Wilkinson, R. G., & Pickett, K. E. (2007). Social Science & Medicine, 65(9), 1965-1978.

The problems of relative deprivation: why some societies do better than others.

Richard G. Wilkinson and Kate E. Pickett

This is a pre-publication copy of the manuscript published as: Wilkinson, R. G., & Pickett, K. E. (2007). The problems of relative deprivation: Why some societies do better than others. Social Science & Medicine, 65(9), 19651978.

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Wilkinson, R. G., & Pickett, K. E. (2007). Social Science & Medicine, 65(9), 1965-1978.

The problems of relative deprivation: why some societies do better than others.
ABSTRACT In this paper we present evidence which suggests that key processes of social status differentiation, affecting health and numerous other social outcomes, take place at the societal level. Understanding them seems likely to involve analyses and comparisons of whole societies. Using income inequality as an indicator and determinant of the scale of socioeconomic stratification in a society, we show that many problems associated with relative deprivation are more prevalent in more unequal societies. We summarise previously published evidence suggesting that this may be true of morbidity and mortality, obesity, teenage birth rates, mental illness, homicide, low trust, low social capital, hostility, and racism. To these we add new analyses which suggest that this is also true of poor educational performance among school children, the proportion of the population imprisoned, drug overdose mortality and low social mobility. That ill health and a wide range of other social problems associated with social status within societies are also more common in more unequal societies, may imply that income inequality is central to the creation of the apparently deep-seated social problems associated with poverty, relative deprivation or low social status. We suggest that the degree of material inequality in a society may not only be central to the social forces involved in national patterns of social stratification, but also that many of the problems related to low social status may be amenable to changes in income distribution. If the prevalence of these problems varies so much from society to society according to differences in income distribution, it suggests that the familiar social gradients in health and other outcomes are unlikely to result from social mobility sorting people merely by prior characteristics. Instead, the picture suggests that their frequency in a population is affected by the scale of social stratification which differs substantially from one society to another.

INTRODUCTION A typical approach to examining contextual area effects on health is to start by controlling out the compositional effects of the socioeconomic characteristics of the population in those areas (Diez-Roux, 1998; Merlo, 2003; Pickett & Pearl, 2001). Because individual characteristics usually have the most powerful influence on the local health profile, researchers adjust for them in order to see whether there are residual positive or negative health effects associated with features of the area itself. At the local area level the proportion of people with various socioeconomic characteristics may be primarily a distributional issue – how does an area become a deprived area, inhabited by a disproportionate share of poorer, less well educated people, while a neighbouring area attracts better off people (Macintyre, Maciver, & Sooman, 1993; Tunstall, Shaw, & Dorling, 2004)? However, on another level this is not a question about the distribution in physical space of people with given 2

that these processes are structured primarily at the national level. risks of teenage pregnancy. we suggest that the social processes related to income distribution are involved in the deeper ways our personal and class characteristics are constituted (Bourdieu.. along with others.. E. cycles of deprivation. it is instead about the social forces which create those characteristics in the first place. with different levels of educational qualifications? The answer to a question like that may seem to depend on the outcome of hundreds of different processes covering every aspect of poverty and wealth creation: educational policies and teaching methods. low trust. all involving the complexities and minutiae of interactions between individuals. and trying to formulate separate policies which might have an impact on each of these. What determines the proportions of people in the wider society belonging to different social classes. Rather than being left with the infinite complexities of different determinants of people’s standard of health. in different income groups. However. their social environments. & Pickett. As Taylor and Flint state. If the distribution of each of these health and social problems is related to relative deprivation within societies. then perhaps this tells us something fundamental about the impact of the processes of social differentiation within the population. 2002). also determines class-related inequalities in many other outcomes. the educational performance of school children. Rather than thinking of populations as made up of basically similar people who – by luck or judgement – have become attached to different incomes and make up societies with different levels of income inequality. social mobility. K. For several reasons we believe. teenage births. 65(9). as we would argue. Our thinking is not only based on the fact that the distribution of income reflects market incomes (earned and unearned) from the national economy. Our theory is that processes of social status differentiation. 1984). The range of outcomes which we shall show are statistically related to income distribution suggests that income inequality is related to deep-seated processes of social differentiation. 2000). it may be that there are also some simpler patterns. imprisonment.Wilkinson. (including ill health. propensities to violence. and also all tend to be more common in more unequal societies. as had been noted in previous 3 . 2006). The social processes which become structured round income distribution probably also include many of the early childhood influences on social and cognitive development which seem to affect both health and social mobility and are important in social class differentiation (Ben-Shlomo & Kuh. As Williams argues. (2007). G. 1965-1978. education. We found. imprisonment etc. it is also informed by our recent review of the literature on income inequality and health (Wilkinson & Pickett. the durability of class cultures – to name but a few. violence. R. 1995) and. plus the effects of varying degrees of redistribution resulting from national systems of taxes and benefits. and the wider society. in this paper we will show that a wide range of problems associated with relative deprivation. in discussing Bourdieu’s complex concept of “habitus” it “is the (class-related) habitus which…determine(s) not only lifestyles and the chances of success…but also class-related inequalities in health and illness” (Williams. are intimately related to the scale of income distribution. are all strongly related to one factor – societal measures of income distribution. including whether a society has a more or less hierarchical class structure. “classes have most commonly defined themselves on a state-by-state basis” (Taylor & Flint. In this paper we consider income inequality as both an indicator and a determinant of the scale of social stratification in a society. characteristics. drug abuse and obesity). Social Science & Medicine.

