income inequality and mental illness am ong men w as consistent in both sources.

H ow ever, income inequality is associated w ith mental illness in adult wom en. It is not a particularly strong relationship, but too strong to be dismissed as chance. In general, problem s related to inequality have steep social gradients becoming more com m on low er dow n the social ladder. Psychologist and journalist O liver Jam es uses an analogy with infectious disease to explain the link. These kinds o f values place us at greater risk o f depression, anxiety, substance abuse and personality disorder, and are closely related to those w e discussed in Chapter 3.

Advertisers play on this, m aking us dissatisfied with w hat we have, and encouraging invidious social com parisons. Internationally, the United N ations Office on Drugs and Crime publishes a W orld D ru g R ep o rt,57 which contains separate data on the use o f opiates such as heroin , cocaine, cannabis, ecstasy and amphetamines. We com bined these data to form a single index, giving each drug category the same weight so that the figures were not dom inated by the use o f any one drug.

We use this index in Figure 5. W ithin the United States, there is also a tendency for addiction to illegal drugs and deaths from drug overdose to be higher in more unequal states. Serotonin and dopamine are among the chemicals that play im portant roles in the regulation o f m ood: in hum ans, low levels o f dopamine and serotonin have been linked to depression and other mental disorders. In a clever experiment, researchers at W ake Forest School o f M edicine in N orth C arolina took twenty macaque m onkeys and housed them for a while in individual cages.

N ext, they taught the monkeys that they could administer cocaine to themselves by pressing a lever - they could take as much or as little as they liked. The results o f this experiment were rem arkable. M onkeys that had become dom inant had more dopam ine activity in their brains than they had exhibited before becoming dom inant, while monkeys that became subordinate when housed in groups showed no changes in their brain chemistry.

The dom inant m onkeys took much less cocaine than the subordinate m onkeys. In effect, the subordinate monkeys were medicating themselves against the impact o f their low social status. This kind o f experim ental evidence in monkeys adds plausibility to our inference that inequality is causally related to mental illness.

A t the beginning o f this chapter w e mentioned the huge number o f prescriptions written for m ood-altering drugs in the U K and U S A ; add these to the self-medicating users o f illegal drugs and w e see the pain w rought by inequality on a very large scale. Physical health and life expectancy A sad soul can kill you quicker than a germ. The history o f public health is one o f shifting ideas about the causes o f disease.

This led to the great reform s o f the Sanitary M ovem ent. Sm oking, high-fat diets, exercise and alcohol were the focus o f attention. But in the latter part of the twentieth century, researchers began to m ake some surprising discoveries about the determinants o f health. They had started to believe that stress w as a cause o f chronic disease, particularly heart disease. Researchers expected to find the highest risk o f heart disease among men in the highest status jobs; instead, they found a strong inverse association between position in the civil service hierarchy and death rates.

M en in the low est grade messengers, doorkeepers, etc. Those in lower grades were indeed more likely to be obese, to sm oke, to have higher blood pressure and to be less physically active, but these risk factors explained only one-third o f their increased risk o f deaths from heart disease.

There are now numerous studies that show the same thing, in different societies and for m ost kinds o f ill-health - low social status has a clear impact on physical health, and not just for people at the very bottom o f the social hierarchy. There is a social gradient in health running right across society, and where w e are placed in relation to other people matters; those above us have better health, those below us have w orse health, from the very bottom to the very top.

The relationships w e have w ith other people matter too. This idea goes back as far as the w o rk on suicide by Emile Durkheim , one o f the founding fathers o f sociology, in the late nineteenth century. H aving friends, being m arried, belonging to a religious group or other association and having people w ho w ill provide support, are all protective o f health. In a striking experiment, researchers have also show n that people w ith friends are less likely to catch a cold when given the same m easured exposure to the cold virus - in fact the more friends they had, the m ore resistant they w ere.

In more threatening circumstances, then, more reckless strategies are perhaps necessary to gain status, m axim ize sexual opportunities, and enjoy at least some short-term gratifications. Perhaps only in m ore relaxed conditions, in which a longer life is assured, can people afford to plan for a long-term future. W hen they put the tw o together, they showed a rem arkably close relationship, seen in Figure 6. Something about these neighbourhoods seemed to be affecting both health and violence.

Calculation o f life expectancy included deaths from all causes except homicide. There are sixfold differences in levels o f trust between developed countries and fourfold differences am ong U S states. We mentioned that levels o f trust have been linked to population health and, in fact, research on social cohesion and social capital has mushroom ed over the past ten years or so.

M ore than forty papers on the links between health and social capital have now been published. The higher the group membership, the low er the death rate. R obert Putnam looked at social capital in relation to an index o f health and health care for the US states. The health index w as closely linked to social capital; states such as M innesota and Verm ont had high levels o f social capital and scored high on the health index, states such as Louisiana and N evada scored badly on both.

