Nation's Health Depends on Equality, Not Wealth

By Crawford Kilian, Georgia Straight (Vancouver, BC), 8 June 2000

Measured by life expectancy, good health in the advanced industrial countries doesn't depend on national wealth, good medical care, or even good genes. Instead, you will live a healthier, longer life if you are a part of a tightly cohesive, egalitarian society in which the incomes of the poorest and the richest are not that far apart. Among public-health experts, this basic point is settled, but it still hasn't sunk in with politicians and the public. Canada is such a country, but it may not remain so for long.

A remarkable book has gained almost canonical status in this field. Unhealthy Societies: The Afflictions of Inequality, by Richard G. Wilkinson (Routledge, 1996), summarizes decades of research in Europe, North America, and Japan. Wilkinson, a professorial research fellow at the University of Sussex, England, shows that a country's overall wealth doesn't buy longterm health. After per-capita income hits about $10,000, further increases in personal wealth bring relatively poor improvements in life expectancy. What matters is the income gap between a country's richest and poorest citizens.

Wilkinson mentions the Whitehall survey—headed by Michael Marmot, an epidemiologist with University College London-which has studied 17,000 British civil servants since the 1960s. All of them were well educated and have good access to health care. Yet the clerks at the bottom of the income scale have had three times the mortality rate of the senior administrators at the top, and four times the rate of death from coronary heart disease. An American study, the Multiple Risk Factor Intervention Trial, first published in the Journal of the American Medical Association in 1982, has surveyed 300,000 men since the early 1980s and found that every income class is healthier than the one below it, and sicker than the one above it.

But health isn't just a function of personal income. In 1965 Japan had a slightly lower life expectancy than Britain. By 1986, however, Japan had the highest life expectancy in the world, and the narrowest range between its rich and poor. During this period, Japanese society was also tightly cohesive, providing a place, and respect, for everyone.

In effect, disease and death rates are grounded in psychosocial factors according to Wilkinson. When people experience economic insecurity, when they lack control over their lives and jobs, chronic stress and anxiety weaken their immune systems. Stress and insecurity early in life can stunt both children's growth and their chances for success as adults.

Wilkinson and other researchers contend that stress also encourages hostility, mistrust, depression, rage, and destructive behaviour such as drug use, alcoholism, violence, homicide, and spousal and child abuse - all of them with deadly impact on life expectancy, and all of them much worse in societies with wide gaps between rich and poor.

Research in North America has largely confirmed Wilkinson's findings. In the US the key factor seems to be the percentage of state or metropolitan income on which the bottom half of the population must live. The poorer half of Louisiana, for example, was living on just 17% of the state's income in 1990. (In effect, out of every $100, one person received $83 while another received only $17.) According to the US Census and the National Center for Health Statistics, Louisiana had the highest mortality rates (and homicide rates) in the US that year.

According to a study published this past April in the British Medical Journal, Canada has maintained a narrower income range than the Americans. The widest income gap in Canada is in Saskatchewan, with the poorer half living on 22% of provincial income. The narrowest gap, at 24%, is in Prince Edward Island. The chief virtue of our health-care system, despite its funding problems, is that it effectively narrows the income gap still more, saving relatively poor Canadians from anxiety about falling ill. And the less anxiety people feel, the healthier they are.

James Dunn, an assistant professor of geography at UBC, is one of the authors of the BMJ study. He says he and his colleagues were surprised by their own findings.

We knew from hundreds of studies in developed countries over a century that for individuals, wealthier is consistently healthier, he said in an interview. There's a persistent relationship between social status and health status. We expected to see the same consistency for the relationship between income inequality and population health in Canadian provinces and cities, but we didn't. It seems Canada has transcended the relationship altogether. Our social safety net has helped us produce high standards of health across all provinces and cities.

Income inequality in wages, Dunn said, has grown since the mid-1980s. But the tax redistribution system is ameliorating the effect. Redistribution means employment insurance, social assistance, and better access to education as well as health care, he said, and that gives less-wealthy Canadians a strong sense of stability, predictability and control.

One critical factor, Dunn suggested, is that most social services are funded by provincial or federal governments. No matter where you live in Canada, health, education and other social services will be pretty good. In the US, by contrast, local municipalities fund those services to the extent that their taxpayers are willing and able to do so. This, Dunn said, leads to excellent social services at low tax rates in rich communities with few needs, and less adequate services at high cost in communities with greater need. Anyone who can afford to escape such poor communities will do so, aggravating the problem for those left behind.

Current trends—toward two-tiered health care, toward privatized education- carry the seeds of more psychosocial stress, more hostility and mistrust, and greater relative inequalities. Those in turn mean more disease, more destructive behaviour, and earlier deaths. Poor and middle-income Canadians should therefore defend their social programs as if their lives depended on them.