the evidence suggested a graded relationship such that small area studies in parishes. black American men had a median income of $26. G.522 and an average life expectancy of only 66. 2001). Social Science & Medicine. Wilkinson.606) points out “Whether or not the scalar structuration of a given social process generates sociologically or politically significant outcomes is an empirical question that can only be resolved through context-specific inquiries” (Brenner. We are sensitive to Marston’s point that “contemporary writing about scale in human geography has failed to comprehend the real complexity behind the social construction of scale” (Marston. and to assume that its relation to health is independent of the wider context is to forget that poor areas are poor in relation to the wider society. region. 2005). 2007). Indeed. studies and commentaries (Franzini.1 years. Ribble. while “other social practices are cordoned off in their respective localities” ignoring the fact “that even the most privileged social actors…are no less (locally) situated than the workers they seek to command” (Marston. Dorling. Income inequalities in large areas can of course be decomposed into income inequalities within and between their smaller constituent areas (Lobmayer & Wilkinson. 1997). that population health is most reliably related to income distribution when income differences are measured across nation-states and other large geo-political units. consider that in 1996. the role of nationally constituted social differentiation in relation to health and social outcomes remains an open question.410. and studies comparing nation-states showed the strongest and most consistent evidence. This observation is given additional weight by the fact that the same pattern was independently reported in an earlier review of studies looking at the relationship between income inequality and violence (Hsieh & Pugh. and the complex ways in which systems operating at different scales interact. In comparison. To give a particularly dramatic example. studies of states. 65(9). men in Costa Rica had a mean income (at purchasing power parity) of only $6. Nevertheless. Rather than ignoring the fabric of people’s lives which. regions and cities tended to show stronger. K. country or possibly to diaspora groups in other countries or with people of whom they know little? There are many other kinds of non-geographical groups…to which we may compare ourselves and with whom we consider ourselves to be of a similar social standing. 2001. as Ballas asks. 2001). (2007). 2000)and her argument that the emphasis has too often been on the functional agency of “the international economy” or to “national social formations”. Jones. Nevertheless. neighbourhoods and counties showed either weak or non-existent relationships. 1965-1978. & Woodward. 1993). more consistent relationships. yet their average life expectancy was 75 years (Marmot & Wilkinson. but because they are deprived in relation to the wider society. as Brenner (2001 p. & Shaw. city. And of course social comparisons with neighbours may sometimes have detectable effects on health.Wilkinson. E. It is far from clear how reference groups are constituted” (Ballas. R. As we have argued previously. “do (people) compare themselves to “peer groups” in their neighbourhood. & Pickett.. 2002). and one that can be empirically examined. we are suggesting that social classes are 4 . We realize that there has been considerable debate within the disciplines of economic and political geography concerning the spatial scales at which social processes are structured. However. as Marston pointed out are always locally situated (Marston. 2000). the health of people in a deprived neighbourhood is worse not because of inequalities within that neighbourhood. To call any local level of income an effect of “absolute” income (or education or deprivation). & Spears.

