Unhealthy state of affairs

People live longer in egalitarian communities. Marek Kohn on the cost of a winner-takes-all society

SITTING in a car at a pedestrian crossing in Brazil, Richard Wilkinson began to think about the relationship between equality and road accidents. An economic historian based at Sussex University, he was in the country to speak at a conference about the relationship between income distribution and health. His Brazilian companion had stopped their car in the middle lane, but the pedestrians were unable to cross because cars either side of them continued to whizz past, while those behind him began to hoot.

The Brazilian remarked that one of the things he respected most about Britain was the way that motorists let pedestrians cross at crossings. But on his most recent visit, he added, he had noticed that their courtesy had begun to fray.

Wilkinson reflected that the way we drive speaks powerfully about our social relationships. "Perhaps nothing is so indicative of the standards of people's behaviour towards unknown others... " he writes in his new book Unhealthy Societies: The Afflictions of Inequality (Routledge). "Do people see other members of the public as fellow citizens with whom their welfare is interdependent, or ... merely as obstacles in each other's way?" Brett Easton Ellis made a similar point in the first sentence of his debut novel, Less Than Zero, as an introductory metaphor for his portrait of alienated, solipsistic American youth: "People are afraid to merge on freeways in Los Angeles."

When Wilkinson looked at the available world data, he found that it supported his colleague's anecdotal observation about Brazil, one of the least equal societies in the world, and Britain, which has become less equal than it used to be. Road accidents - and indeed accidents in general - have a close relationship with income distribution. They are more frequent in countries with wider income differences.

"My impression is that health is no longer affected very much by improvements in material prosperity in the developed countries," says Wilkinson. Such societies have made the "epidemiological transition", from a condition in which infectious diseases are the main causes of death, to one in which degenerative diseases are the principal killers. "What is important is that people should recognise how crucial the quality of the social environment is," he says.

Eight teams of researchers around the world have now confirmed, by comparing death rates, that more equal societies are healthier societies. Wilkinson uses this realisation as the point of departure for an exploration of what, in the broader sense, makes a society healthy.

His approach matches a public mood increasingly concerned about the quality of life experienced by the comfortably off, while being dubious about just how badly off the poor really are. He notes, for example, that although the real incomes of the poorest 10 per cent of Britons have declined in the past 10 years, and those of the bottom 20 per cent as a whole have remained static, about three-quarters of this 20 per cent now have freezers, phones and central heating.

The malaise we sense is real enough, he believes, but poorly measured by consumer durables. Annual death rates are probably the clearest measure of health: a study in the North of England during the 1980s found that the poorest 10 per cent had death rates four times those of the richest 10 per cent.

Nor are the poor a separate species from the rest, as they are so often depicted nowadays. Perhaps the most striking evidence that inequality affects health in all strata of society comes from the Whitehall study of 17,000 London civil servants, which found that heart disease was four times more common among junior staff than among senior grades. Junior civil servants may not be considered affluent by prevailing standards, but they are undoubtedly paid enough to cover the necessities of life. It seemstheir relative status, not their absolute standard of living, may underlie their relatively poorer health.

They may not be flattered to learn that both Wilkinson and the Whitehall researchers themselves turned to baboons in search of an explanation. Robert Sapolsky, who studies these primates in the Serengeti, has found that males of lower rank have higher levels of glucocorticoids, steroid hormones triggered by stress. These are vital at times of crisis, but have corrosive effects on bodies set to a permanent emergency mode. The Great Leveller, an Equinox documentary based on Wilkinson's work to be shown on Channel 4 later this month, tells how primatologists transferred high-ranking monkeys to groups where their status was reduced - and saw their arteries clog up.

It's easy to see how low rank can induce stress, ulcers and high blood pressure in rigid, hierarchical, rule-bound societies of the kind occupied by civil servants and other primates. But Wilkinson believes that the effects of inequality can operate across much more diffuse relationships. That neighbour with a bigger car may be damaging your health, even though you don't work for him. Many of us know colleagues who suffer great unhappiness because they feel they are not valued at work, Wilkinson notes. "For some people, that is their experience of society," he points out.

The greater the gap between rich and poor, moreover, the further there is to fall. Middle-class people in such societies may suffer greater stress because of the fear of what will happen if they lose their grip on the ladder. Their mortality statistics may be worsened as they see the fates of those who do come unstuck. The death rates of the poorest classes in egalitarian Sweden are lower than those of all classes in Britain, right up to the wealthiest.

Looking at relatively equal societies in search of factors that might underlie their better health, Wilkinson felt that what really stood out was social cohesion, and that this could outweigh other known health hazards. In the 1960s, social scientists found that the incidence of heart attacks in Roseto, Pennsylvania, was half that in neighbouring towns, despite the Rosetans' taste for food cooked in lard. Individuals lost the Roseto benefit if they moved away, suggesting that the effect was not genetic, and the entire town lost it when the younger generation abandoned community values in favour of Cadillacs.

Roseto was a quintessential small American town of 1,600 souls. But the effect of cohesion can also be observed in a nation of 120 million. By the end of the 1980s, Japan had both the highest life expectancy and the lowest income differences of any developed country. The former had risen, spectacularly, since the 1960s, while the latter had fallen. Meanwhile the Japanese commitment to social cohesion remained largely constant.

Social cohesion is essentially qualitative and therefore difficult to measure and integrate with health and income statistics. There is a danger that the data might acquire a rosy tint of nostalgia, for small- town America or the spirit of the Blitz. Recently, however, a team of American researchers has attempted to rate "social trust" on a numerical scale, asking subjects questions such as "Would people take advantage of you if they had the chance?".

Wilkinson sees this as important quantitative evidence for his theories. He is not alone in identifying the limitations of "rational choice" economic theories and simplistic monetary measures of satisfaction in affluent societies. Robert Frank and Philip Cook, authors of The Winner-Take-All Society, have similarly emphasised relative social position. And his vision of community is similar to that invoked by Charles Murray and Richard Herrnstein in The Bell Curve, though he views it from the left and they from the right. His concerns are of the moment, but his arguments look like sketches for the reinvention of social democracy, this time with the emphasis on "social".

"The single most important thing about this story is that it suggests there are structural handles on the social quality of life. Things like income distribution really make a difference to the social fabric,"he says.

A healthier, more cohesive society must surely be a more economically productive one. Wilkinson points to a number of studies, covering dozens of countries, which show that greater equity leads to faster growth. Researchers have suggested several means by which it might exert this effect: by promoting political stability, and thereby encouraging investment, by encouraging families to value education, or by removing obstacles to individual achievement. But the unavoidable implication of Wilkinson's argument is that in order to make an unequal society healthier, its wealth must first be redistributed.

We aver that nothing really matters as long as we have our health. Richard Wilkinson is presenting us with evidence that if we want our health, we need to stitch our social fabric back together again. He warns us that we will have to pay for it. So far, at the shops or in the polling stations, the British apparently prefer 5p off to paying for quality.