Income Inequality and Health

In this guest post, Ronald Labonté moves from describing the impact of income inequality on health to the implications of this relationship for both the Canadian and global context. He presents two sets of policy reforms necessary for acting on these contexts and illustrates the scope for Canadian engagement with national and global policy options. This post is based on an invited presentation given to the Liberal Open Caucus, Senate of Canada, March 11, 2015. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Concern about the health effects of income inequality are not new. Considerable attention was paid to the low life expectancies and deprived lives of the poor and the working class throughout the era of industrial capitalism, stretching from the late 18th through to the late 19th centuries. The reasons then were simple. The material contexts in which many of the non-rich lived during this period were the determining factors:

  • poor food
  • inadequate shelter
  • unsafe working conditions
  • lack of potable water or sanitation, and
  • little opportunity for social mobility to a better life apart from petty crime

The reasons today are more complicated, but derive from the basic findings that life expectancy across the income spectrum in countries such as Canada (and indeed, globally) follow a gradient. Those higher up the income ladder have longer, healthier lives; and the pattern holds for each step up the gradient. This pattern has led to contentious efforts to explain these findings, especially since many of those slightly lower on the income ladder are not living in materially deprived circumstances, nor are they necessarily leading unhealthier lifestyles.

The Income Inequality Debate

Sir Michael Marmot, who designed the British Whitehall Studies that first brought international attention to the gradient effect, argued that these life expectancy differences, apart from those explained by proximal behavioural risks, were caused at least in part by negative social comparison, leading to a loss of self-esteem, psychosocial stress and poor health. This later became known as the ‘relative income’ or ‘income inequality’ hypothesis, which essentially stated that health inequalities were worse where income inequalities were greatest. Richard Wilkinson and Kate Pickett in their book, The Spirit Level1 became the most famous proponents of this argument, finding that for each of eleven different health and social problems outcomes are significantly worse in more unequal rich countries:

  • The Spirit Level by Richard Wilkinson and Kate Pickett
    The Spirit Level by Richard Wilkinson and Kate Pickett

    physical health

  • mental health
  • drug abuse
  • education
  • imprisonment
  • obesity
  • social mobility
  • trust and community life
  • violence
  • teenage pregnancies
  • child well-being

Many epidemiologists, however, were and remain skeptical of their use of co-relational data. An earlier 2004 systematic review of the literature concluded that there was little evidence that the size of income inequalities in itself explained differences in health within and between affluent countries, at least so far as the social comparison explanation is concerned.2 These findings are consistent with a larger literature that finds that it is not the scale of income inequality per se that is responsible for these health differences, but rather that those with different levels of income experience different levels of advantage and deprivation and psychosocial stress which is tightly related to their actual conditions or material conditions of life. As the authors of this 2004 study conclude:

“Although we found little evidence to support a direct effect of income inequality on health, this should not be interpreted to mean that factors that drive unequal income distribution at the system level are not important to individual and population health. Reducing income inequality by raising the incomes of more disadvantaged people will improve the health of poor individuals, health reduce health inequalities, and increase average population health (p.83)2.”

Why the Income Gap Still Matters

In other words, it is not so much the size of the gap between top and bottom income groups that accounts for health inequalities, but the fact that there is a gap in the first place. Reducing that gap remains a public health imperative. Moreover, one of the reasons why income inequalities in some countries do not lead to the same health inequalities as in others has to do with how that gap is reduced through the tax-funded provision of public goods (such as accessible quality education and health care, income transfers, even public transportation and active labour market policies).

This finding is similar to an argument made by the Princeton health economist, Angus Deaton3, whose own reading of the literature on income inequalities as a health determinant concluded that “childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes.” A more recent study, however, suggests that the income inequality and health hypothesis is still not entirely resolved. Using 31 years of panel data (1975 – 2006) from 21 OECD countries, the analysis found that, as income inequality increased, life expectancy decreased for both men and women, largely the result of excess mortality for children (aged 1 – 14).4

The study could not disentangle the reasons, but suggested that this was probably the result of under-investments in services for low-income parents, working poverty, long work hours and high household debt burdens, all leading to poorer living conditions and diets and high familial stress. Although the study used mortality data only, where there is high childhood mortality there is almost certain to be high childhood morbidity, creating an unhealthy start that accumulates over a lifetime; and demanding a focus on “on breaking or weakening the injustice of parental circumstances determining child outcomes,” as Angus Deaton expressed it.

