This might be the best book dealing with social issues that I’ve read in a long, long time. It is also the only inequality, poverty, and global health related book, other than those of Paul Farmer, that left me with a feeling of hope when I finished. The thesis of the book is that inequality is at the root of many societal problems in rich countries. The authors of the book do a great job in showing a strong association between income inequality and many of society’s ills — from the percentage of the population that is currently in prison, to teen birth rates, to life expectancy, to obese teenagers, every single country that does well in these metrics appears near the top of the list for egalitarianism. Conversely, the United States often finds itself at the the bottom corner of the myriad charts in this book, generally far outlying but closest to Singapore, Portugal, and the UK.
For the sake of further discussion the authors have also found data for the fifty United States and often show a chart as it applies to rich countries (including the US), and then that same chart broken out with all fifty states individually. Utah, Hawaii, Minnesota, North Dakota, Vermont, Washington, and so on generally do better, and Mississippi, Louisiana, Alabama, and so on do poorly.
If you’re interested in inequality or structural violence, especially if you like graphs, you must read this book. And, as I said above, despite spending about 250 pages depressing me with hard data, by page 300 I finished the book with a feeling of hope. The last few chapters are smartly dedicated to discussing what you, I, all of us can do to address inequality and bring about positive social change. The authors have done a good job of including both data and anecdotes that left me feeling not that we’re all doomed, but that change really is possible — that the majority of us really do want equality, and all it takes is a catalyzing moment to make it happen.
I highlighted several portions of this book, and I found one paragraph on page 25 to be instructive,
“…surveys of the 12.6 percent of Americans living bellow the federal poverty line … show that 80 percent of them have air-conditioning, almost 75 percent own at least one car or truck and around 33 percent have a computer, a dishwasher or a second car. What this means is that when people lack money for essentials such as food, it is usually a reflection of the strength of their desire to live up to the prevailing stands. You may, for instance, feel it more important to maintain appearances by spending on clothes while stinting on food. We knew of a young man who was unemployed and had spent a month’s income on a new mobile phone because he said girls ignored people hadn’t got the right stuff. As Adam Smith emphasized, it is important to be able to present oneself credibly in society without the shame and stigma of apparent poverty.”
This rings particularly true for me, having seen firsthand those in Ghana and Nigeria the social value of a mobile phone trump the private value of clean water and sanitation.
Some have called this contagiousness of consumption affluenza, and the authors of the book do a good job addressing how it can influence not just social determinants of physical health but also mental health. They also note Robert Frank’s characterization of “luxury fever”.
“As inequality grows and the super-rich as the top spend more and more on luxury goods, the desire for such things cascades down the income scale and the rest of us struggle to compete and keep up. Advertisers play on this, making us dissatisfied with what we have, and encouraging invidious social comparisons.”
Page 26 contains another great quote, although it does not (sadly) have a citation,
“… differences in the quality of medical care have less effect on people’s life expectancy than the social difference in their risks of getting some life-threatening disease in the first place.”
A psychologist at San Diego State University found hundreds of studies, covering 52,000 people, from the 1950s through the 1990s. She found that there was a steadily increasing level of anxiety in the US, so much so that the average child in the 1980s was more anxious than the average child psychiatric patient in the 1950s! In Britain, depression of those in their mid-20s born in 1970 was twice as common as it was for those in 1958s.
Writing about social connections and levels of trust, the authors note a heatwave in Chicago that killed many more African Americans than Latinos, due (according to sociologist Eric Klinenberg) to blacks being afraid to open their windows or leave their homes, and neighbors not checking on one another. There are lots of examples one can select to highlight the value of social relationships, and I think that is probably a reasonable one. I am also aware that the infant mortality rate in the UK for ethnic minorities can vary widely, with Bangladeshis having a lower rate than whites, and those of Afro-Caribbean decent having a rate more than double either — informed speculation might attribute the lower rate of Bangladeshis to the social connections within families and a resultant tendency to see pregnant women looked after.
There is some good cursory coverage of the Whitehall I Study (I’ll get around to reviewing some of Sir Michael Marmot’s writings in the future), which I couldn’t possibly do justice here. Suffice to say that both human and animal studies have found that surprisingly those at the top of a hierarchy (say, the CEO of a company) are at much lower risk for adverse health effects from stress than those at the bottom (the folks in the mailroom or on the assembly line).
The book also mentions the oft-cited-by-Paul-Farmer study that found black men in Harlem to have a lower life expectancy than men in Bangladesh. This, for me, is a critical point — when we think of rich countries we think of better outcomes than poor countries, but in fact many in rich countries, especially those in certain sub-populations, do not have good outcomes. These poor outcomes are hidden by averaging. And, in fact, even for those who seem to have good outcomes, even for those at the top of the social ladder, often being a resident of a more fair country, even if it meant being closer to the bottom of the economic ladder, would imply better outcomes (e.g. higher infant mortality for the richest 20% in UK cf the poorest 20% in Sweden).
They describe 360 people in California in 2004 who were serving life sentences for shoplifting. Between 1984 and 1998 California built one new college and twenty-one new prisons. The statistics go on and on.
I could cite more, but really you should just read this book; it’s quite brilliant.