After adjustment for various control variables (including ones which could be either mediating or confounding variables). Italy. hostility. The same study also showed that greater inequality was associated with higher total calorie intake. UK. Chile. drug overdose mortality and low social mobility are also related to greater income inequality. These relationships were statistically significant for obesity among both men and women. In contrast. evidence confirming this pattern also came from studies of regions. (2007). regardless of its social distribution. 1965-1978. but that greater income inequality is associated with a higher prevalence of ill health and social problems in a society as a whole. states. but noticeably stronger among women. We found 104 studies of health in which income inequality was measured across whole nations. teenage birth rates. 2006). Health Morbidity and mortality In a recent review of 168 analyses of the relationship between income inequality and population health we found that a large majority of studies reported that more egalitarian societies tend to be healthier (Wilkinson & Pickett. tracts and parishes) produced more equivocal results. and racism. Taiwan. Studies of small areas – such as parishes and census tracts – were the only major exceptions to this pattern. 2006). 65(9). and cities in a number of different countries including Canada. & Wilkinson. 2005). R. China. the proportion of the population imprisoned. constituted in relation to each other partly through what may look like action at a distance – through the effects of the population class structure outside one’s immediate locality. 5 . We start our empirical investigation by summarising previously published evidence suggesting that the societal scale of income inequality is related to morbidity and mortality. RECENT EVIDENCE LINKING INEQUALITY TO SOCIAL OUTCOMES. obesity. Before adjustment the proportion supporting this relationship was higher still.. regions or cities – areas large enough for income inequality to be indicative of the overall scale of social differentiation and social hierarchy in those societies (Wilkinson & Pickett. even after adjusting for calorie consumption. low trust. states. and USA. 81 of the 104 studies (78%) found all or some of the health variables they measured were significantly related to inequality. As well as a large number of international comparisons of developed and developing countries. low social capital. studies which measured inequality and health in smaller areas (counties. Ecuador. Lobstein. Social Science & Medicine. Obesity In a study of obesity rates (BMI >30) in 21 of the richest countries we reported that rates were higher in more unequal societies (Pickett. that poor educational performance among school children. K. Russia. The relation between obesity and inequality was attenuated. homicide. Brunner. Kelly. We then go on to test new hypotheses. & Pickett. mental illness. but remained significant. G. E.Wilkinson. We would emphasise that the issue throughout is not that greater income inequality means simply greater inequality in outcomes localized within societies.

E. As summarised elsewhere (Wilkinson. 2002.002) in an expanded dataset. Kawachi. Connell. p=0.. was stronger when the areas measured were larger rather than smaller (Hsieh & Pugh. Posada-Villa. including data from a further WHO survey for New Zealand. trust. In the less unequal states only 10 or 15 percent felt they could not trust others. like health. & Pickett. Kennedy. including trust and social capital. social capital.Wilkinson. Gold. the World Health Organization (WHO) recently produced comparable estimates of the prevalence of mental illness for eight developed countries – six in Western Europe plus Japan and the USA (Demyttenaere. Kovess. teenage births are often considered a problem with health and social consequences for both mothers and children. & Wilkinson. Lepine et al. Lochner. Numerous analyses including homicide. We have since confirmed this correlation (r=0. 2000). Writing of the United States in the first half of the 19th Century. 2002) as well as an analysis among the 50 states of the USA (Kawachi. Gasquet. The differences related to inequality internationally were just as large. Homicide A large body of evidence suggests that there is a robust relationship between greater inequality and higher homicide rates. 1965-1978. 2005). states or cities) reported significant relationships (Wilkinson & Pickett. we found no evidence of such a relation among the 50 states of the USA. Pickett. 2005). Trust There have been a number of analyses of the relation between inequality and various measures of the quality of social relations. Mental Illness Using surveys of random samples of the population. & Kawachi. An earlier review also reported a robust relationship which. hostility and racism. The teenage birth rate was reported to be closely related to income inequality both internationally among 21 rich countries and among the 50 states of the USA (Gold. 1993). 2005). & Connell. Lynch. 6 . & Wilkinson. 2001. The Quality of Social Relations Many people have intuited that inequality is socially divisive and corrosive of human relations. and suggest that the quality of social relations is poorer in more unequal societies. Kennedy. However. 65(9). 2004). We found statistically significant correlations between income inequality and the prevalence of both serious and any mental illness (Pickett.. An international analysis of data from 38 countries (Uslaner. Bruffaerts. Teenage birth rates Whether for biological or social reasons. regions. James. & Prothrow-Stith. Kennedy. these results are consistent with the findings on violence. this rose to 35 or 40 percent in the more unequal states. (2007). K. suggest that the quality of social relations in a society is poorer where there is more inequality (Wilkinson. Social Science & Medicine. Canada and the UK (Figure 1). 2006). G.79. Mookherjee. de Tocqueville emphasised his belief that the strength of the associational and civic life to which he drew attention was based (with the crucial exception of slavery) on what he called the “equality of conditions” (de Tocqueville. R. and non-WHO population based prevalence estimates for Australia. All 24 studies of inequality and homicide rates in large areas (whole countries. 1997) have shown substantially lower levels of trust where income differences are bigger. 2006).

