There are two important reasons for interpreting income inequality in this way. The first pointer is that only the health and social problems which have strong social class gradients – becoming more common further down the social hierarchy – are more common in more unequal societies. This seems to be a general phenomenon: the steeper the social gradient a problem has within society, the more strongly it will be related to inequality.8 This not only applies to each problem – to teenage birth rates or to children doing badly at school, for example – it looks as if it also applies to sex differences in the same problem. The reason why women’s obesity rates turn out – as we shall see – to be more closely related to inequality than men’s, seems to be that the social gradient in obesity is steeper among women than men. Health problems such as breast cancer, which are not usually more common among the less well off, are unrelated to inequality.9
The other pointer which suggests that income inequality reflects how hierarchical societies are, became clear when we reviewed nearly 170 academic papers reporting different pieces of research on the relationship between income inequality and health.10 The size of the areas over which researchers had measured inequality varied substantially. Some had calculated how much inequality there was in local neighbourhoods and looked to see if it was related to average death rates in those neighbourhoods. Others had used whole towns and cities as the units in which inequality and health were measured. Still others had looked at regions and states, or done international studies comparing whole countries. When we reviewed all this research, a clear pattern emerged. While there was overwhelming evidence that inequality was related to health when both were measured in large areas (regions, states or whole countries), the findings were much more mixed when inequality was measured in small local areas.
This makes perfect sense if we think about why health tends to be worse in more deprived local areas. What marks out the neighbourhoods with poor health – where life expectancy may be as much as ten years shorter than in the healthiest neighbourhoods – is not of course the inequality within them. It is instead that they are unequal – or deprived – in relation to the rest of society. What matters is the extent of inequality right across society.
We concluded that, rather than telling us about some previously unknown influence on health (or social problems), the scale of income differences in a society was telling us about the social hierarchy across which gradients in so many social outcomes occur. Because gradients in health and social problems reflect social status differences in culture and behaviour, it looks as if material inequality is probably central to those differences.
We should perhaps regard the scale of material inequalities in a society as providing the skeleton, or framework, round which class and cultural differences are formed. Over time, crude differences in wealth gradually become overlaid by differences in clothing, aesthetic taste, education, sense of self and all the other markers of class identity. Think, for instance, of how the comparatively recent emergence of huge income differences in Russia will come to affect its class structure. When the children of the new Russian oligarchs have grown up in grand houses, attended private schools and travelled the world, they will have developed all the cultural trappings of an upper class. A British Conservative politician was famously described by another as someone who ‘had to buy his own furniture’. Although there has always been prejudice against the nouveau riche, wealth does not remain new for ever: once the furniture is inherited it becomes old money. Even as far back as the eighteenth century, when people thought that birth and breeding were what defined the upper echelons of society, if you lost your fortune you might maintain status briefly as ‘genteel poor’, but after a generation or so there would be little to distinguish you from the rest of the poor. Moreover, as Jane Austen shows in both Mansfield Park and Sense and Sensibility, the consequences – whatever your birth – of marrying for love rather than money could be serious. Whether material wealth is made or lost, you cannot long remain ‘a person of substance’ without it. And it is surely because material differences provide the framework round which social distinctions develop that people have often regarded inequality as socially divisive.
QUALITY OF LIFE FOR ALL AND NATIONAL STANDARDS OF PERFORMANCE
Having come to the end of what higher material living standards can offer us, we are the first generation to have to find other ways of improving the real quality of life. The evidence shows that reducing inequality is the best way of improving the quality of the social environment, and so the real quality of life, for all of us. As we shall see in Chapter 13, this includes the better-off.
It is clear that greater equality, as well as improving the wellbeing of the whole population, is also the key to national standards of achievement and how countries perform in lots of different fields. When health inequalities first came to prominence on the public health agenda in the early 1980s, people would sometimes ask why there was so much fuss about inequalities. They argued that the task of people working in public health was to raise overall standards of health as fast as possible. In relation to that, it was suggested that health inequalities were a side issue of little relevance. We can now see that the situation may be almost the opposite of that. National standards of health, and of other important outcomes which we shall discuss in later chapters, are substantially determined by the amount of inequality in a society. If you want to know why one country does better or worse than another, the first thing to look at is the extent of inequality. There is not one policy for reducing inequality in health or the educational performance of school children, and another for raising national standards of performance. Reducing inequality is the best way of doing both. And if, for instance, a country wants higher average levels of educational achievement among its school children, it must address the underlying inequality which creates a steeper social gradient in educational achievement.
DEVELOPING COUNTRIES
Before leaving this topic, we should emphasize that although inequality also matters in developing countries, it may do so for a different mix of reasons. In the rich countries, it is now the symbolic importance of wealth and possessions that matters. What purchases say about status and identity is often more important than the goods themselves. Put crudely, second-rate goods are assumed to reflect second-rate people.