These findings were underscored further by a comparison in changes in child well-being between 2007 and 2013 in the same 21 wealthy OECD countries5, a period during which income inequalities had risen in many of these countries subsequent to the 2007/2008 financial crisis. Child well-being (an index comprised of measures of health, education, behaviours, housing and environment and safety) improved in some countries but declined in others, including Canada. The declines were greatest in those countries that had experienced the largest increase in income inequality. The causal pathways, once again, were linked to a decline in material resources, maternal stresses creating epigenetic impacts in pregnancy and early childhood, precarious employment and reduced access to health and other public goods and services.

What Can We Conclude from This?

  • Income inequalities in themselves are likely not the best explanation for health inequalities
  • Within and between countries, however, there are stark health differences between people at different income levels
  • Part of this difference can be explained by different lifestyles (e.g. smoking rates, poor diets, lack of physical exercise), but not all of the difference
  • Lifestyle differences themselves are socially constructed and relate in many ways to affordability of healthier foods, more secure housing, opportunities for recreation and other ‘social determinants of health’
  • Psychosocial stresses associated with income inequality may account for some of the differences in health outcomes, but are more likely the result of material deprivations or shortfalls, and changes in employment or economic conditions that create greater precariousness and insecurity
  • Early childhood experiences (from pregnancy onwards) set the table for later life inequalities: both in income, and in health
  • Children are not born poor; they are born into poor families, and supports to reduce poverty by raising income levels of the bottom 40 percent of households become one of the most important policy levers that governments can use to create greater health equity over the lifespan

It is finally important to emphasize that it is generally the same economic policies and public policy responses that give rise to income differentials between people, and to the widening income inequalities that still appear to have an influence on the material conditions affecting peoples’ health opportunities.

How Well Is Canada Faring?

Since 1991, at least, Canada hasn’t made much progress in shrinking this income and health gap. Differences in the remaining years of life expectancy at age 25 for men in highest compared to the lowest income quintile was 7.1 in 1991. In 2006 it was still 7.1. For women the differences were 4.9 in 1991 and, well, in 2006: still 4.9.

How do these average individual differences stack up when the whole population is considered?

In 2013, Statistics Canada published the most comprehensive look at income differentials in mortality. The study examined cause-specific mortality rates by income adequacy among Canadian adults, using data from the 1991 to 2006 Canadian census mortality and cancer follow-up study. This study followed 2.7 million people aged 25 or older at baseline, 426,979 of whom died during the 16-year period. Age-standardized mortality rates (ASMRs), rate ratios, rate differences and excess mortality were calculated by income adequacy quintile for various causes of death.6 The result:

“If all cohort members had experienced the age-specific mortality rates of those in the highest quintile, the all-cause ASMRs would have been 19% lower for men and 17% lower for women. Extrapolated to the total non-institutional adult population, that amounts to an estimated 40,000 fewer deaths per year (25,000 fewer among men and 15,000 fewer among women)—the equivalent of eliminating all ischemic heart disease deaths (p.17)6.”

Two colleagues of mine, Dennis Raphael and Toba Bryant rather sensationally described these findings in this way:

“The health effects of income inequality in Canada are like 110 passenger jet falling out of the sky every day, 365 days a year.” 7

This led to some ridicule in a Financial Post blog 8, for which I have some sympathy. Describing the airplane analogy as “junk science,” the author, Peter Taylor, correctly points out that these figures are not about income inequality, which would require a measure of the size of the gap between rich and poor. Rather, it is about the fact “that people at the bottom of the income ladder tend to die earlier than those at the top.” As Taylor goes on:

“Why this is so is cause for vigorous debate. It could be a simple lack of resources. Low income Canadians might lack the ability to successfully navigate the complexities of Medicare. It might also reflect the fact lifestyle risk factors such as smoking, drinking and lack of exercise are more prevalent among lower incomes. Whatever the reasons, however, there’s a world of difference between acknowledging a link between poverty and health, and indicting income inequality as the cause of 40,000 deaths a year.” 8 plane

Fair enough, and Taylor is pretty correct in identifying the proximal causes of some of these gradient differences in health as they relate to one’s level of income. But we seem to be much more complacent in making similar claims that compare the mortality risks of smokers vs. non-smokers. Is it so misleading to describe the life expectancy differences between the richest 1/5th and the rest of Canadians as an inequality? More to the point: Taylor is wrong to ridicule public health’s concerns with these differences as “junk science”, arguing that public health should stick to vaccinations and steer clear of economics. The causes of these income differences in Canadian deaths are located within the economic and political policy choices that affect income distributions, and the social and environmental contexts that in turn affect poorer lifestyles, poorer living conditions and poorer opportunities for health.

That makes them a public health concern, just as the impoverished circumstances of early European industrial capitalism were the incubator of modern public health and its concerns with the conditions that create infectious and other diseases.

The Global Context

To put these findings into a larger global frame, since that is where most of my work is now focused:

  1. Income inequalities are at the highest level amongst OECD nations since 1985 – incidentally a period not only of economic recession, but also of the global diffusion of neoliberal economic models and market de-regulation.
  2. These inequalities are not just in relative income, but also in absolute income, including Canada.
  3. There is a negative and statistically significant impact between the scale of income inequalities and economic growth9. Income inequalities thus have a bearing on health due to any of the health-positive ‘trickle down’ effects of economic growth.
  4. The negative effect of income inequalities on growth is greatest when the gap between lower and median income households rises. Although the ‘breakaway’ wealth of the 1% is unrelated to economic growth (whether positive or negative), this breakaway wealth nonetheless correlates with decreases in the share of economic product going to labour (vs. to capital) and to a disproportionate control over politics and policy by a very small economic elite.
  5. Globally, wealth inequalities are even more extreme, as groups like OXFAM have been challenging much of the world on. Just 67 individuals (some estimate 72, but what’s another 5?) now have more wealth than the bottom 3.5 billion of the world’s population.10 10 individuals in Africa have more wealth than bottom 50% of that still impoverished continent.11labonte2
  6. Why wealth inequalities matter: globally we cannot eliminate life-threatening poverty without shifting economic policies to greater redistribution, both pre- and post-market. And certainly not if we are concerned with the ecological limits of growth, since as the 2009 UK Sustainability Commission noted, “there is as yet no credible, socially just, ecologically sustainable scenario of continually growing incomes for a world of nine billion people.”12

Acting on these global contexts and the national level requires two interrelated sets of policy reforms:

  1. Pre-market: elimination of low pay and precarious employment conditions through strengthened core labour rights, high minimum wages and strengthened collective bargaining to establish or re-establish a social contract between capital and labour; and changes in working hours and remuneration allowing employment opportunities to be more equitably shared.
  2. Post-market: redistribution through progressive taxation of incomes, inheritance, and rents; improved royalties on resources especially in low-income countries; capital controls to prevent legal or illicit capital flight; closure of tax havens; and a financial transaction tax or other systems of global taxation.

Most of the OECD nations, however, have been going in the opposite direction in both of these policy areas. Respecting taxation and globally, the picture is even more pronounced, with net global taxation in the past 10 years (2002 – 2012) on a steady decline, resulting in USD 30 trillion more in untaxed wealth floating around the world now than just a decade ago (author calculations based on the World Bank data set). Yet OECD and IMF studies generally conclude that low income inequality is robustly associated with better economic growth, and that redistribution through progressive taxation that lowers income inequality “is benign in terms of its impact on growth (p.4).”13 Several recent studies have affirmed this:

  • A US review of econometric studies that concluded that raising the marginal tax rate from its present low 35% to its historic high of 68% would have no impact on factors driving economic growth, but would reduce poverty, inequality and stimulate growth through public spending.14
  • An IMF study that more cautiously suggest that capping the marginal rate at 60% would have little or no effect on growth rates.15
  • Emmanuel Saez and Thomas Piketty, although never believing this would be achieved, have argued that there is no economically justifiable reason why the marginal rate shouldn’t be at 80%.16
  • More recently, a paper drawing on the concept of economic optimality concluded that a 90% marginal rate tax on incomes > $300,000 may lead to some declines in GDP and aggregate wealth, but would also lead to greater overall well-being and happiness.17

This leaves unchallenged the fact, from an environmental vantage, we need to abandon the concept of growth as a measure of prosperity and develop other metrics that capture the capabilities and social interactions that are the bases of health and happiness.12

Not a Crisis of Scarcity, but a Deficit of Fairness

But what these bases nonetheless tells us is that, in Canada, and in much of the rest of the rich world, we do not have a problem of scarcity; we have a severe deficit of fairness, whether we frame our social justice remedies as increasing equal opportunity or improving equal outcome. This deficit, in turn, still diffuses globally, characterizing differences within and between nations.

With respect to the pre-market reforms mentioned above, and in the words of Henry Ford a century ago:

“I have to pay workers enough that they can afford to buy my cars.”

With respect to post-market conditions we need to enhance, and in the words of the American jurist, Oliver Wendell Holmes, expressed at another time when income and wealth inequalities were racing out of control:

“Taxes are the price we pay for a civilized society.”

Repeated opinion polls find that the majority of Canadians would agree to paying higher taxes, if such revenues went into the health and education, environmental protection, and other public good programs that most Canadians value – all investments that would lower market inequalities perhaps even better than income transfers or tax credits alone (the market has a way of stealing new dollars from the pockets of the poor, through higher food, housing or other commodity or service prices).

For Canadians, we should heed the caution of an OECD cross-national study that suggests that once a nation’s Gini income co-efficient rises above 0.3 there will be as much as a 9.6% increase in adult mortality (15-60 age group).18 In Canada, we are now considerably above the 0.3 Gini threshold, even after taking account of our (now slightly less generous) post-tax and transfers.

As a country, Canada is unlikely to proceed alone in making dramatic policy shifts in our taxation, minimum wage or social protection policies. To do so would put us in a competitive disadvantage with our Anglo-American economic neighbours and, with open global financial markets, risk capital flight (licit or otherwise) by corporations and high-income earners. Compared to many northern European countries, however, we could embrace much higher marginal taxes than we levy at present. But we would also need to engage in changing the rules of the global economy such that the growing gap between the tops, bottoms and most of the in-betweens is stopped, and then shrunk. Reducing inequalities, and not just eliminating absolute poverty, is now on the global Sustainable Development Goals agenda, which will be normatively binding on all nations if approved at a special UN General Assembly this September. There is renewed global discussion of global financial taxes of one form or another; and on the need to levy a social protection pool based on countries’ abilities to pay, to be drawn upon based on needs.

Indeed, there is no shortage of potential policy initiatives that can address income inequalities and remedy the negative health externalities these create, if not by their scale so much as simply by their existence. It is unlikely that the present Canadian government will embrace these new global policy discussions with any earnest, since it has had a long-standing political platform of going in the opposite direction.

But at the very least these policy options need national debate and a healthy re-kindling.

Can the Canadian Senate add more fuel to this important policy fire?

References

1. Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why More Equal Societies Almost Always Do Better, London: Penguin.

2. Lynch, J., Smith, G.D., Harper, S., et al. (2004) “Is Income Inequality a Determinant of Population Health? Part 1: A Systematic Review,” Milbank Quarterly, 82(1):5-99.

3. Deaton, A. (2011) What does the empirical evidence tell us about the injustice of health inequalities? Mimeo: Centre for Health and Wellbeing, Princeton University. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1746951

4. Torre, R. and Myrskylä, M. (2014) “Income inequality and population health: An analysis of panel data for 21 developed countries, 1975–2006,” Population Studies, 68:1-13.

5. Pickett, K., and Wilkinson, R. (2015) “The Ethical and Policy Implications of Research on Income Inequality and Child Well-Being,” Pediatrics, 135 (Supplement 2):S39-S47.