. R. Until the late 1960s income differences narrowed and social capital strengthened. prison populations. Norway. 65(9). NEW ANALYSES In the light of these findings we decided to see if there were relations between inequality and other social problems associated with relative deprivation. we excluded countries with populations of less than three million. Social Capital Measures of the strength of associational and community life have also been reported to be related to income inequality. the United Kingdom. and a similar relation between inequality and his index of social capital among the states of the USA (Putnam. Slovenia. 2003. The outcomes we were able to look at were limited by the availability of comparable data but. Feaganes. This ratio ranged from 3. To avoid tax havens. Ireland. (2007). Jones. Social Science & Medicine. & Prothrow-Stith. 7 . reporting dates vary slightly from country to country but are within the period 1992– 1998 (United Nations Development Program. Putnam reported a strong cross-sectional relation between income inequality and his index of the strength of the “civic community” in the 20 regions of Italy (Putnam. France. Spain.Wilkinson. Hostility and racism The last indicators that greater inequality is accompanied by less good social relations come from US data on hostility scores and racism. Belgium. G. & Barefoot. Putnam also mentions a “striking” similarity in the trends in inequality and social capital during the 20th century. Finland. the most equal country. 2000). 2003). Israel. 2003 and 2004 reports as the figure for 2003 was anomalous. & Pickett. 1993). Denmark. Data on income inequality came from the Human Development Indicators (HDI). Lochner. 2005). For consistency with our other recent publications. Portugal. The average score for each city was significantly related to its income inequality (Wilkinson. to 9. Sweden. in addition to the outcomes discussed above. 1997). Switzerland. and social mobility. Canada. Greece. In a separate study. the most unequal. we limited the international analyses to countries among the richest 50 (by Gross National Income per capita at purchasing power parities) in 2002. income inequality was measured as the ratio of the total annual income received by the richest 20% of the population to the total annual income received by the poorest 20% of the population. For Germany we used an average of the HDI figures given in the 2002. and the United States. but around 1965-70 both reversed direction: income differences widened and social capital weakened. Data Sources and Results To improve comparability. The Netherlands. 1995). Austria. Japan. Germany. New Zealand. we now report analyses of the relationship between income inequality and the educational performance of school children. Singapore. E. Kennedy et al found that people held more racist attitudes and beliefs in US states where income differences were large (Kennedy. drug overdose mortality. Williams measured hostility scores in random samples of the population in 10 US cities (Williams. Income distribution data were available for 24 countries which met these criteria: Australia.7 in Singapore. Italy.4 in Japan. Kawachi. K. 1965-1978.

We also found a statistically significant tendency for the proportion of children not completing high school to be greater in more unequal states. we looked at the same association among the 50 states (& DC) of the USA.01). 2000). Relating these to income inequality we found a correlation of r = 0. Bureau of Justice Statistics (US Department of Justice). Because the USA is an outlier. The correlation coefficient was r = 0.01. 65(9). E. the correlation then rose to r = 0.01).69 p-value<0..Wilkinson. we also checked the association when it was excluded. indicating total equality (Allison.01. With DC excluded. the next highest.56 but remained statistically significant (p-value <0. we used the Gini coefficient of the inequality of family income for 1999 as provided by the US Census Bureau (U. Rather than calculating our own measure. p-value <0. we used estimates of the combined maths and literacy scores for 15year olds taken from the Programme for International Student Assessment 2003 (OECD Programme for International Student Assessment. Figures for imprisonment in 1997-8 were taken from the US Department of Justice. we combined maths and reading performance scores for 8th graders (about 14 years old) from the US Department of Education. 2004). p-value < 0. The correlation coefficient was r = -0. Abolition appears to be more common in the more egalitarian states. p-value < 0. DC was an outlier but the association remained highly significant when it was excluded. pvalue = 0. DC was an extreme outlier in this relationship. with much the highest level of income inequality and an imprisonment rate of 1. 2004a. With Singapore also excluded the correlation was r = 0.75. These data were available for 19 countries and the distribution of educational performance in relation to income inequality is shown in Figure 2.50. Social Science & Medicine. 1965-1978. The data are shown in Figure 3. G. The data (with DC excluded to facilitate scaling) are shown in Figure 4. Drug Overdose Mortality 8 . K.69.S. & Pickett. which also shows which states retain and which have abolished the death penalty. 1978)) Educational performance To see if the educational performance of school children was related to inequality internationally. To check if a similar relationship existed among the 50 states (& DC) of the USA. 2004). (The Gini coefficient varies between 1. Census Bureau. National Center for Education Statistics for 2003.77 (p-value<0. p-value <0. The correlation coefficient relating imprisonment rates to income inequality was r = 0.66.60. .01. where data were available we also analysed relationships with income inequality among the 50 United States and the District of Columbia (DC). indicating maximum inequality. 2004b) The scores were significantly lower in states with wider income differences: r = -0. (US Department of Education. Imprisonment Figures on the proportion of the population imprisoned in different countries come from the United Nations Survey on Crime Trends and the Operations of Criminal Justice Systems (United Nations Crime and Justice Information Network.029.01. the correlation was attenuated to r = 0.000 . and 0. R. (2007). To supplement the international analyses.more than twice that of Louisiana.566 per 100. Again.01.

