The Spirit Level: Why Greater Equality Makes Societies Stronger

by Richard Wilkinson

  WHAT WE HAVE LEARNED

  In this chapter, we have shown that levels of social trust are connected to income inequality, but of course showing a correlation is not the same thing as showing causality.

  There are several reasons why we believe that equality is the precondition for greater trust (although almost certainly there is a feedback loop between the two). One factor is the strength of the relationship, which is shown by the steepness of the lines in Figures 4.1 and 4.2. People in Sweden are much more likely to trust each other than people in Portugal. Any alternative explanation would need to be just as strong, and in our own statistical models we find that neither poverty nor average standards of living can explain our findings. We also see a consistent association among both the United States and the developed countries. Earlier we described how Uslaner and Rothstein used a statistical model to show the ordering of inequality and trust: inequality affects trust, not the other way round. The relationships between inequality and women’s status and between inequality and foreign aid also add coherence and plausibility to our belief that inequality increases the social distance between different groups of people, making us less willing to see them as ‘us’ rather than ‘them’.

  In summary, we can think of trust as an important marker of the ways in which greater material equality can help to create a cohesive, co-operative community, to the benefit of all.

  5

  Mental health and drug use

  It is no measure of health to be well-adjusted to a profoundly sick society.

  Krishnamurti

  MENTAL ILLNESS IN THE UK AND USA

  Children’s mental health now makes the front pages of newspapers, Britain’s Daily Mail for example, under banner headlines such as ‘THE DISTURBED GENERATION’. A million British children – one in ten between the ages of 5 and 16 – are estimated to be mentally ill.39 It has been suggested that in any secondary school with 1,000 students, 50 will be severely depressed, 100 will be distressed, 10–20 will be suffering from obsessive-compulsive disorder and between 5–10 girls will have an eating disorder.40 This is backed up by a 2008 report from the Good Childhood Inquiry, an independent inquiry commissioned by the Children’s Society.41 After surveying thousands of children, they report that increasing numbers of children have mental health problems, over a quarter regularly feeling depressed, mostly as a result of family breakdown and peer pressure.

  In the USA, 6 per cent of children have been diagnosed with Attention Deficit Hyperactivity Disorder, a behavioural syndrome characterized by serious distractibility, impulsivity and restlessness.42 In a national survey, almost 10 per cent of children aged 3–17 had moderate or severe difficulties in ‘the areas of emotions, concentration, behaviour, or being able to get along with other people’.43

  And how are adults doing in these same two societies? In the UK,

  in a national survey conducted in 2000, 23 per cent of adults had either a neurotic disorder, a psychotic disorder, or were addicted to alcohol or drugs, 4 per cent of adults having more than one disorder.44 In 2005, doctors in England alone wrote 29 million prescriptions for anti-depressant drugs, costing over £400 million to the National Health Service.45 In the USA, one in four adults have been mentally ill in the past year and almost a quarter of these episodes were severe; over their lifetime more than half will suffer from a mental illness.46 In 2003, the USA spent $100 billion on mental health treatments.47

  MENTAL WELLBEING

  Before we turn to comparisons of mental illness in other societies, it’s worth asking – what is a healthy mind?

  MIND, the National Association for Mental Health in the UK, publishes a pamphlet called ‘How to Improve Your Mental Wellbeing’. It begins with the premise that:

  Good mental health isn’t something you have, but something you do. To be mentally healthy you must value and accept yourself.48

  It concludes that people who are mentally well are able to look after themselves, see themselves as valuable people and judge themselves by reasonable, rather than unrealistic, standards. People who don’t value themselves become frightened of rejection; they keep others at a distance, and get trapped in a vicious circle of loneliness.

  It is also important to note that although people with mental illness sometimes have changes in the levels of certain chemicals in their brains, nobody has shown that these are causes of depression, rather than changes caused by depression. Similarly, although genetic vulnerability may underlie some mental illness, this can’t by itself explain the huge rises in illness in recent decades – our genes can’t change that fast.

  APPLES AND ORANGES?

  Can we really compare levels of mental illness in different countries? Don’t different cultures have different labels for mental disorders, and different standards of normality, or tolerance of differences?

  Aren’t people in different societies more or less reluctant to admit to emotional problems, or drug use, or any stigmatized condition?

  Not surprisingly, it hasn’t always been easy to get comparable measures of how many people are suffering from mental illness in different countries. But this began to get easier in the 1980s, when researchers developed diagnostic interviews – sets of questions that could be asked by non-psychiatrists and non-psychologists, allowing researchers to measure on a large scale the numbers of people meeting diagnostic criteria for different mental illnessess.