6. Tjepkema, M., Wilkins, R. and Long, A. (2013) “Cause-specific mortality by income adequacy in Canada: A 16-year follow-up study,” Health Reports, 24(7):14-22.

7. Raphael, D. and Bryant, T. (2014) “The Health Effects of Income Inequality: A Jet with 110 Canadians Falling Out of the Sky Each Day, Every Day, 365 Days a Year,” http://www.thinkupstream.net/health_effects_of_income_inequality

8. Taylor, P.S. (2015) “Junk Science Week: Death by One Percenter,” FP Comment, March 3. http://business.financialpost.com/2015/03/03/junk-science-week-public-health-officials-are-blaming-income-inequality-for-poor-health-so-they-can-exercise-control-over-the-economy/

9. Cingano, F. (2014), “Trends in Income Inequality and its Impact on Economic Growth”, OECD Social, Employment and Migration Working Papers, No. 163, OECD Publishing. http://dx.doi.org/10.1787/5jxrjncwxv6j-en

10. Moreno K. (2014) The 67 People As Wealthy As The World’s Poorest 3.5 Billion. Forbes March 25. http://www.forbes.com/sites/forbesinsights/2014/03/25/the-67-people-as-wealthy-as-the-worlds-poorest-3-5-billion/

11. Lakner, C. (2015) “The ten richest Africans own as much as the poorest half of the continent,” Let’s Talk Development World Bank blog, March 11. http://blogs.worldbank.org/developmenttalk/ten-richest-africans-own-much-poorest-half-continent

12. Jackson T. (2009) Prosperity without growth: The transition to a sustainable economy?  London: UK Sustainable Development Commission.

13. Ostry, J., Berg, A. and Tsangarides, C. (2014) Redistribution, Inequality and Growth, Washington: International Monetary Fund. http://www.imf.org/external/pubs/ft/sdn/2014/sdn1402.pdf   

14. Fieldhouse, A. (2013) A review of the economic research on the effects of raising ordinary income tax rates, Economic Policy Institute, New York. http://www.epi.org/publication/raising-income-taxes/

15. Elliot, L. (2013) IMF eyes tax potential of the world’s super-rich, The Guardian: http://www.theguardian.com/business/2013/oct/13/imf-meeting-united-states-debt-ceiling.

16. Saez, E. and Picketty, T. (2013) “Why the 1% should pay tax at 80%,” The Guardian, October 24. http://www.theguardian.com/commentisfree/2013/oct/24/1percent-pay-tax-rate-80percent

17. Kindermann, F. and Krueger, D. (2014) “High marginal tax rates on the 1%,”, CEPR’s Policy Portal, November 15. http://www.voxeu.org/article/high-marginal-tax-rates-top-1

18.  Kondo, N., Sembajwe, G., Kawachi, I., van Dam, R., Subramanian, S. and Yamagata, Z. (2009). “Income Inequality, Mortality and Self-Rated Health,” British Medical Journal, 339, b4471.

Healthcare spending and health: looking beyond the money

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This graph was posted on the Atlantic last week and illustrates the striking relationship between healthcare spending and life expectancy.  There are many important and interesting aspects to this relationship, which has been documented for some time, but there is one aspect which is seldom discussed when the topic surfaces in mainstream media outlets.

One of the most discussed features of this relationship, and the one covered by Atlantic author Matthew O’Brien, is the isolated position of the US (in the top right area of the graph). O’Brien notes that ‘[Americans] spend much more than any other rich country, but [they] certainly don’t get more for it. [They] get less. [They] get about the same health outcomes, but don’t cover everybody like other rich countries do.’

With US life expectancy clearly positioned below 80 years, and other countries approaching levels closer to 85, I can’t agree with O’Brien that Americans ‘get about the same health outcomes’, but let’s leave that aside for now.

The obvious questions prompted here are why does healthcare cost so much in the US, and relatedly, how can this wasteful spending be eliminated? O’Brien points his finger at culprits like high doctors’ pay and patients’ opposition to having their coverage change.