61 (p-value<0.01). 1965-1978. 65(9). Social mobility was measured by estimating the correlation between father’s and son’s incomes (when sons were close to age 30) and calculated from large. Age-adjusted mortality rates for deaths from accidental narcotic and hallucinogen poisoning (ICD-10 Code X42) were taken for US states (& DC) from the Center for Disease Control and Prevention’s Compressed Mortality Files for the years 1999-2002 (Center for Disease Control and Prevention). Despite having data for only eight countries. but the association remained statistically significant when it was excluded. When the USA and UK are excluded as possible outliers. Hill. DC was an outlier. Whilst causal inference from observational studies. 2005). Wilkinson & Pickett. DISCUSSION The evidence outlined here. As for education and imprisonment (above). Findings at the scale of nations and states (but not more local areas) have been well replicated (Subramanian & Kawachi. Higher correlations between father’s and son’s incomes therefore indicate less social mobility. The relationship is shown in Figure 5: among these eight countries bigger income differences are associated with lower social mobility.93. and the biology of chronic stress provides a plausible biological explanation of the findings (Sapolsky. G.01). p-value < 0. However. Social Mobility International data on intergenerational social mobility are available for a few countries from a study by Blanden and colleagues (Blanden.. we found that the use of non-parametric Spearman rank correlations produced broadly similar results and in no instance affected statistical inference. goes some way to establishing the simple but important point that numerous social problems associated with relative deprivation – from ill health to poorer educational performance – are more common in more unequal societies. 2005). (2007). 2004. The correlation with state income inequality was r = 0. as inequality increases so does poor health (Wilkinson & Pickett. As well as several time series analyses (Marmot & Bobak. but also to the ratio of the top and bottom 10 percent and to the Gini coefficient. Gregg. there are also examples of societies – such as Britain during the two World Wars and the formerly centrally planned societies 9 . 1992). & Machin. 2006). E. Previous studies of associations between income inequality and health have shown that these are strong relationships and that they exhibit a dose-response form. the correlation remains close (r = 0. It appears that there are no reliable international data on drug related deaths (Advisory Council on the Misuse of Drugs. the relationship between intergenerational social mobility and income inequality was statistically significant (r = 0.60) but with only six data points is not statistically significant. consistent as it is across outcomes and setting. 2006). representative cohort studies in each of eight countries. this body of evidence meets epidemiological guidelines for assessing causality (Gordis. is inherently problematic. 1965). K. Social Science & Medicine. R. Wilkinson. For comparability with earlier work the new analyses presented in this paper used Pearson correlation coefficients which assume normal distributions and linearity. 2000.Wilkinson. We also checked to see if the international results were robust to the use not only of the ratio of the top to bottom 20 percent of incomes. 2004. & Pickett. 2000). particularly from ecological studies. In all cases the measure of inequality made no substantive difference to the results.