Possessions are markers of status everywhere, but in poorer societies, where necessities are a much larger part of consumption, the reasons why more equal societies do better may have less to do with status issues and more to do with fewer people being denied access to food, clean water and shelter. It is only among the very richest countries that health and wellbeing are no longer related to Gross National Income per person. In poorer countries it is still essential to raise living standards and it is most important among the poorest. In those societies a more equal distribution of resources will mean fewer people will be living in shanty towns, with dirty water and food insecurity, or trying to scrape a living from inadequate land-holdings.
In the next chapter we will look in a little more detail at why people in the developed world are so sensitive to inequality that it can exert such a major effect on the psychological and social wellbeing of modern populations.
3
How inequality gets under the skin
’Tis very certain that each man carries in his eye the exact indication of his rank in the immense scale of men, and we are always learning to read it.
Ralph Waldo Emerson, The Conduct of Life
How is it that we are affected as strongly by inequality and our position within society as the data in the last chapter suggest? Before exploring – as we shall in the next nine chapters – the relations between inequality and a wide range of social problems, including those in our Index of Health and Social Problems, we want to suggest why human beings might be so sensitive to inequality.
As inequality is an aspect of the broad structure of societies, explanations of its effects involve showing how individu
als are affected by the social structure. It is individuals – not the societies themselves – who have poor health, are violent or become teenage mothers. Although individuals do not have an income distribution, they do have a relative income, social status or class position in the wider society. So in this chapter we will show the ways in which our individual sensitivity to the wider society explains why living in more unequal societies might have such profound effects.
To understand our vulnerability to inequality means discussing some of our common psychological characteristics. Too often when we speak or write about these issues, people misinterpret our purpose. We are not suggesting that the problem is a matter of individual psychology, or that it is really people’s sensitivity, rather than the scale of inequality, that should be changed. The solution to
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problems caused by inequality is not mass psychotherapy aimed at making everyone less vulnerable. The best way of responding to the harm done by high levels of inequality would be to reduce inequality itself. Rather than requiring anti-anxiety drugs in the water supply or mass psychotherapy, what is most exciting about the picture we present is that it shows that reducing inequality would increase the wellbeing and quality of life for all of us. Far from being inevitable and unstoppable, the sense of deterioration in social wellbeing and the quality of social relations in society is reversible. Understanding the effects of inequality means that we suddenly have a policy handle on the wellbeing of whole societies.
The powerful mechanisms which make people sensitive to inequality cannot be understood in terms either of social structure or of individual psychology alone. Individual psychology and societal inequality relate to each other like lock and key. One reason why the effects of inequality have not been properly understood before is because of a failure to understand the relationship between them.
THE RISE IN ANXIETY
Given the unprecedented material comfort and physical convenience of modern societies, it might seem sensible to be sceptical of the way everyone talks of stress, as if life was barely survivable. However, Jean Twenge, a psychologist at San Diego State University, has put together impressive evidence that we really are much more anxious than we used to be. By reviewing the large number of studies of anxiety levels in the population carried out at different dates, she has documented very clear trends. She found 269 broadly comparable studies measuring anxiety levels in the USA at various times between 1952 and 1993.11 Together the surveys covered over 52,000 individuals. What they showed was a continuous upward trend throughout this forty-year period. Her results for men and women are shown in Figure 3.1. Each dot in the graph shows the average level of anxiety found in a study recorded against the date it was undertaken. The rising trend across so many studies is unmistakable. Whether she looked at college students or at children, Twenge found the same pattern: the average college student at the end of the period was more anxious than 85 per cent of the population at the beginning of it and, even more staggering, by the late 1980s the average American child was more anxious than child psychiatric patients in the 1950s.
Figure 3.1 Rise in anxiety levels among US college students 1952–93. Data from 269 samples covering 52,000 individuals.15(Reproduced with kind permission from Jean M. Twenge.)
This evidence comes from the administration of standardized anxiety measures to samples of the population. It cannot be explained away by saying that people have become more aware of anxiety. The worsening trend also fits what we know has been happening in related conditions such as depression. Depression and anxiety are closely connected: people who suffer from one often suffer from the other, and psychiatrists sometimes treat the two conditions in similar ways. There are now large numbers of studies showing substantial increases in rates of depression in developed countries. Some studies have looked at change over the last half century or so by comparing the experience of one generation with another, while taking care to avoid pitfalls such as an increased awareness leading to more frequent reporting of depression.12 Others have compared rates in studies which have followed up representative samples of the population born in different years. In Britain, for example, depression measured among people in their mid-20s was found to be twice as common in a study of 10,000 or so people born in 1970 as it had been in a similar study carried out earlier of people in their mid-20s born in 1958.13
Reviews of research conclude that people in many developed countries have experienced substantial rises in anxiety and depression. Among adolescents, these have been accompanied by increases in the frequency of behavioural problems, including crime, alcohol and drugs.12,14 They ‘affected males and females, in all social classes and all family types’.13
It is important to understand what these rises in anxiety are about before their relevance to inequality becomes clear. We are not suggesting that they were triggered by increased inequality. That possibility can be discounted because the rises in anxiety and depression seem to start well before the increases in inequality which in many countries took place during the last quarter of the twentieth century. (It is possible, however, that the trends between the 1970s and 1990s may have been aggravated by increased inequality.)