A  more extensive debate on this relationship is happening on the blog, The Incidental Economist, which is the original source of the graph used in the Atlantic piece. Nonetheless, the bottom line of many of these conversations is likely to be some form of O’Briens conclusion:  [Americans] can’t afford [their] healthcare exceptionalism’.  With an extreme and growing number of Americans underinsured, unemployed and underfed, this conclusion is hard to deny.

But there is another important conversation to be had.

This conversation emerges when we look at the cluster of countries spending more than $2000 per capita on healthcare. Here the data begins to flatten out and after this point, spending on healthcare appears to buy little in terms of health improvement. This particular feature of the graph prompts different sorts of questions than those outlined above. Questions like: if healthcare spending is not buying health improvements then what  is responsible for better health; and why does the US lag so far behind in international health comparisons? The bottom line of conversations centred on these questions point to a different sort of American exceptionalism.

There are several, well-documented, reasons why healthcare does not produce health. These reasons derive from population health research and generally speaking, relate health to societal structures that govern the amount of inequality in a society. In this field of work, American exceptionalism is found in graphs like this one:

infant mortality

In this graph, the US (again, at the top right) is isolated for its extremely high level of income inequality and high level of infant deaths.

Despite the fact that there are now over 170 studies which show that health is worse in more unequal societies, even  journalists hired to cover health stories neglect to identify inequality as a crucial determinant of health.

The relationship between spending on healthcare and health illustrates the limited returns of exorbitant US spending, but it also demonstrates the limitations of medical care in producing health: a story whose time is beyond ripe.

Paul Krugman: America’s Greatest Public Health Champion?

Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading this article, one is likely to deduce that these declines are largely the result of individual health behaviours and life style choices.

Per the NYT,  reasons offered by researchers for this decline include “a spike in prescription drug overdoses among young whites, higher rates of smoking among less educated white women, rising obesity, and a steady increase in the number of the least educated Americans who lack health insurance”.

A range of public health experts are also quoted in the piece and offer roughly the same type of behavioural explanations. At the end of the article, Lisa Berkman, director of the Harvard Center for Population and Development studies, at least begins to shift the focus further up the causal chain and notes that the reversal in life expectancies “should be seen against the backdrop of sweeping changes in the American economy and in women’s lives”, highlighting the deleterious impact of low-wage jobs on women’s health.

Two days later it is Paul Krugman, an economist, not a public health expert, who highlights that worsening trends in life expectancies have taken place in the context of increasing income inequality (see also Katherine Greir’s  piece on Alternet, which Krugman cites).

Is this surprising? Not really. Krugman has noted the corrosive impacts of income inequality before; he’s even made direct references to the Spirit Level, a book which systematically outlines how income inequality is related to societies’ physical and mental health, as well as their levels of drug abuse, education, violence, and community life.

Unfortunately, Krugman’s easy receptivity to the political determinants of health is not mirrored in the work of national public health campaigns. In 2010, the US Department of Health and Human Services launched Healthy People 2020, a 10-year agenda for improving the health of Americans. However, despite its stated goal of achieving health equity by 2020, nowhere in its description of the social determinants of health is attention drawn to income inequality. Moreover, attention is scantily paid to the socio-political factors responsible for unequal distributions of resources important for health: resources like income, food, transportation options, social support, etc.

It is now well evidenced that in places where income inequality is greater, population health outcomes, like life expectancy and infant mortality, are worse. Unfortunately American public health professionals, and health journalists alike, continuously fail to acknowledge and translate the implications of this evidence.

Root Causes of Ill Health Fall Flat in Bloomberg’s Soda Ban

While reactions to Bloomberg’s soda ban continue to effervesce, those truly concerned with the public’s health would be well advised to hold their praise.

Yesterday the New York City Board of Health approved Mayer Bloomberg’s controversial plan to ban large-sized sugary drinks. Across the web, the ban has sparked a range of debates. Proposed in an effort to curb obesity, many are concerned about how far the government should go in controlling people’s individual health choices; others wonder about its effectiveness in achieving smaller waistlines.