Reinforcing this impression is the fact that while income differences widened in Britain and the United States. 1965-1978. as if greater social distances were translated into greater geographical distances. Portugal and often the UK) tend to have poorer outcomes. residential segregation of rich and poor increased (Berube. 2001). Kawachi. Singapore and the US are ethnically diverse. Social Science & Medicine. and so a new approach to a vital arena for social research. equal opportunity is a more distant prospect where there are greater inequalities of outcome. Norway and often other Scandinavian countries) perform well on a variety of outcomes.4%. 2006). Even their pathways to greater equality of incomes differ substantially: Sweden depends primarily on redistribution through taxes and benefits while Japan has smaller differences in earnings even before taxes and benefits..1% (Central Intelligence Agency. seems to confirm the relation between income inequality and social stratification. What our new evidence adds is coherence and specificity: if relative deprivation links income inequality to poor health then we would expect to find. 2002. Erdal & Whiten. undergoing transition to market economies (Wilkinson. This picture suggests that more unequal societies are socially dysfunctional in many different ways. much closer to Portugal’s 7. In effect. We find it hard to think of other possible explanations – apart from inequality – for these patterns. but Portugal has a more homogeneous population like Finland or Japan. K. 2005. (2007). social mobility slowed (Blanden. & Pickett.Wilkinson. Japan and the US are service-based economies. Modern societies almost certainly continue to differ in how hierarchical and socially differentiated they are. E. Sweden. 1996) – showing that changes in income inequality are followed by changes in health outcomes. ranging from the most egalitarian foraging societies of prehistory to the most tyrannical hierarchies (Boehm. while Singapore and Finland have a heavier manufacturing base.6% than to Japan’s 4. the apparent tendency for societies with wider income differences to have less social mobility. Mayer. G. It is striking that a group of more egalitarian countries (usually including Japan. and a similar group of more unequal countries (including the USA. Gregg. Sweden has one of the strongest welfare systems. 10 . 1993. as we do. In addition. Sweden and Japan show marked contrasts in the position of women in society and in their participation in paid employment. Interpretation Human beings have lived in every kind of society. which is more like Singapore’s 3. & Machin. the same cannot be said of the US and Portugal or Singapore which also tend to perform badly. Although there are clearly numerous similarities between the US and Britain. 1996). that other social problems linked to relative deprivation are also associated with income inequality but are not associated with absolute levels of income as such.4%. Despite having data for only eight countries. 65(9). 2005) and. while Japan devotes an unusually small proportion of its National Income to public social expenditure. Japan – in contrast to Sweden – has low rates of single parenthood and divorce. Despite performing well on almost all outcomes. The development of comparable measures of income inequality seems at last to have given us a rough indication of the extent of social differentiation from one society to another. R. Bigger income differences seem to solidify the social structure and decrease the chances of social mobility. Not even unemployment rates fit the pattern: Finland has an unemployment rate of 8.

and inequality increases that burden. beyond health. Goldman. (2007). effects of material factors. social gradients in health might result from the way people’s health risks are shaped by less favourable social and material circumstances. Alternatively. Naveh. As if to confirm that the link between income inequality and these outcomes is indeed mediated by changes in the burden of relative deprivation. Warner. are also those most closely related to income inequality. It is instead much more likely that causation runs the other way – wider income differences leading to more violence and more obesity. then this strongly suggests the operation of powerful processes of social causation for health as well. & Kuulasmaa. And if greater economic inequality in a society is associated with more of most of the problems associated with relative deprivation. 2003. This does not mean that social mobility does not also act selectively: it may in turn select according to how people have been shaped by greater inequality. 2000. Dohrenwend. Schwartz. & Pickett. For example. Similarly. the relation between population mortality rates and income distribution is typically strongest among men of working age. & Davey Smith. 2000).. According to social selection theory. Violence and teenage births also seem to be examples of problems which are particularly strongly related to both relative deprivation and to income inequality (Health Development Agency. 1997). there are indications that the outcomes most strongly related to deprivation and showing steeper social gradients within societies. McMunn. As well as sharing roots in relative deprivation. 1992. social gradients may reflect a tendency for social mobility to discriminate between the healthy and the unhealthy. this is also the age and sex group in which the social class gradient in health tends to be steepest. Hudson. if low social status increases chronic stress. so that the healthiest and most capable people move up the social ladder and end up with the highest incomes. Sans. Ritsher. The relation between inequality and a range of health and social problems may also contribute to the debate around theories of social selection versus social causation in the production of social gradients in these problems. we might gain a new perspective on the problem of social selection versus social causation. 2005. Hardy. it is unlikely that having a higher level of violence or a greater proportion of heavy people has caused income distributions to be wider. many social problems – including poor health – may also involve similar causal processes involving psychosocial pathways related to chronic stress. & Kuh. 11 . Marmot & Wilkinson. see for example: (Claussen. 1994.Wilkinson. Bartley. many of the social problems which seem to be related to income inequality are inherently behavioural and provide evidence that income inequality has psychosocial effects. G. If we can demonstrate a strong relationship between national levels of income inequality and a range of social problems. 65(9). & Dohrenwend. The relative contributions to the link between inequality and population health of psychosocially mediated. E. & House. These observations seem to confirm the simplest interpretation: that the reason why greater inequality is associated with a higher prevalence of these problems is that they are partly responses to the burden of relative deprivation. just as income inequality is more closely related to the population prevalence of obesity among women than men. while the least healthy end up at the bottom of the income distribution. However. 1965-1978. Shrout. in relation to health. Indeed. Levav. so too is the social gradient in obesity more marked among women than men (Molarius. 2001).. Link et al. Johnson. If we observe more homicides or a higher prevalence of obesity. unmediated. Tuomilehto. Naess. in more unequal societies. K. Smith. This is particularly plausible in relation to the long-term effects of circumstances in early life. R. or of the direct. Smits. Social Science & Medicine. 2001). Wilson & Daly. Kaplan. Seidell. 2005. 2006. have been disputed (Lynch.

