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Reading between the lines

Reports which claim that poverty and ill health are on the increase are not as worthy as they might seem, suggests Toby Andrew

You poor things

  • Death in Britain: how local mortality rates have changed 1950s-1990s
    Daniel Dorling, Joseph Rowntree Foundation, £11.95 pbk

  • Unhealthy societies: the afflictions of inequality
    Richard G Wilkinson, Routledge, £13.99 pbk

  • Equality
    Jane Franklin (ed), IPPR, £11.95 pbk

According to the Joseph Rowntree Foundation people living in areas with high mortality rates, generally northern cities like Manchester and Glasgow, are now almost twice as likely to die prematurely as those who live where mortality rates are low, generally small towns in the South of England (Death in Britain). Richard Wilkinson in his book Unhealthy Societies produces figures that seem to show that life expectancy is profoundly affected by social inequality, making relative income the best predictor of health differences. For example infant mortality among unskilled manual workers is twice that of professionals.

The 1995 Rowntree report 'Income and wealth' announced that while average income grew by nearly 36 per cent for the whole population between 1979 and 1992, the gap between top and bottom earners increased so that 'the poorest 20-30 per cent of the population failed to benefit from economic growth'.

These figures certainly make alarming reading, but do they paint the whole picture? Conventional wisdom has it that there is a British underclass, the health of which is suffering because of exclusion from society. A closer examination of the facts of inequality, however, shows that the deprivations of the poorest are largely exaggerated, and that the most important division in society - between those who have to work for a living and their employers - has been sidelined from the discussion.

The New Labour government has been torn between a commitment to firm finances and a desire to act upon poverty. On the one hand benefits for single mothers have been cut, but on the other, Downing Street has formed a unit to deal with what it perceives is a growing problem of 'social exclusion'. As an opposition party Labour set up a Social Justice Commission that reported in October 1994, and whose policies are revisited in the report Equality, published by the New Labour think-tank the Institute for Public Policy Research. At the centre of social justice, say the authors, is the idea that everybody is entitled, as a 'right of citizenship', to 'be able meet their basic needs'.

Much of the debate on social justice is about the social causes of ill health and whether ill health is caused by poverty. The Joseph Rowntree Foundation study, Death in Britain, confirms that although absolute mortality rates for all groups in Britain have fallen steadily since the 1950s, the gap or relative mortality between people living in different areas has widened, particularly since the 1980s.

The report does not, however, try to explain the rise in health inequalities. It might seem obvious that poor people are more likely to become ill and more likely to die at an earlier age than rich people. But what is less apparent and what is contested are the causes of these health inequalities.

Popular accounts of health differences in Britain today often argue that these are because of extremes of poverty. But is it true that poverty has increased over the last 20 years?

The Rowntree report's claim that up to 30 per cent of people became worse off between 1979 and 1992 is clearly an exaggeration, contradicted by other data in the same report. These figures reveal that, while the real net income of the bottom 10 per cent declined or stayed the same over this period (depending respectively on whether the figures cited are 'after housing costs' or 'before housing costs'), the income for the second decile from the bottom stayed about the same and the third decile of the population showed a slight increase in living standards. In reality the report shows that something like 90 per cent of the population over the last 20 years has improved or maintained their living standards.

When the 1995 Rowntree report was published, it sparked a row with rival poverty statisticians signalled by the Institute for Fiscal Studies' publication of a report that showed household spending for the same period increasing for all income groups including the bottom 10 per cent. According to the IFS, if wealth is measured by spending rather than by income, the living standards of all sections of society improved between 1979 and 1992. Indeed in a report 'The changing distribution of the social wage' published in May this year, Rowntree backtracked on its previous report conceding that the income of the poorest fifth of the population grew by 6 per cent between 1979 and 1993, including government spending on education, health and housing the average incomes for this group grew by much as 13 per cent. It is true that the poor benefited less than the better-off, but they did not get worse off in absolute terms.

The debate between welfare advocates like the Joseph Rowntree Foundation and the free marketeers like the Institute for Fiscal Studies is fundamentally a debate about whether poverty is to be understood as a relative or an absolute measure. Rowntree's report compares incomes relatively between different income groups. The Institute for Fiscal Studies' proposed changes shift attention from the relative advantages in income to absolute measures like consumption of goods and services.

In a seeming paradox, inequality in Britain soared in the eighties, while at the same time absolute poverty has decreased. This is possible because relative inequality and absolute poverty are two different standards. The absolute standard of poverty looks at the material things people consume. The relative standard of inequality looks at the differentials in people's incomes. Absolute poverty can fall while the differentials in income rise.

The official measure of poverty is a relative one, recording all those whose income is less than half the national average, 17.5 million in 1988/9. But on closer examination the figures do not reveal an absolute fall in consumption. This apparently contradictory state of affairs can come about because increased productivity means that more of the things of life are being made more cheaply, but that these are distributed more unevenly. The poorest 10 per cent are getting a smaller slice of a bigger cake.