Back in April, Toronto based family physician, Ritika Goel, wrote about her encounter with the Mayor at the Johns Hopkins Bloomberg School of Public Health. As Goel writes, Bloomberg is well known in public health circles for spearheading a variety of health-related initiatives. Unfortunately, when questioned about one most fundamental determinants of health, income-inequality, Bloomberg was quick to dismiss its existence, let alone acknowledge its significance for improved population health.

For those of us concerned with improving the public’s health, Goel’s article about her experience meeting the Mayor should be carefully considered. For whether the soda ban policy is a step in the right direction ultimately depends on the wider policy approach within which it is enacted. And given Bloomberg’s failure to recognize the health importance of the socio-political context, we have great cause to be wary.

Interview with Exploring Equality: Lessons from Sweden

Providing an impressive evidence base for why economic inequality is bad for everyone (even the rich!), The Spirit Level has failed to gain much political attention in the US.

Controversies over this book however, continue to make headlines in the UK and even inspired two UK graduates to cycle tour Sweden in hopes of finding out what life is like in a more equal society. Interviewing academics, politicians, and ordinary folk alike, the adventurists, Steven Bland and Hacon Bickerton, have been blogging about their experiences  and posting video of their interviews at Exploring Equality

Excited about this project, I couldn’t help but contact Steven, recently returned from Sweden, for an interview. Steven filled me in about what equality means to the Swedes and how it comes from a place of trust and strong belief in autonomy. He highlights the good, the bad, and the blonde aspects of living in a more equal society. He has some really good ideas about what the UK can learn from Sweden and an exciting project to take Exploring Equality into 2011. Find out more below.

HP: What do you feel is the Swedish attitude towards equality?

Steven: From our limited experiences, we felt that Swedish people trust others more, feel a responsibility to other Swedes, and have an assumption towards equality in almost all senses of the word.  In general, this assumption is towards equality being a good, necessary thing. Deep in the psyche of the people and politics is a belief that no-one should suffer from being exploited or poor: and the social system is aggressively set-up to prevent this. This extends from income to gender (and to race as well but the reality on this one is a little more complicated). This has developed over many decades, and has historical starting points, but it’s important not to overstate the role of culture. Specific policies have been introduced in recent years to further promote equality. For example, the establishment of subsidised daycare systems so mothers can go to work, is not something specifically culturally Swedish!

HP: What expectations did you have of Sweden before you set off and to what extent did those change?

Steven:

Our expectations

Sweden was cropping up in lots of news stories and articles as a bit of a utopia. We knew it wasn’t and suspected that there would be some deep problems underneath the surface- like high levels of suicide. I guess I also suspected it would feel like one big community-focussed collective in some way which the UK was not. Some people also told us it would be a bit of a boring place with stuffy people!

How they changed

  • Suicide is not above average in Sweden: it’s a myth started it seems by a Presidential address in the US many decades ago!
  • While Sweden has been famously tolerant of immigration, recent year’s treatment of asylum seekers and the rise of the political far right demonstrate significant changes.
  • People on the street were hard to approach initially, but incredibly friendly and helpful once you started a conversation.
  • Most importantly, it wasn’t some crazy socialist collective. Swedes love privatisation! See below for more on this…

We also suspected we’d see IKEA, blondes and trees everywhere. This was all true!

HP: Individualism and the idea of personal freedom are both themes that come up a lot in the interviews. What would you say are the biggest differences between how these ideas are understood in Sweden versus the UK?

Steven: This is crucial. In short, Swedes believe in autonomy: liberal freedom from relationships which might reduce their ability to be truly free from repression. So they don’t mind a big use of the state to ensure everyone in society- including the poor, disabled, vulnerable etc- can keep as much autonomy as possible. This is a way of explaining what we saw: relatively happy, free people in a society with high taxes and a powerful state. In some senses, they are freer from many trapping forces in our societies: like the institution of marriage, unequal gender relations, and perhaps most importantly being trapped by low social mobility and poverty. Social mobility in the UK is the lowest in Europe- it’s even worse in the USA I believe.