  In 1998, the World Health Organization set up the World Mental Health Survey Consortium in an attempt to estimate the numbers of people with mental illness in different countries, the severity of their illness and patterns of treatment. Although their methods don’t entirely overcome worries about cultural differences in interpreting and responding to such questions, at least the same questions are being asked, in the same way, in different places. Among our set of rich developed countries, WHO surveys have been completed in nine: Belgium, France, Germany, Italy, Japan, Netherlands, New Zealand, Spain and the USA.49–50 Although not strictly comparable, very similar national surveys give estimates of the proportion of the adult population with mental illness in another three countries – Australia,51 Canada52 and the UK.44

  INCOME INEQUALITY AND MENTAL ILLNESS

  In Figure 5.1 we use these surveys to show the association in rich countries between income inequality and the proportion of adults who had been mentally ill in the twelve months prior to being interviewed. This is a strong relationship: a much higher percentage of the population suffer from mental illness in more unequal countries. Such a close relationship cannot be due to chance, indeed the countries line up almost perfectly, with only Italy standing out as having lower levels of mental illness than we might expect, based on its level of income inequality.

  Figure 5.1 More people suffer from mental illnesses in more unequal countries.

  Just as we saw with levels of trust in the previous chapter, there are big differences in the proportion of people with mental illness (from 8 per cent to 26 per cent) between countries. In Germany, Italy, Japan and Spain, fewer than 1 in 10 people had been mentally ill within the previous year; in Australia, Canada, New Zealand and the UK the numbers are more than 1 in 5 people; and in the USA, as we described above, more than 1 in 4. Overall, it looks as if differences in inequality tally with more than threefold differences in the percentage of people with mental illness in different countries.

  For our nine countries with data from the WHO surveys, we can also look at sub-types of mental illness, specifically anxiety disorders, mood disorders, impulse-control disorders and addictions, as well as a measure of severe mental illness. Anxiety disorders, impulse-control disorders and severe illness are all strongly correlated with inequality; mood disorders less so. We saw in Chapter 3 how anxiety has been increasing in developed countries in recent decades. Anxiety disorders represent the largest sub-group of mental illness in all our countries. Indeed, the percentage of all mental illnesses that are anxiety disorders is itself significantly higher in more unequal countries
. Unfortunately, there are no international sources of comparable data on the mental health of children and adolescents.

  Turning now to our other test-bed, the fifty states of the USA, we discovered something rather surprising. Alone among the numerous health and social problems we examine in this book, we found no relationship between adult male mental illness and income inequality among the US states. State-specific estimates of mental illness are collected both by the United States Behavioral Risk Factor Surveillance Study and by the National Survey on Drug Use and Health, but the lack of a relationship between income inequality and mental illness among men was consistent in both sources.

  However, income inequality is associated with mental illness in adult women. It is not a particularly strong relationship, but too strong to be dismissed as chance. There is also a similar relationship with the mental health of children. The National Survey of Children’s Health provides estimates of the percentage of children in each state with ‘moderate or severe difficulties in the area of emotions, concentration, behavior, or getting along with others’.43 Although, as for adult women, the relationship with state inequality is not particularly strong, children’s mental health is significantly correlated with state levels of income inequality.

  There are several plausible explanations for the lack of an association between the available measures of adult mental health among men and inequality. In general, problems related to inequality have steep social gradients (becoming more common lower down the social ladder).8 Some indicators suggest that mental health in the USA does not show a consistent social gradient. Whether the explanation for this lies in methods of data collection, gender differences in reporting mental illness, the apparent resilience of ethnic minority populations to mental illness (see Figure 5.2), or a delay in being able to observe the effects of growing inequality, it is important to remember that, from an international perspective, levels of mental illness in the USA as a whole are exactly what we would expect, given its high overall level of inequality.

  Figure 5.2 US adults reporting frequent mental distress, 1993–2001.M53

  CLINGING TO THE LADDER

  So why do more people tend to have mental health problems in more unequal places? Psychologist and journalist Oliver James uses an analogy with infectious disease to explain the link. The ‘affluenza’ virus, according to James, is a ‘set of values which increase our vulnerability to emotional distress’, which he believes is more common in affluent societies.54 It entails placing a high value on acquiring money and possessions, looking good in the eyes of others and wanting to be famous. These kinds of values place us at greater risk of depression, anxiety, substance abuse and personality disorder, and are closely related to those we discussed in Chapter 3. In another recent book on the same subject, philosopher Alain de Botton describes ‘status anxiety’ as ‘a worry so pernicious as to be capable of ruining extended stretches of our lives’. When we fail to maintain our position in the social hierarchy we are ‘condemned to consider the successful with bitterness and ourselves with shame’.55

  Economist Robert Frank observes the same phenomenon and calls it ‘luxury fever’.56 As inequality grows and the super-rich at the top spend more and more on luxury goods, the desire for such things cascades down the income scale and the rest of us struggle to compete and keep up. Advertisers play on this, making us dissatisfied with what we have, and encouraging invidious social comparisons. Another economist, Richard Layard, describes our ‘addiction to income’ – the more we have, the more we feel we need and the more time we spend on striving for material wealth and possessions, at the expense of our family life, relationships, and quality of life.3

  Given the importance of social relationships for mental health, it is not surprising that societies with low levels of trust and weaker community life are also those with worse mental health.