Spending on drug treatments and high-tech scanning equipment is particularly high. D octors in this country earn alm ost twice as much as doctors elsewhere and medical care is often described as the best in the w orld.

B aby B is born in one o f the poorer o f the western democracies, Greece, where average income is not much m ore than h alf that o f the U S A. This is in real terms, after taking into account the different costs o f medical care. And Greece has six times fewer high-tech scanners per person than the U S A. A nd B aby A has a 40 per cent higher risk o f dying in the first year after birth than B aby B.

Some com parisons are even m ore shocking: in 19 9 0 , C olin M cC o rd and H arold Freeman in the Departm ent o f Surgery at C olum bia University calculated that black men in H arlem were less likely to reach the age o f 65 than men in Bangladesh. There are now a large number o f studies o f income inequality and health that com pare countries, Am erican states, or other large regions, and the m ajority o f these studies show that m ore egalitarian societies tend to be healthier.

The more equally wealth is distributed the better the health of that society. Figures 6. O f course, population averages hide the differences in health w ithin any population, and these can be even more dram atic than the differences betw een countries.

Infant deaths per iooo live births Low H igh Income inequality Figure 6. Infant deaths per iooo live births Low High Incom e inequality Figure 6. N ote that, as the W hitehall study show ed, these gaps cannot be explained aw ay by w orse health behaviours am ong those low er dow n the social scale. W e exam ined several different causes o f death to see which had the biggest class differences in health.

We found that deaths among working-age adults, deaths from heart disease, and deaths from homicide had the biggest class differences. In contrast, death rates from prostate cancer had small class differences and breast cancer death rates were com pletely unrelated to social class.

Then we looked at how those different death rates were affected by income inequality, and found that those with big class differences were much more sensitive to inequality. Instead, they run right across society so that even the reasonably w ell-off have shorter lives than the very rich.

Likew ise, the benefits o f greater equality spread right across society, im proving health for everyone - not just those at the bottom. A dram atic exam ple o f how reductions in inequality can lead to rapid improvements in health is the experience o f Britain during the tw o w orld w a rs. In the decades which contain the w orld w ars, life expectancy increased between 6 and 7 years for men and wom en, whereas in the decades before, between and after, life expectancy increased by between 1 and 4 years.

H ow ever, both wartim es were characterized by full em ploym ent and considerably narrow er income differences - the result o f deliberate governm ent policies to promote co-operation w ith the w a r effort. D uring the Second W orld W ar, for exam ple, w orking-class incomes rose by 9 per cent, while incomes o f the middle class fell by 7 per cent; rates o f relative poverty were halved.

The resulting sense o f cam araderie and social cohesion not only led to better health - crime rates also fell. W hen w e experience some kind o f acute stress and experience something traum atic, our bodies go into the fight-or-flight response.

O ur senses and m em ory are enhanced and our immune system perks up. We are prim ed and ready to fight or run aw ay from w hatever has caused the stress. If the emergency is over in a few minutes, this am azing response is healthy and protective, but when w e go on w orrying for weeks or months and stress becomes chronic, then our bodies are in a constant state of anticipation o f some challenge or threat, and all those fight-or-flight responses become damaging.

The human body is superb at responding to the acute stress of a physical challenge, such as chasing down prey or escaping a predator. The circulatory, nervous and immune systems are mobilized while the digestive and reproductive processes are suppressed. If the stress becomes chronic, though, the continual repetition of theses responses can cause major damage. N eurons in some areas o f the brain are damaged and cognitive function declines. We have trouble sleeping. Chronic stress w ears us dow n and wears us out.

O ur belief that this is a causal relationship is enhanced by the coherent picture that emerges from research on the psychosocial determinants o f health, and the social gradients in health in developed countries. Sim ilarly, in Ja p an , the influence o f the post-Second W orld W ar A llied occupation on dem ilitarization, dem ocracy and redistribution o f wealth and pow er led to an egalitarian econom y and unrivalled improvements in population health.

In some countries rates have doubled in just a few years. In the U S A , in the late 19 7 0 s , close to h alf the population were overweight and 15 per cent were obese; now three-quarters o f the population are overweight, and close to a third are obese. T h at w ould be the first reversal in life expectancy in m any developed countries since governments started keeping track in the nineteenth century.

H is weight w as so great that he often missed school due to his difficulties in w alking there and back, and w as exem pt from w earing school uniform because none w as available to fit him. His elder sister, aged 9, weighed 19 6 lb 14 stone and w as also being bullied and teased, by both children and adults. H eaviest w as the oldest boy w ho, at the age o f 1 2 , weighed lbs 20 stone. H e w as desperately unhappy - expelled from tw o schools and suspended from a third, for lashing out at children w ho called him names.