BUT Swedes can’t get super-rich. The social system prevents it. In the UK, we have a narrower concept of freedom, as you do in the USA. Freedom is to maximise your personal disposable income. The UK sits somewhere in the middle between Sweden and the USA on this front. Our narrower conception of what it means to be free does us wrong I think- we end up being more trapped by family, marriage, poverty, and a state that abuses its powers (we have more CCTV cameras than China!!), just to hold on to that one freedom we care most about: getting rich. In this sense, I prefer the Swede’s definition of personal freedom, which allows them the apparent contradiction of loving private property and privatisation, while not minding paying higher taxes. This is their way of practicing social responsibility for others.

HP: What lessons do you feel the UK can learn from Sweden?

Steven: I love the UK. I think we have a rich social history, a vibrant civil society and diversity by the bucket loads which make it a fascinating place to live. But I do think we can learn from Sweden’s experiences over the years, without turning into it!

There are two ways to think about ‘lessons’. The first is specific policy measures we could adopt. The big example that struck me was paternity rights. In the 1990’s, Sweden mandated shared childcare arrangements between mother and father. While many fathers aren’t taking up what they’re entitled to, the measure is already changing the concept of what it is to be a ‘good father’. Why do fathers in the UK only get two weeks off to see their kids?! That’s outrageous. I’m seriously considering starting a movement for change in this area…I wonder if not having a kid will be an advantage or disadvantage!

But we have to also recognise the UK is a different place- with an economic situation at the moment where it’s all about “cuts cuts cuts” to public services. So just as important I think is to get a proper debate going about individual freedom, social responsibility, and wellbeing. We need to debate our narrow definition of freedom as I argue above. We need to inculcate a sense of personal and social responsibility in our children. And we need to continue the debate that has started in recent years about ‘the good life’ and what it actually might be.

We have to also learn from Sweden’s mistakes. The state can get too powerful. And we found examples of people frustrated by the social system’s tendency to prevent people from being different and standing out from the crowd. We have to find a way in the UK, and the USA, to reward people who are talented and different, without allowing inequality to grow so big it starts to define how our society runs.

HP: How do you plan to spread these messages and how can people stay informed of your activities?

Steven: We’ve come back to the UK political reality with a bang. The debate about inequality is live and raging- but in the mainstream press it’s really all about fairness- what is fair? Who must take the hit of budget cuts? How do we protect the poor from the worst of the cuts? We cannot simply sit back and accept all of these cuts without debating what kind of society they are going to create.

To that end, we are creating a short documentary of our trip, which will also focus on inequality in the UK and what we can do to reduce it.

  • Take a look at our website at www.exploringequality.tk to find out what we did.
  • Sign up to our blog to receive updates of stories about inequality in the news, and progress of our film-making so you know when the film will be released.
  • Donate some cash to help us make our dream of a documentary film a reality: we are total amateur filming enthusiasts and have never done something like this before. You can help make it happen!
  • Watch our film when it comes out in 2011!

Surprising Side Effect of HCR: Economic Equality

Now that US health care reform has finally passed, everyone is scrambling to decipher what it actually means for America’s future.  Healthy Policies has been pretty quiet on the HCR front. This is because while the passage of this bill will definitely provide more people with access to health care, the impact HCR will  have on the overall health of Americans is less clear. Middle class Americans with access to health care are typically far less healthy than their counterparts in other developed countries. Health care is an important determinant of health, but in the US it is a small piece of a much bigger problem.

A remarkable piece by Sam Pizzigati of the online newsletter Too Much however, outlines two major components of  the health care reform legislation that begin to address the root cause of  ill health in America: economic inequality.

One  provision of the legislation subjects the investment income of individuals making over $200,000 a year to a 3.8% Medicare tax. Sam explains that “this represents a major shift in tax policy” because “up until now, Medicare taxes have been, at worst, a minor irritant for the rich, since the wealthy get most of their income from the money their money makes, not the work they do.

Another provision of  HCR legislation discourages excessive executive pay by denying health insurance companies any corporate tax deductions on paychecks exceeding $500,000 a year.

Although these provisions don’t go nearly as far as they could, they do provide a welcome basis from which future efforts can most definitely be supported.