yet empirical investigation of the scales and pathways that underpin social comparisons is lacking. As we said above. Although statistically significant for both. Yet it is still not uncommon to refer to associations between the mean income and health for small areas as indicating effects of “absolute” income. there 12 . or because of where it places you in the national status hierarchy. the correlations with health were stronger when people’s incomes were related to province-level income than they were when related to neighbourhood income. 2000). Only when we compare income in different societies. What we are suggesting may look like action at a distance. rather than the effects of how the local population fits into the scale of national relativities – whether the area is deprived or not in relation to the standards of the rest of society. 65(9). They found that self-rated health was predicted by whether or not people felt they were better or worse off than the average Canadian. When income distribution first appeared on the public health agenda. Glass. this implies that we are dealing with effects of relativities across a much larger scale. & Pickett. 2000. people frequently refer to actual levels of monetary income as “absolute” income. & Seeman. Researchers have frequently assumed that if income differences are important. A long tradition of sociological theory. They also calculated how people’s actual incomes compared in relation to incomes in their neighbourhood and in their province. Schwartz & Diez-Roux. suggests that the salience of income distribution involves something much deeper than comparisons of income.. But within a single nation it is of course impossible to tell whether relationships between health and income arise because of the absolute material standards of living which any given level of income buys. (2007). 2002) and Durkheim’s notion of “social facts” (Berkman. 2001). But if income inequality is related to health more closely when the units of analysis are whole societies than when they are smaller areas. Following Runciman (1966). stretching back to Marx’s assumptions about the importance of the larger social framework (Bergesen & Bata. Bartley. & Ross. Because of the tendency to expect reference points for income to be local. E. based on our review of studies of income inequality and health (Wilkinson & Pickett. 2006). this would provide fertile ground suggesting why so many health and behavioural problems seem rooted in relative deprivation and show similar social gradients and relationships with income inequality. 2006). this implies the importance of processes of social comparison. G. & Joshi. R. and the fact that they are also related to relative deprivation. as in our comparison of black Americans and Costa Rican’s above. Social Science & Medicine. This fits with what we would expect. Dunn and colleagues recently reported relationships between health and various measures of socioeconomic status in a Canadian survey (Dunn. 1965-1978. such comparisons are often thought to take place primarily at the local level. Brissette. do we see how weak the relation between absolute income levels and population health may be. Veenstra. although there is some recognition that those “who are spatial neighbours are not always social neighbours” (Mitchell. K. has emphasized the ways in which individuals are shaped by the social environment. Wiggins.Wilkinson. This looks less implausible if we are thinking of income distribution as a determinant of processes of social class differentiation rather than simply in terms of income comparisons. The less local provincial reference point was more salient than the neighbourhood reference point. or when we look at life expectancy and Gross National Income per capita among the richest countries. the range of health and social problems which seem to be related to income distribution. Gleave. Relativities and comparisons beyond the local seem more important than purely local ones.