But the sudden rapid increase in obesity in many societies cannot be explained by genetic factors. The obesity epidemic is caused by changes in how we live. Others point to the decline in physical activity, both at work and in leisure time, increasing car use and the reduction in physical education programmes in schools. If there w as no more to it than that, then w e might expect to see more obesity am ong richer people, w ho are able to buy more food, more cars, etc.

But this is not w hat happens. In the past the rich were fat and the poor were thin, but in developed countries these patterns are now reversed. It found that, as rates o f obesity have increased, their social gradient has steepened. The data on obesity come from the International Obesity T ask Force and show the proportion o f the adult population, both men and wom en, w ho are obese - a Body M ass Index B M I o f more than 3 0.

In the U S A , just over 30 per cent o f adults are obese; a level more than twelve times higher than Ja p an , where only 2. Income inequality Figure 7. The same pattern can be seen internationally for children Figure 7. The differences between countries are sm aller for overweight children than for adult obesity.

In the country with the lowest level, the N etherlands, 7. W ithin the U S A , there are no states w ith levels o f adult obesity low er than 20 per cent. Other researchers have found sim ilar relationships. One study found that higher state-level income inequality w as associated with abdom inal weight gain in m en, others have found that income inequality increases the risk o f inactive lifestyles.

Ju st as for the international figures for children, these data are for overweight rather than obese children, aged 1 0 - 1 7 years. Professor Ezzati bases his calculations o f the prevalence o f obesity in each state on actual measures o f height and weight. Per cent obese Low H igh Income inequality Figure 7. The pathw ays linking income inequality to obesity are likely to include calorie intake and physical activity. Indeed, our own research has show n that per capita calorie intake is higher in more unequal countries.

This explained part o f the relationship between inequality and obesity, but less for wom en than for m en. But in studies in A ustralia, the U K and Sweden the am ount that people eat, and the am ount o f exercise they do, fails to fully account for social class differences in weight gain and obesity. People w ith a long history o f stress seem to respond to food in different w ays from people w h o are not stressed. Their bodies respond by depositing fat particularly round the middle, in the abdom en, rather than low er dow n on hips and thighs.

People w ho accum ulate fat around the middle are at particularly high risk of obesity-associated illnesses. N o t only does it make us put on w eight in the w orst places, it can also increase our food intake and change our food choices, a pattern know n as stress-eating or eating for com fort. In experiments with rats, when the anim als are stressed they eat more sugar and fat.

People w ho are chronically stressed tend either to over-eat and gain weight, or under-eat and lose weight. In a study in Finland, people w hose eating w as driven by stress ate sausages, ham burgers, pizza and chocolate, and drank m ore alcohol than other people.

I turned to Pepsi - it was like a drug for me. I used to wake up with a Pepsi in my hand. A three-liter bottle would just see me through the day. Recent research suggests that food stimulates the brains o f chronic over-eaters in just the same w ays that drugs stimulate the brains o f addicts.

A year-old man said he spent half his w ages on fast food. On the day he w as interviewed he had been to M cD onalds three times and w as planning to go to Kentucky Fried Chicken and a Chinese take-out shop before the day w as out. But the fast-food restaurants had a m eaning for him that went w ell beyond the cheap food. I wanted to live the life of a man. Fast food gets you status and respect.

O ur ow n w o rk , like the studies o f other researchers, show s that the relation between income inequality and obesity is stronger for wom en than for men. In the H ealth Survey for England, the positive association between lo w socio-econom ic status and obesity is very clear for wom en but am ong men there is no association. M ayb e obese young wom en suffer more discrim ination in labour m arkets and the m arriage m arket, than obese young men.

O r m aybe lo w social status is more o f a risk factor for obesity in wom en than in men. These studies are surveys o f large sam ples o f people born at the same time, and follow ed from birth. In the past, wom en with voluptuous bodies w ere much adm ired, but in m any m odern, richer cultures, being thin signals high social class and attractiveness.

British wom en in higher social classes are more likely to m onitor their weight and to be dieting than wom en in low er social class groups, and are also more dissatisfied w ith their bodies. Changes in m arital status also p lay a role: in a U S study, wom en w ho m arried gained more weight than wom en w h o remained single or wom en w ho divorced or separated.

H er w ords are a reminder o f the w ays in which social class is related to being overweight in the developing w orld, where only the affluent can afford to be fat. A recent 12 -y e a r study o f w orking-age men in the U S A found that if they became unemployed, they gained w eight. Put simply, this theory suggests that when a pregnant w om an is stressed, the development o f her unborn child is modified to prepare it for life in a stressful environment.

In other w ords, they are adapted for an environment where food is scarce - they are small and need less food. Babies with a thirfty phenotype in a w orld where food is plentiful are more prone to obesity, to diabetes and to cardiovascular disease. In the U S A , about i z per cent o f the population are poor, but more than 75 per cent are overweight. In a study o f middle- aged British w om en , 84 per cent knew they should be eating five fruits and vegetables each day, and another study showed that obese people are better than thinner people at guessing the calorie content o f snack food s.