The argument about absolute and relative poverty has thrown welfare advocates onto the defensive. They think that you need to show people destitute to invoke any public sympathy. When Prince Philip said that there was no absolute poverty in Britain a few years ago, you could see his point. But welfare advocates reacted with horror, fearing that the Prince's comment would encourage public indifference. In response, proponents of more welfare spending have emphasised the impact of inequality upon health, to underline the seriousness of the problem.

The recognition of health inequalities is not new. In 1976 Richard Wilkinson wrote an open letter in New Society calling on the Labour government of the day to set up an urgent inquiry into the causes of difference in mortality between social classes in Britain. What subsequently became known as the Black Report began a lonely life in the 1980s, suppressed by the government and branded as a left-wing cause, but with its unabridged re-publication in the 1990s all that has changed. Now everybody is talking about poverty and health.

In the introduction to Unhealthy Societies, Wilkinson describes 'the long journey' from the study of social class differences in health to the effects of 'income distribution on social cohesion and national mortality rates'. Daniel Dorling, the author of the Rowntree report, says that his study shows disparities in health between regions rather than social classes, but the implications seem clear enough.

The Black Report suggests that social causes which contribute to health differences in Britain might include overcrowding, a lack of warmth, and hygiene. However as Wilkinson points out, such factors are unlikely to impact upon overall health figures, simply because the incidence of these hardships are too low. Wilkinson cites DSS figures to show that, of the poorest 20 per cent of the population in 1990/1, 84 per cent had a washing machine, 97 per cent a fridge and 72 per cent central heating, making such explanations unlikely (p46). Although bad housing is associated with increased levels of cancer and heart disease, there is little evidence that these conditions contribute directly to the causes of death. Damp housing is known to cause an excess of respiratory diseases, but only seven per cent of the total population live in such conditions (p177).

Wilkinson recognises that absolute poverty cannot provide a causal explanation for relative health inequalities. He therefore concludes that relative inequality must be responsible. In the more advanced countries of the OECD, health is not determined by material living standards so much as by relative income or the extent to which income is distributed throughout society, he argues. The evidence for this is the way in which epidemiological data shows that the best predictor for health differences are measures of relative income. This means that measures of income distribution provide a better prediction of mortality than measures of overall wealth, such as the population's median income. Wilkinson argues, health variations within a society are no longer related to the overall wealth of that society, but to the extent to which existing income is distributed throughout society.

A recent study from the USA supports this idea. The study measured inequality in all 50 states of the USA as the percentage of total household income received by the less well-off 50 per cent of households. What the researchers found was that the greater the inequality in income distribution the greater was the death rate. These results did not change even when they were adjusted for the median income for each state (G Kaplan et al, BMJ, April 20 1996, pp999-1003). In other words the argument is that it is the gap between rich and poor, and not the actual level of local income, that best predicts the death rate in each state.

Since there are no other intermediaries that provide a stronger prediction of mortality, income inequality is thought to be a literal killer, although the precise mechanism remains unclear. Wilkinson speculates that the underlying causes of excess mortality and morbidity are likely to be 'psychosocial' rather than more 'material' factors such as housing or poor diet. We die younger and are ill more frequently because of the chronic stress involved with living in a hierarchical social order, money worries and so on. There is some evidence, mainly indirect, that chronic stress can contribute to reduced growth, coronary heart disease and even cancer.

Alongside the psychosocial account of health inequality is the argument that bad dietary habits among the poor account for ill health. In April this year the National Food Alliance produced a report arguing that the reason poor people are at greater risk from high blood pressure, heart disease and strokes is because of unhealthy diets, while Save the Children's director-general warned that Britain is facing 'the spectre of child malnutrition' (Times, 25 April 97).

In the midst of all of the data about health inequality, it is important to recognise that the health differentials under discussion are surprisingly small and that, seen in the round, health is improving for everybody.

For example the Black Report found that, among manual workers in 1984, 13 infants died before the age of one year for every 1000 live births; for professionals the figure was 6.5 in every thousand - half as many. In 1930-32 the corresponding figures were 80 and 32 out of 1000, in 1949-53 the figures were 42 and 19 out of 1000, and in 1970-72 the figures were 31 and 12 out of 1000 births (quoted in 'A phantom carnage', Social Affairs Unit, 1993). In other words, while relative infant mortality has remained pretty constant for much of this century (by a factor of about two), the absolute figures for infant mortality have declined for all classes.

Although it is true that health is only weakly related to economic growth at any given point in time, there is a strong relationship between the two over time. In fact life expectancy has on average increased by 2-3 years every decade this century. Perversely Wilkinson argues that it is both possible and desirable to have improvements in quality and scientific innovation without economic growth. Health indices, Wilkinson argues, should be used to form better measures of living standards than economic indicators, because these indices take into account quality of life and not just standard of living as conventional economic measures do.

Wilkinson's approach is artificially to separate the economy from the issue of how people's needs are to be met. In the 'epidemiological transition' he describes, basic needs such as health and a minimum income are taken for granted since both no longer appear to be contingent upon economic growth. The economy is something that cannot be altered, but exists auton-omously. As a result he calls for the 'demotion of economic growth from its role as a societal goal' (p222).