The remaining question is of course how one knows one’s class or social status in the wider society. mainly as a result of deaths at younger ages. 65(9). An indication of the range of the processes which may be set in motion by greater social differentiation comes from the data shown in figures 3 and 4 on imprisonment. However. Somehow we all learn the degrees of superiority and inferiority in our society and know where we stand. K. that more unequal states are more likely to retain the death penalty. there are ten-fold differences in homicide rates between more and less equal countries and US states. 13 . sixfold differences in teenage birth rates. What matters is perhaps that the associations between inequality and the prevalence of different outcomes are telling us more about the causal processes rooted in social differentiation. Greater inequality and bigger social distances may then be accompanied by hardening of social attitudes. six-fold differences in the prevalence of obesity. 1965-1978. four-fold differences in how much people feel they can trust each other. then it may be mistaken to analyse its effects after adjusting for other factors closely related to class. But it now seems much more likely that it is telling us more about the nature of the factors driving the familiar social class differences in health. was a tendency to assume that. If. perhaps the most important implication of the relationships with inequality shown here is that the achievement of higher national standards of performance may be substantially dependent on reducing inequalities in each country. A person may assess these relativities in relation to those she was at school with. Analyses of the increase in prison populations in Britain and the United States during the later 20th century. when income differences were widening. the rich and powerful. the social connotations of her house and the part of town in which she lives.Wilkinson. The associations we have seen between income inequality and a range of health and social problems are far from trivial. if it was related to health at all. 2001). As Emerson said. As well as improving health. income distribution is really telling us about more general processes of social class differentiation. increase trust.or tenfold differences in imprisonment rates and. and her knowledge – gained through the media – of the lives of the elite. such as education. and we are always learning to read it” (Emerson. A relation between wider income differences and more punitive attitudes to crime is suggested in Figure 4 which shows. & Pickett. Social Science & Medicine. her educational achievements. while decreasing violence and teenage births. and so on. 1883). in addition. the income and social standing of her parents. E. G. suggest that the greater part of the increase resulted from more punitive sentencing rather than from increases in crime (Mauer. it must reflect some additional and previously unknown causal process. The answer is likely to involve a knowledge of where one fits into many different relativities. Conclusions It is often assumed that the desire to raise national standards of performance in fields such as education and health is a quite separate problem from the desire to reduce health and educational inequalities within a society.. “Tis very certain that each man carries in his eye the exact indication of his rank in the immense scale of men. Even ignoring extreme examples. place in the job hierarchy. reducing inequality may also raise the educational performance of school children. R. five. all substantially influenced by income. cross-sectionally. the celebrities. where her school fitted into the social hierarchy. (2007).

in expensive and at best only partially effective attempts to offset the problems of relative deprivation. 2005. they seem to show the importance of the existing differences in inequality which occur now between developed market democracies or between US states. 1965-1978. However. 2006b). E. then it is possible that some of the health and social problems marked by social gradients share roots in chronic stress. Indeed. after all. G. (2007). They attract strings of policy initiatives designed to tackle each of these issues separately: policies to reduce overcrowded prisons. and which can only be revealed through comparative analysis at the scale of whole societies. Instead. health promoters. Rather than providing ever more prisons. not differences between an impractical perfect equality and practical reality. to raise children’s educational performance and so on as if there was no connection between them. The differences in inequality we have been looking at are. it may be cheaper and more rewarding to tackle the underlying inequalities themselves. 2006a). Perhaps that is because they have focussed less on decreasing the burden of relative deprivation than on attempts to reduce its effects on health. if inequality has psychosocial effects. perhaps involving chronic stress and the aversive effects of low social status. 65(9). social workers.. doctors. so far they have met with little success (Department of Health. K. It is difficult to stop relative deprivation having its familiar effects on health. R. educational psychologists and drug rehabilitation units. to reduce violence or teenage births. three years difference in the average length of life. 14 . then there are likely to be substantial and widespread benefits of tackling the underlying inequality itself. Mackenbach. if ill health is just one of the many social problems related to relative deprivation which are less common in more egalitarian countries. & Pickett.Wilkinson. Although Britain is said to be “ahead of continental Europe in developing and implementing policies to reduce socio-economic inequalities in health” (Mackenbach. Social Science & Medicine. These issues go to the heart of problems which beset our societies and are constantly in the news.

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(2007).Wilkinson. 65(9). also indicating states with and without the death penalty Figure 5 Intergenerational social mobility in relation to income inequality among rich countries 19 . Social Science & Medicine. & Pickett. R. G. E. 1965-1978. K. FIGURE LEGENDS Figure 1 Prevalence in mental illness in relation to income inequality among rich countries Figure 2 Educational achievement in relation to income inequality among rich countries Figure 3 Imprisonment in relation to income inequality among rich countries Figure 4 Imprisonment in relation to income inequality among the 50 US states and DC..

G. 65(9). (2007). 1965-1978. E.Wilkinson. & Pickett. K. Social Science & Medicine. 20 . R..

21 . 1965-1978. G. K. (2007). 65(9). E. Social Science & Medicine..Wilkinson. & Pickett. R.

(2007).Wilkinson. Social Science & Medicine. 1965-1978.. 22 . & Pickett. K. 65(9). R. E. G.

Wilkinson. E. K. Social Science & Medicine. G. 65(9). (2007). & Pickett. 1965-1978. R.. 23 .

G. 1965-1978.. R. (2007). 65(9). & Pickett.Wilkinson. K. Social Science & Medicine. 24 . E.

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