The health of nations: why inequality is harmful to your health Ichiro Kawachi and Bruce P. Kennedy New York: The New Press; 2002 232 pp. US$25.95 (cloth) ISBN 1-56584-582-X
Figure. Photo by: Barbara Sibbald
Perhaps Canadians may be forgiven if they feel smug about the fact that, although they are not quite as wealthy as their American neighbours, they live longer and healthier lives. If money can buy health (otherwise, what good is it?) shouldn't our cousins to the south be outliving us?
One reason why they aren't might be that wealth is distributed more equally in Canada than in the United States. This concept — that inequality is harmful to health — is what Richard Smith, editor of BMJ, referred to several years ago as “the big idea.” It is supported by two lines of reasoning: one is simple and uncontroversial; the other is not.
Let's tackle the simple part first. Suppose there are two countries, Equaland and Unequaland. In Equaland, everybody earns $50 000 a year. In Unequaland, half the population earns $1000 a year and half $99 000. Although these countries have identical average incomes, no one would be surprised if average life expectancy were higher in Equaland. We intuitively expect that the health benefits of being a dollar richer are greater for the poor than for the rich, and a substantial body of work supports this notion.
The more controversial idea can also be framed simply. If you are paid $50 000 a year, are you better off living in a country where everyone earns about the same as you, or in one where, although your earnings are average, some are paid a pittance and others a fortune? In other words, is it true, as Ichiro Kawachi and Bruce Kennedy suggest in the subtitle of this book, that inequality is harmful to your health?
The Health of Nations starts by describing just how profound the inequality chasm has become. In the United States (despite the title, the book focuses mostly on one country), the wealthiest 1% own almost 40% of the nation's assets. Moreover, the gulf between rich and poor is not only wide but growing. While the richest Americans have seen their incomes double over the last quarter-century, the poor have seen theirs decline by almost 10%.
Kawachi and Kennedy then move on to the links between prosperity, happiness and health. Using a variety of social science studies, they convincingly argue that, beyond a certain income, money does not buy more happiness. Moreover, as inequality grows so does the desire to “keep up with the Joneses.” People work harder and take fewer holidays, spend less time with their children and more time stuck in traffic jams. They buy more toys but do not feel more satisfied.
How inequality leads to lower self-esteem and increased consumption is reasonably clear; how it leads to illness and death is less so. Kawachi and Kennedy present some hypotheses: that more money spent on the “hedonic treadmill” leads to worse lifestyle habits, or that inequality creates tears in the social fabric, resulting in increased crime and reduced community support. But we don't need a convincing pathophysiology to believe that inequality can potentially affect health.
Inequality might be acceptable if it had benefits worth the costs. Some economists point out that the American dream would be meaningless without inequality, and it is that dream that encourages people to work hard and thus improve the common lot. But do the data back up the assumption that inequality improves productivity? In arguing that it doesn't, Kawachi and Kennedy turn to a wide variety of studies, including one on baseball.
Just as inequality has increased in the general population over the last quarter-century, it has also increased within professional sports franchises. What is obvious to a casual sports fan — that teams with one or two highly paid superstars are generally unsuccessful — has now been shown rigorously. In an intriguing study by Matt Bloom, a professor at Notre Dame, income inequality within a baseball team predicted not only poor team performance but also poor individual performance. Examples like these keep The Health of Nations accessible and entertaining, even as it persuades and informs.
Kawachi and Kennedy spend a final chapter discussing politics. These pages are among the book's most interesting. Despite living in a country with profound differences in wealth, low-income Americans are less likely than those in other developed countries to support decent living standards for the unemployed. The American dream dies hard, the authors argue, and the average American has little interest in redistributing wealth through increased taxes. This leaves Kennedy and Kawachi (and they are not alone) at a loss for solutions.
Kawachi and Kennedy present a cogent and lively case against inequality, and the praise on the back cover from the Nobel Prize-winning economist Amartya Sen is well deserved. At just over 200 easily read pages, this book is perfect fare for a long flight or a short holiday. For clinicians and students interested in the determinants of health, The Health of Nations is well worth reading.
Irfan Dhalla Medical Student University of Toronto Toronto, Ont.