If we look across the Western democracies, there are dramatic and puzzling disparities between countries in overall health outcomes, such as average life expectancy, and in other measures of human development, such as rates of literacy, teenage pregnancy or incarceration.
For example, life expectancy is five years longer in Japan than in Portugal. Obesity rates are six times higher in the United States than in Switzerland. Mental illness is three times more likely in Britain than in Germany.
One reason these differences are puzzling is that they are unrelated to gross national product, or to spending on health care. Some affluent countries that invest heavily in health care do very well (Norway). But other wealthy countries with expensive health-care systems do much worse (the United States or Switzerland).
The Spirit Level: Why More Equal Societies Almost Always Do Better
, by Richard Wilkinson and Kate Pickett, Allen Lane, 331 pages, $38
Conversely, while some less affluent Western countries with minimal health-care spending have poor health outcomes (Portugal), other comparable countries do relatively well (Greece or Spain). Once a country reaches a per capita income of around $25,000, there is simply no correlation between levels of national wealth or health spending and levels of health and human development.
So what explains why some countries do better than others? A growing consensus points to the quality of people's social relationships, whether in the home, the neighbourhood or at work. In some societies, these relationships are toxic, putting health-damaging stresses on individuals. In other societies, these relationships are supportive, helping individuals deal with life's challenges.
For 30 years, researchers around the world have been studying these “social determinants of health.” In this book, Richard Wilkinson and Kate Pickett – long-standing British experts in the field – survey the research to date.
The result is an impressive body of evidence, presented in an easily digestible form, which is highly relevant for debates here in Canada
A number of factors have been identified as influencing whether social relationships are supportive or toxic. Some researchers highlight the importance of neighbourhoods where people trust, rather than fear, one another. Others focus on the importance of a workplace that fosters a sense of autonomy rather than powerlessness. Yet others emphasize being part of diffuse social networks. Each of these factors has been shown to have important effects on health.
However, Wilkinson and Pickett argue that these different factors are all symptoms of a deeper issue – namely, inequality. Among wealthy countries, Norway and Japan do better than the United States or Switzerland because the gap between rich and poor is smaller. Among less affluent countries, Spain and Greece do better than Portugal because they have less inequality. Indeed, across all the Western democracies, and across a wide range of indicators, there is a consistent pattern in which outcomes get worse as levels of inequality increase. (Much worse – often three to six times worse.)
This is true of rates of infant mortality, illiteracy, obesity, mental illness, incarceration, homicide, drug use and teenage pregnancy (although not, interestingly, of suicide). Similarly, as inequality rises, social trust and social mobility decline while violence increases. This is true not only between Western countries, but also within them. For example, if we compare the 50 states of the United States, these indicators are worse in states with greater inequality.
This is the authors' “big idea”: People's health depends on the quality of their social relationships, and the most important determinant of the quality of social relationships is the level of inequality. This is not a new idea – for instance, the link between levels of inequality and violence has been known for a long time. But this book brings together the data in a more systematic way, across a wider range of countries and indicators.
The result is an impressive body of evidence, presented in an easily digestible form, which is highly relevant for debates here in Canada. Polls show that most people believe that inequalities have grown too large in recent years, and this book will surely reinforce that sentiment. Many of us feel that the growing level of inequality is unfair, and harmful to a sense of shared citizenship and community cohesion. But as Wilkinson and Pickett show, it is also harmful to our health. And the striking recent increases in inequality in Canada – more dramatic than in most Organization for Economic Co-operation and Development countries – are already showing up in health outcomes.