Wilkinson's attempt to separate the issue of how needs are met from the broader issue of economic growth shows the extent to which the issue of inequality has been depoliticised. No longer is the division of society's resources subject to the annual row of the wage round. Today's debate is the property of a small clique of professionals in the health and welfare sectors and fixates upon the most narrowly technical definitions of poverty and 'basic needs'. The attempt to redefine social inequality in medical terms, as if it were simply a flu epidemic, is the culmination of its depoliticisation.

As Wilkinson's own research shows, even seen in medical terms, the effects of poverty are not reducible to human biology. Rather, the most onerous aspect of low incomes is the differential social position that these embody - the very relative disadvantage that seems so unworthy of our interest. However, the characterisation of relative inequality in psychosocial terms is no step forward.

Turning our attention to questions of esteem and social exclusion, as New Labour would like, might seem to be a more all-rounded approach. But in fact it only further separates the issue of inequality from that of social production, emphasising the individual psychology of the 'excluded'. In this discussion a job is not seen as a way that an individual earns a living or makes a real contribution to society's wealth. Rather it is seen as a way that a person gets 'self-esteem' and feels as if he is making a contribution to society. This is an assessment that turns even a real job into a consumption good, or even a counselling session, as if working were just another status symbol. In policy terms this is the agenda of the Restart programmes, in which jobseeker advisers probe 'clients' as to the motivational barriers they have to finding work, and all work is reduced to the level of work-experience.

At the heart of the discussion of inequality is a belief that the question of production itself is closed. The fact that all of society's needs are met through work does not feature in the current discussion of inequality, no more than that most people meet their basic and not-so-basic needs by working for a living. Instead, the goal is to curb the worst excesses of unequal income distribution. Of course that means that the central source of social inequality within the realm of production itself is obscured: the few who own the country's firms and industries are able to keep the lion's share of the social product for themselves; the many who have to work for a living are only very rarely allowed to earn enough to make themselves independent.

In the debate between government and welfare advocates all attention is on the very poorest 10 per cent. The vast majority of working people do not feature in this discussion, only those at the extremes: the greedy rich 'fat cats' and the feckless poor of the 'underclass'. But the most spectacular income inequalities are between the top 10 per cent and the rest. The fact that the class of wage workers have managed to defend their incomes, often by taking on extra work, means that the welfare advocates are not concerned for them (if anything, it is the 'work rich' who are blamed for making the poor poor). The poverty professionals are only interested in people that they can patronise.

The attempt to redefine poverty as a medical and health issue is a further step down that road. Concentrating upon the psychosocial problems of poverty can only lead to a greater regulation of the poor, through closer integration of health professionals, social services and the Employment Service. The ominous signs of dietary regulation are already evident, as are the curbs on such simple pleasures as tobacco and alcohol, all imposed 'for their own good' of course.

Read On

  • Wall Street: how it works and for whom
    Doug Henwood, Verso, £20 hbk

Wall Street is that most rare thing, a critique of capitalism that knows what it is talking about. Doug Henwood has been writing about Wall Street for some time. He produces the Left Business Observer, subtitled 'accumulation and its discontents', which looks like a cross between a bulletin for investors and a revolutionary manifesto. Henwood's insider knowledge of Wall Street means that he can be as radical as he likes, without being shrugged off as inconsequential.

Henwood is scathing about the idea that the stock market and its financial off-shoots exist to mobilise resources for production. As he points out, that is not what they have been doing. If anything the mergers and shake-outs are about taking resources out of production where profits are low. Over and over again Henwood emphasies the divergence between making money on the markets and real production. As he points out, growth in the stock exchange can as easily reflect faltering production as a boom.

Henwood reports the growth of investor-power in the USA, the increasing clamour for a greater return on their stock. Astutely, he traces its origins to the first stirrings of ethical investment, when small investors first started to make their voices heard at shareholders meetings by demanding disinvestment from apartheid South Africa. But as Henwood notes, what started with the highest of intentions quickly turned into furious demands for bigger dividends, to be paid for by more lay-offs.

Henwood's sources are eclectic: the most up-to-date neo-Keynesians jostle Sandor Ferenczi's psychoanalytic theories of money, Karl Marx's Capital and even the lyrics of a song by seventies punk band the Slits. But what keeps Henwood sharp is his basic intuition that it is the whole system that is at fault, not any singular feature of it. Introducing a chapter on the key players, he says that he could go on about Ivan Boesky and other disgraced traders, but that would only make the rest look artificially good. And, by way of a conclusion ('What is (not) to be done'), Henwood explains the weakness of every piecemeal scheme of reforming the markets, from ethical capitalism, to democratising the federal bank.

In that spirit he knows, too, that the current trend for knocking the financial markets only to praise capitalist industry must be wrong. The reason is that the perverse growth of the financial markets is a symptom of the slowdown of capitalist investment, but not its cause.

James Heartfield

Reproduced from LM issue 104, October 1997

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