If w e can observe that changes in societal income inequality are follow ed by changes in obesity, this w ould also be supportive evidence for a causal association. An exam ple o f a society that has experienced a rapid increase in inequality is post-reunification Germ any. But these approaches overlook the reasons w h y people continue to live a sedentary lifestyle and eat an unhealthy diet, h o w these behaviours give com fort or status, w h y there is a social gradient in obesity, h o w depression and stress in pregnancy p lay a role.

Because behaviour changes are easier for people w h o feel in control and in a good em otional state, lessening the burdens o f inequality could m ake an im portant contribution tow ards resolving the epidemic o f obesity. The human mind is our fundamental resource.

John F. Kennedy, Special message to the Congress on Education, 20 February 19 6 1 A cross the developed w orld, and across the political spectrum, everybody agrees about the importance o f education. So w h y, when all developed societies are com mitted to education and equality o f opportunity at least in theory , do disadvantaged children do less well at school and miss out on the m yriad benefits of education, how ever good the school system?

A s w e shall see, some societies come a lot closer to achieving equality o f opportunity than others. M ore unequal countries and more unequal states have w orse educational attainment - and these relationships are strong enough for us to be sure that they are not due to chance. C om parable international data on educational achievement come from the Program m e for International Student Assessm ent P ISA , which w as set up to administer standardized tests to 1 5 -year-olds in schools in different countries.

The program m e began in 43 countries in zooo, and assesses children every three years, typically testing between 4,50 0 and 10 ,0 0 0 children in each country each time; schools are random ly selected. P IS A tests year-old s because they are com ing to the end o f com pulsory education in most countries.

Each survey gives tests in reading, m athem atical and scientific literacy. The goal is to test how w ell children can apply knowledge and skills. Income inequality Figure 8. For consistency w ith the data available for the U S , w e combine national average scores for reading and maths only and plot them against income inequality Figure 8.

H ow ever, if scientific literacy scores are added in it makes little difference to the results. The same strong international relationship w ith income inequality has been show n for adult literacy scores as w ell, using data from the International Adult Literacy Survey. The scores are significantly low er in states w ith wider income differences. A s a further test, w e looked at the proportion o f children dropping out o f high school in the U S A.

A s Figure 8. The Income inequality Figure 8. In three states, M ississippi, Louisiana and Kentucky, m ore than a quarter o f children drop out o f high school with no educational qualifications. Y o u might think that this striking association is due to absolute poverty - that kids drop out o f high school more frequently in poor states, so that they can start earning sooner and contribute to the fam ily budget.

A nd it is true that high school drop-out rates are higher in poor states, but poverty and inequality have independent effects. Poverty does not explain the inequality effect. N o state has a poverty rate higher than 1 7 per cent but drop-out rates are above 2. But the truth m ay be alm ost the opposite o f this. This figure suggests that even if your parents are well educated - and so presum ably o f high social status - the country you live in makes some difference to your educational success.

But for those low er dow n the social scale with less well-educated parents, it m akes a very much larger difference. It is also clear that an im portant influence on the average literacy scores - on national levels of achievement - in each o f these countries is the steepness o f the social gradient. Epidem iologist Arjum and Siddiqi and colleagues have also looked at social gradients in reading literacy in 1 5 -year-olds, using data from P IS A 2 0 0 0. Finland and Sweden have high average reading scores and low levels o f inequality in reading scores; Greece and Portugal have low average scores and a high degree o f inequality in reading literacy.

Siddiqi and colleagues do, how ever, note some exceptions to this general pattern. On the other hand N o rw ay com bines a rather mediocre average score w ith very little socio-econom ic inequality in reading literacy. One explanation offered by these researchers is that N e w Z ealan d and the U K have a greater proportion o f children w h o should sit the tests, but do not, because they have dropped out, or are truants.

This is a point w e w ill return to in Chapter i z , when w e look at public spending on education in relation to income inequality. But how else might income inequality affect educational outcomes? One im portant connection is likely to be through the impact o f inequality on the quality o f fam ily life and relationships.

Social inequalities in early childhood development are entrenched long before the start o f form al education. We know a lot now about the im portance o f the early years for later development - learning begins at birth and the first few years o f life are a critical period for brain development. This early learning can be enhanced or inhibited by the environment in which a child grow s up.

Th ey need to be talked to, loved and interacted with. A ll o f these things are harder for parents and other care-givers to provide when they are poor, or stressed, or unsupported. In Chapter 4 w e described h ow the general quality o f social relationships is low er in more unequal societies, and in Chapters 5 and 6 w e showed h ow inequality is linked to poor physical and mental health and more substance abuse.

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