The key argument of this report can be stated in three sentences. Overall health standards in developed countries are highly dependent on how equal or unequal people’s incomes are. The most effective way of improving health is to make incomes more equal. This is more important than providing better public services or making everyone better off while ignoring the inequalities between them.
The aim of this report is to bring the results of some recent academic research to a wider readership, and to consider its policy implications. This may sound remote from the worries of many of those concerned with public health. But in fact it deals with one of the most exciting new perspectives on the determinants of health which has come to light for many years. It provides an opportunity to gain rapid advances in overall health standards while simultaneously making major reductions in the health disadvantage of the less well-off. This may seem to be simply a reflection of the familiar concern with material conditions among the relatively poor. But it is much more than that. Essentially, there is something about the quality of life in an unequal society that is damaging to people’s health, over and above the direct effects of the material conditions themselves. The health benefits of income redistribution to the population as a whole are much too great to be explained by a reduction in the health disadvantage of the poor alone. This is a crucial point. It is widely accepted that the main problem of poverty in Britain and other developed societies is relative rather than absolute poverty. Increasingly discussions of the amount of money people need to live on to avoid poverty focus less on minimum material standards than on the idea of a minimum needed to be part of the mainstream of society, to take part in the activities and share the aspirations of society as a whole and to maintain one’s self-esteem. But in relation to health, discussions of the effects of poverty still tend to focus exclusively on the material deprivation it causes. There is a steady stream of otherwise excellent reports focusing on matters such as the prevalence of damp housing among the poor, the deterrent effect of charges for health services on take-up, and on the difficulty of shopping for a healthy diet on social security benefits. Such issues have been the traditional focus of those concerned with inequality in health. Yet the evidence points clearly to the fact that differences in material conditions are not in themselves the most important factor in determining health.
This point is argued in more detail later, but understanding it is so fundamental that it is worth outlining just two reasons why the main health effects of income differences cannot be regarded as the result of simple material processes. First, that the average standard of living may be twice as high in some developed countries as in others without any benefit to health, shows that absolute material standards are no longer crucial. Although the poor in the richest countries tend to have higher standards of consumption than the poor in the poorer developed countries, it seems to have little effect on their health. However, what does make a dramatic difference is how much poorer they are relative to other people in their society. It is relative rather than absolute income that counts. The second point is that the benefits of income redistribution are too large and spread too widely across the majority of the population for them to be the results of changes in material deprivation among a poor minority alone. It appears that health standards improve most rapidly as income differences throughout the population get smaller. Economic inequality probably has its main effect on health through psychological and social processes such as the damage it does to people’s self-confidence, to social relations and to the quality of the social fabric.
To take these results on board requires a reorientation of much of the thinking which has shaped even the more radical traditions of the public health movement. We have frequently found people responding to the evidence with apparent understanding and growing excitement only to confound us by coming up with comments which show that its real implications have been missed. ‘But there is no point in throwing money at people if public services are still lousy’ or ‘more money won’t make any difference unless people are encouraged to spend it sensibly.’ (Even on its own, income transferred from the rich to the poor seems to make a lot of difference.) Another common response is ‘You seem to think that money is the only thing that matters’. (No, but we are impressed by the evidence that income differences have such a profound impact on things like social relations and people’s sense of self-worth which matter very much.)
The idea that public health depends primarily on better public services is a fallacy. Services such as better housing, public transport, clean, well-lit streets, home helps, a well funded NHS are vital to the quality of people’s lives. They should be a priority for government spending. They will undoubtedly have an effect on health – perhaps by more numerous routes than are usually recognised. But purely from the health point of view the need for better public services should not be allowed to divert attention from the even greater need for income redistribution. In particular, improvements in health should not be seen as dependent on ‘getting the economy right’ so that more can be spent on public services. Health need not wait for what the Labour Party has started to call ‘the growth dividend’. There are poorer countries with better health and richer countries with worse. Indeed it is salutary to note that it was during the two World Wars, when resources and material infrastructure of society was most overstretched, that civilian life expectancy in Britain achieved its most rapid increases.
For Britain to become an even more wealthy society is neither a necessary nor a sufficient condition for more rapid advances in health. But, given current levels of affluence, becoming a more equal society is both a necessary and a sufficient condition. Reducing economic inequality has to be the main public health task for the immediate future. Despite the concern over poverty, those involved in public health have not, in general, devoted their professional attention to how this should be done. Inequality of incomes is a function both of the differences in original incomes and of the way that is adjusted by the tax and benefit system. What comes as a surprise to some is that differences in taxes and benefits account for a large part of the differences in the amount of inequality in the developed countries. For better or worse, whether they like it or not, governments exercise a very substantial measure of control over what is probably the most important determinant of health in the developed world. We therefore make no apology for devoting a considerable part of this report to explaining the major issues involved in reforming the tax/benefit system.
It is essential that public health advocates and all those who are concerned with the population’s health gain a better understanding of what is involved in making the tax/benefit system more redistributive. However, there are few subjects that are more complicated or controversial. We have avoided technicalities as much as possible and have dealt only briefly with short-term policies (such as the need to link pensions to wage inflation or the advantages of increasing child benefit).
These matters have been thoroughly covered elsewhere. Instead, the discussion in the latter part of this report focuses on the issues of principle involved in making more fundamental reforms. It is hoped that the discussion will help to familiarise people with the issues that should be at the centre of debates over public health policy.
The three sections which follow this introduction discuss the evidence on the relationship between income and health.