SELF-ESTEEM AND SOCIAL INSECURITY
An important clue to what lies behind the mental health trends comes from evidence that they were accompanied by a surprising rise in what at first was thought to be self-esteem. When compared over time, in much the same way as the trends in anxiety are shown in Figure 3.1, standard measures of self-esteem also showed a very clear long-term upward trend. It looked as if, despite the rising anxiety levels, people were also taking a more positive view of themselves over time. They were, for instance, more likely to say they felt proud of themselves; they were more likely to agree with statements such as ‘I am a person of worth’; and they seemed to have put aside self-doubts and feelings that they were ‘useless’ or ‘no good at all’. Twenge says that in the 1950s only 12 per cent of teenagers agreed with the statement ‘I am an important person’, but by the late 1980s this proportion had risen to 80 per cent.
So what could have been going on? People becoming much more self-confident doesn’t seem to fit with them also becoming much more anxious and depressed. The answer turns out to be a picture of increasing anxieties about how we are seen and what others think of us which has, in turn, produced a kind of defensive attempt to shore up our confidence in the face of those insecurities. The defence involves a kind of self-promoting, insecure egotism which is easily mistaken for high self-esteem. This might seem like a difficult set of issues to pin down, particularly as we are talking about general trends in whole populations. But let us look briefly at the evidence which has accumulated since the self-esteem movement of the 1980s, which shows what has been happening.
Over the years, many research groups looking at individual differences in self-esteem at a point in time (rather than at trends in population averages over time) began to notice two categories of people who came out with high scores. In one category, high self-esteem went with positive outcomes and was associated with happiness, confidence, being able to accept criticism, an ability to make friends, and so on. But as well as positive outcomes, studies repeatedly found that there was another group who scored well on self-esteem measures. They were people who showed tendencies to violence, to racism, who were insensitive to others and were bad at personal relationships.
The task was then to develop psychological tests which could distinguish between people with a healthy and those with an unhealthy kind of self-esteem. The healthier kind seemed to centre on a fairly well-founded sense of confidence, with a reasonably accurate view of one’s strengths in different situations and an ability to recognize one’s weaknesses. The other seemed to be primarily defensive and involved a denial of weaknesses, a kind of internal attempt to talk oneself up and maintain a positive sense of oneself in the face of threats to self-esteem. It was (and is) therefore fragile, like whistling in the dark, and reacts badl
y to criticism. People with insecure high self-esteem tend to be insensitive to others and to show an excessive preoccupation with themselves, with success, and with their image and appearance in the eyes of others. This unhealthy high self-esteem is often called ‘threatened egotism’, ‘insecure high self-esteem’, or ‘narcissism’. During the comparatively short time over which data are available to compare trends in narcissism without getting it mixed up with real self-esteem, Twenge has shown a rising trend. She found that by 2006, two-thirds of American college students scored above what had been the average narcissism score in 1982. The recognition that what we have seen is the rise of an insecure narcissism – particularly among young people – rather than a rise in genuine self-esteem now seems widely accepted.
THREATS TO THE SOCIAL SELF
So the picture of self-esteem rising along with anxiety levels isn’t true. It is now fairly clear that the rises in anxiety have been accompanied by rising narcissism and that the two have common roots. Both are caused by an increase in what has been called ‘social evaluative threat’. There are now good pointers to the main sources of stress in modern societies. As living with high levels of stress is now recognized as harmful to health, researchers have spent a lot of time trying to understand both how the body responds to stress and what the most important sources of stress are in society at large. Much of the research has been focused on a central stress hormone called cortisol which can be easily measured in saliva or blood. Its release is triggered by the brain and it serves to prepare us physiologically for dealing with potential threats and emergencies. There have now been numerous experiments in which volunteers have been invited to come into a laboratory to have their salivary cortisol levels measured while being exposed to some situation or task designed to be stressful. Different experiments have used different stressors: some have tried asking volunteers to do a series of arithmetic problems – sometimes publicly comparing results with those of others – some have exposed them to loud noises or asked them to write about an unpleasant experience, or filmed them while doing a task. Because so many different kinds of stressor have been used in these experiments, Sally Dickerson and Margaret Kemeny, both psychologists at the University of California, Los Angeles, realized that they could use the results of all these experiments to see what kinds of stressors most reliably caused people’s cortisol levels to rise.16
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