By Annavajhula J.C. Bose, PhD
Department of Economics, SRCC
I have not yet done a first-hand reading of ‘The Spirit Level’ and ‘The Inner Level’, the two books by the British epidemiologists Richard Wilkinson and Kate Pickett. But from what I have gathered about them through second-hand and third-hand accounts, this academic couple has quite a few sensible things to say, a taste of which I want to share with you here. This may inspire you to savor the branch of Epidemiological Economics or Economic Epidemiology, which is certainly superior to the staple food you have been feeding on, viz. neoclassical economics.
When you do critical thinking about National Income Accounting, you do know that health statistics provide a far better indicator of improvements or deteriorations in wellbeing than increases in GDP. Epidemiologists or public health professionals have since long addressed themselves to what makes society healthier, physically and mentally. They have shown that improvements in public health, health of the collective or population health, requires greater income equality and without that societies become highly dysfunctional. “The big idea is that what matters in determining mortality and health in a society is less the overall wealth of that society and more how unevenly wealth is distributed. The more evenly distributed wealth is, the better the health of that society.” There is ample supporting evidence for this idea.
Evidence for a correlation between poor health and income inequality exists for physical as well as mental health and drug addiction. Lower life expectancy, higher rates of infant mortality, shorter height, poor self-reported health, low birth weight, AIDS and depression are all higher in more unequal societies. Also, indicators of educational attainment, violence, measures of imprisonment, and punishment all vary with the degree of income inequality. The size of the prison population, homicide rates, obesity rates, and so on are all high in unequal societies. The stress of poverty in unequal societies negatively influences the cognitive development of babies and children. This is not all. The social demarcation of class, from what we eat and how we talk, to what culture we consume, are also rigorously upheld in more unequal societies, making discrimination much easier and preventing social mobility. In more unequal societies, fewer people marry someone of a different class background, the number of visits to art galleries and museums is lower, the prison population is higher and the age of criminal responsibility for children is lower. There are also more personal, individual effects of inequality. Inequality exacerbates self-doubt, social anxiety, stress, and fear of how we are seen by others, which in turn can negatively impact day-to-day emotions for individuals, relationships and our ability to build functioning communities and the health and happiness of entire populations. “The reality is that inequality causes real suffering, regardless of how we choose to label such distress. Greater inequality heightens social threat and status anxiety, evoking feelings of shame which feed into our instincts for withdrawal, submission and subordination: when the social pyramid gets higher and steeper and status insecurity increases, there are widespread psychological costs.”
This is not all. Economic history provides evidence that the better-off also have their health and life quality improved if society moves towards greater equality. For example, in nineteenth-century Britain, the improvement of public hygiene and clean water supplies not only turned out to be good for the poor but also for the relatively well-off. Wealthy people too had died in the cholera epidemics. They too had suffered from the stench of the drains and the failure to clean the streets.
The Wilkinson-Pickett research is not just important for the extensive statistical evidence that they give that unequal societies are responsible for less fulfilling personal lives, and that they harm public health, scupper educational progress, increase crime and lower life expectancy, and so on and so forth. Their research is all the more important for these reasons: “We debunk some of the myths that people use to explain why society is willing to tolerate greater levels of inequality, namely that inequality is a natural result of our human nature, that we are competitive, individualistic and out for ourselves—that’s the way we are, it’s just human nature and nothing can be done about it…That is not the case. We also provide evidence to counter the argument that actually we’re living in a meritocracy, and that inequality is simply a case of the capable and talented moving up, and those we are less capable, less clever, moving down.”
The American epidemiologist Sandro Galea has argued, and argued well, that public health is a prime example of a public good which helps us to understand the true contribution of public health to society: “First, public health is a collective property that depends principally on the conditions that create public health (i.e. the structural, social, and political forces that produce health of populations) rather than on any individual action…Salutogenic urban environments seek to be both non-excludable and non-rivalrous; so do policies that incentivize healthier foods and efforts to minimize pollution. Knowledge (for example, on health risks), technology, policy, and health systems have many properties of considered public goods—but, modern health technologies are increasingly patented and thus made artificially excludable. Likewise, health systems, absent public financing, are not affordable to many. Second, public health represents a classic example of shared gain from a shared good…herd immunity or the protection from adverse health behaviours by salutogenic group behavior, represents a collective benefit from which no one is excluded. For example, no one can be excluded from the benefit of infectious disease reduction, and one person benefiting certainly does not prevent others from benefiting as well. Third, the interdependence of our health on the health of those in other countries, as underscored by the Ebola and SARS epidemics, suggests that notions of nation-specific public goods are quaint and that the provision of public health is dependent on global public goods that may require universal solutions. For example, no country can be excluded from benefitting from a reduction in carbon dioxide emissions. Fourth, health equity is a core element of public health—the opportunity for all to live in conditions that promote health, minimizing inter-group health differences.
In short, public goods like public health are socially defined and a matter of perceived public need and are essential for a healthy workforce and healthy consumers who can propel the production and consumption of private goods. In other words, economic efficiency is actually encouraged by the provisioning of public goods like public health. And this positions us well to agitate for collectively investing in conditions and promoting policies that make people healthy. These ideas are not explored by the typical neoclassical economist.
And, unfortunately, this is not the case in most countries. There is no public good perspective of health in India despite the Covid-19 disaster so much so that we are not enabled to escape a continuing deplorable and unjust morbidity morass in the country (Ghosh and Qadeer, 2020).
Epidemiologists point to the need for efforts to introduce universal health coverage in all countries which will move healthcare closer towards being a public good. A case is made for social insurance systems or other publicly financed health insurance, where all citizens are insured and can utilize healthcare services regardless of whether they can afford it or not. The state need not be the sole provider of public goods. Non-governmental organizations or actors with private resources can also provide public goods if they ensure open access.
To conclude, almost all over the world, there are two striking facts: on one hand, there is rising inequality of income and wealth and on the other, there is rising commodification of goods that were previously supplied through group membership. Goods supplied through group membership, with elements of non-rivalry and non-excludability, are labeled as public goods by economists. Such goods can be provided by the public sector (when the group is the nation as a whole) but they can also be provided by smaller groups such as associations, communities or families. The retreat from such modes of provision, and their replacement by privatized, individualized modes is labeled as commodification by sociologists. Rising inequality and increased commodification of public goods happening at the same time are the debilitating issues bothering people at large. An interdisciplinary conversation in this regard took place during November 2-3, 2017 among some leading economists (e.g. Ravi Kanbur), political scientists, philosophers, psychologists and sociologists, under the auspices of the Stanford and Cornell Universities.
Now you can follow up on such conferences apart from the Pickett-Wilkinson kind of epidemiological research in order to seek fair and democratic solutions so that citizens identify with a larger community of equal citizenship and thereby become healthier and happier.
Brian Davey. 2015. www.credoeconomics.com
Dawn Foster. 2018. Kate Pickett and Richard Wilkinson: ‘Inequality strikes at our health and happiness’. The Guardian. September 18.
Sandro Galea. 2016. Public Health as Public Good. Boston University School of Public Health. www.bu.edu, January 10.
Sourindra Mohan Ghosh and Imrana Qadeer. 2020. Public Good Perspective of Public Health: Evaluating Health Systems Response to Covid-19. Economic and Political Weekly. 55(36). September 5.