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Do Inequalities Matter?

Michael Marmot

A response to Justice is Good For Our Health, by Norman Daniels, Bruce Kennedy, and Ichiro Kawachi. Click here for all eight responses.

Do inequalities in health matter? Have we not reached the end of history as far as health in the rich (OECD) countries of the world is concerned? My answer to both questions, like that of Daniels and colleagues, is that inequalities in health do matter and that we have not reached the end of history. Dramatic as have been the advances in health this century in OECD countries, there is still a way to go. Taking the simplest summary measure, life expectancy at birth, the United States is in the bottom half of the rich countries.

In fact, the answer to these two questions may be linked. One reason why countries have failed to reach their full health potential is persisting inequalities in health. It has been known for years that there are pockets of extreme deprivation and poor life expectancy within rich countries. In Harlem, for example, life expectancy for young men is lower than for men in Bangladesh. Furthermore, as Daniels and colleagues emphasize, the problem in rich countries is not one of poor health for the deprived and good health for the non-deprived, but of a social gradient in health. In the Whitehall studies of British Civil Servants--white-collar workers in stable jobs--there was a step-wise relation between grade of employment and ill-health: the lower the grade the higher the rate of morbidity and mortality. These findings are typical of those from national figures.

The slope of the ill-health gradient varies over time within countries and between countries. The fact that it is not a fixed property of society suggests that it is potentially changeable.

There are, then, at least three reasons to be concerned about inequalities in health: pragmatic reasons, ethical reasons, and social reasons (what inequalities in health may reflect about the wider society). In practice, the distinction between these may be less than might first appear. First, the pragmatic issue: Daniels, Kennedy, and Kawachi refer to evidence that in those countries where health inequalities are greatest, overall health status of the population is lower. It is difficult to lower the coronary heart disease mortality of the population if only part of the population is experiencing improvement.

Second, inequalities in health that are potentially avoidable are unfair. Margaret Thatcher famously asserted that there is no such thing as society. The rest of us, who think there is, may feel that social justice is a reason for desiring a reduction in social inequalities in health.

Third, and this is at the heart of the authors’ argument, if health is a reflection of wider social influences, then health inequalities are a reflection of inequalities in society. One might complain that this is not a sufficient answer to the question of why we should be concerned with health inequalities: it merely shifts the question further back.

Why, then, should we be concerned with inequalities in society? One could imagine an argument that went as follows: Americans think that economic inequalities are a good thing because they reflect economic freedoms that are essential for wealth creation; they think that social safety nets are a bad thing in principle. Therefore, the type of society people want is one characterized by high inequalities of income and wealth and little spending on social safety nets. If health inequalities happen to follow from such a set of social arrangements that is unfortunate but not of central concern. (Writing from Britain, I am a poor judge of what Americans think, but it is possible that this reflects a prevalent view among the relatively small proportion of people who actually vote in elections, if not of the large proportion, for a democracy, who do not.)

The authors appeal to Rawls’s theory of justice to argue that such a society is not just, because it does not establish "equal liberties, robust equal opportunity, a fair distribution of resources, and support for our self respect." They argue that a just society would go a long way toward eliminating the most important injustices in health outcomes. I agree with their conclusions that therefore priority should be given to early life intervention, ensuring adequate nutrition to those least able to afford it, improving work environments, and income redistribution.

I am too much influenced by the writing of Amartya Sen, however, to accept the appeal to Rawls without a quibble, one that may seem minor given that I accept the conclusions they seem to have reached on the basis of their Rawlsian analysis. Sen argues that any ethical social system requires equality of something. The question is, what? (Or, as Sen might put it, in which space is inequality to be measured?) Equality of economic freedoms is one such space; equality of basic liberties, as in Rawls, is another. How to choose between these different notions of equality? One way is with regard to their consequences, such as health. Some philosophers coin rude words like consequentialist to describe those who are concerned about consequences. But Sen, critical of Rawls because of what he considered an insufficient concern with outcomes, suggested a different evaluative framework for assessing inequality--one that took account of its impact on our capability and freedom to lead the lives that we want to lead.

I suspect that there is the basis for important philosophical disagreement here that perhaps need not detain us at the moment. Even if Daniels and colleagues do not explicitly share Sen’s concern with the consequences of Rawlsian justice, they are nevertheless deeply concerned with health inequalities. Their argument is a strong one. Concern with social inequality follows from Rawlsian analysis. That this leads Daniels, Kennedy, and Kawachi to be concerned with the social determinants of health and to make recommendations that would lead to the reduction of health inequalities is all to the good.

Originally published in the February/March 2000 issue of Boston Review



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