  INEQUALITY AND ILLEGAL DRUGS

  Low position in the social status hierarchy is painful to most people, so it comes as no surprise to find out that the use of illegal drugs, such as cocaine, marijuana and heroin, is more common in more unequal societies.

  Internationally, the United Nations Office on Drugs and Crime publishes a World Drug Report,57 which contains separate data on the use of opiates (such as heroin), cocaine, cannabis, ecstasy and amphetamines. We combined these data to form a single index, giving each drug category the same weight so that the figures were not dominated by the use of any one drug. We use this index in Figure 5.3, which shows a strong tendency for drug use to be more common in more unequal countries.

  Within the United States, there is also a tendency for addiction to illegal drugs and deaths from drug overdose to be higher in more unequal states.58

  Figure 5.3 The use of illegal drugs is more common in more unequal countries.

  MONKEY BUSINESS

  The importance of social status to our mental wellbeing is reflected in the chemical behaviour of our brains. Serotonin and dopamine are among the chemicals that play important roles in the regulation of mood: in humans, low levels of dopamine and serotonin have been linked to depression and other mental disorders. Although we must be cautious in extrapolating to humans, studies in animals show that low social status affects levels of, and responses to, different chemicals in the brain.

  In a clever experiment, researchers at Wake Forest School of Medicine in North Carolina took twenty macaque monkeys and housed them for a while in individual cages.59 They next housed the animals in groups of four and observed the social hierarchies which developed in each group, noting which animals were dominant and which subordinate. They scanned the monkey’s brains before and after they were put into groups. Next, they taught the monkeys that they could administer cocaine to themselves by pressing a lever – they could take as much or as little as they liked.

  The results of this experiment were remarkable. Monkeys that had become dominant had more dopamine activity in their brains than they had exhibited before becoming dominant, while monkeys that became subordinate when housed in groups showed no changes in their brain chemistry. The dominant monkeys took much less cocaine than the subordinate monkeys. In effect, the subordinate monkeys were medicating themselves against the impact of their low social status. This kind of experimental evidence in monkeys adds plausibility to our inference that inequality is causally related to mental illness.

  At the beginning of this chapter we mentioned the huge number of prescriptions written for mood-altering drugs in the UK and USA; add these to the self-medicating users of illegal drugs and we see the pain wrought by inequality on a very large scale.

  6

  Physical health and life expectancy

  A sad soul can kill you quicker than a germ.

  John Steinbeck, Travels with Charley

  MATERIAL AND PSYCHOSOCIAL DETERMINANTS OF HEALTH

  As societies have become richer and our circumstances have changed, so the diseases we suffer from and the most important causes of health and illness have changed.

  The history of public health is one of shifting ideas about the causes of disease.60–61 In the nineteenth century, reformers began to collect statistics which showed the burden of ill-health and premature death suffered by the poor living in city slums. This led to the great reforms of the Sanitary Movement. Drainage and sewage systems, rubbish collection, public baths and decent housing, safer working conditions and improvements in food hygiene – all brought major improvements in population health, and life expectancy lengthened as people’s material standards of living advanced.

  As we described in Chapter 1, when infectious diseases lost their hold as the major causes of death, the industrialized world underwent a shift, known as the ‘epidemiological transition’, and chronic diseases, such as heart disease and cancer, replaced infections as the major causes of death and poor health. During the greater part of the twentieth century, the predominant approach to improving the health of populations was through ‘lifestyle choices’ and ‘risk factors’ to preve
nt these chronic conditions. Smoking, high-fat diets, exercise and alcohol were the focus of attention.

  But in the latter part of the twentieth century, researchers began to make some surprising discoveries about the determinants of health. They had started to believe that stress was a cause of chronic disease, particularly heart disease. Heart disease was then thought of as the executive’s disease, caused by the excess stress experienced by businessmen in responsible positions. The Whitehall I Study, a long-term follow-up study of male civil servants, was set up in 1967 to investigate the causes of heart disease and other chronic illnesses. Researchers expected to find the highest risk of heart disease among men in the highest status jobs; instead, they found a strong inverse association between position in the civil service hierarchy and death rates. Men in the lowest grade (messengers, doorkeepers, etc.) had a death rate three times higher than that of men in the highest grade (administrators).62–63

  Further studies in Whitehall I, and a later study of civil servants, Whitehall II, which included women, have shown that low job status is not only related to a higher risk of heart disease: it is also related to some cancers, chronic lung disease, gastrointestinal disease, depression, suicide, sickness absence from work, back pain and self-reported health.64–66 So was it low status itself that was causing worse health, or could these relationships be explained by differences in lifestyle between civil servants in different grades?