Beyond the income inequality hypothesis: class, neo-liberalism, and health inequalities☆
Introduction
In this paper, I take a view of the relationship between income inequality and health status which is more sociological than epidemiological. Whereas most attention has focused on the consequences of income distributions or socio-economic status (SES) for health I discuss here the class-based production of inequalities. Doing so leads to an alternative conceptualization of the determinants of health inequalities within and between nations to that of the income inequality perspective. The political economy approach taken links study of the health effects of income inequality with social and class changes including the spread of neo-liberalism, the decline of the welfare state, differences amongst nations regarding welfare regime type, and, most generally, the relationships between class structure, economies and human well-being. This approach builds on a model developed to help explain ‘the rise and fall’ of medical dominance (Coburn (1999), Coburn (2001)) and on the theories and findings of a number of others—particularly Navarro (Navarro, 1998; Navarro & Shi, 2 (1999b), Navarro & Shi (2001); Navarro & Shi, 2001) but also Ross and Trachte (1990), Esping-Andersen (1990), Esping-Andersen (1999), Lynch and colleagues (Marmot (1994), Lynch et al., 1998 (2001), Lynch & Kaplan (1999); Muntaner & Lynch, 1999; Lynch & Kaplan, 1999), and of course, Wilkinson (1996) and the many epidemiological researchers who have focused on income inequality (see Kawachi, Kennedy, & Wilkinson, 1999).
After briefly describing and critiquing the income inequality hypothesis I present an alternative model (Fig. 2) and empirically explore its usefulness using available data.
Section snippets
Income inequality and health
Analysis of the relationships between income inequalities and health has become a major focus of studies of the social determinants of health. Within-nations income inequality plays a prominent role in analyses of SES-related health inequalities. That is, it has been found that, everywhere, the rich live longer, healthier lives than do the poor. Moreover, the income inequality hypothesis is the dominant approach to discussion about health inequalities between as well as within the developed
An alternative explanation
An adequate sociological account has to help explain both historical change and contemporary variation. In what follows, I use the idea of global capitalism as a new phase of capitalism replacing earlier forms (from Ross & Trachte, 1990) to analyse historical change and welfare regime types (from Esping-Andersen (1990), Esping-Andersen (1999)) to account for national cross-sectional health inequality differences. This approach is broadly congruent with a critical realist perspective (Archer,
Neo-liberalism, income inequalities and health inequalities within nations
In the developed nations, the onset of neo-liberalism has been associated with increasing within-nation inequalities. The most readily available data concern income inequalities and measures of poverty. Gottschalk and Smeeding (2000) (see Atkinson & Bourguignon, 2000) reporting on data from the Luxembourg Income Studies, show that inequality has increased in 14 of the 17 nations they examined between 1979 and 1995. Increases in inequality have been particularly pronounced in those nations
Differences in health status in the US, the UK and Canada
Before examining the welfare regime thesis regarding between-nation differences more closely the United States, the UK, and Canada will be specially considered. The United States is a striking outlier in respect to income inequalities and national health status. Whereas the US is one of the highest ranked nations in the world in terms of GNP/capita, it displays a dismal inequality and health record. That country ranks well below other, much poorer nations regarding health status. For example,
Infant mortality
Table 2 indicates that regime type (Navarro & Shi, 2001) is highly-related to infant mortality (the number of deaths under 1 year/1,000 live births). The Social Democratic nations show better infant mortality rates than do the Liberal nations. Moreover, while all nations show decreasing infant mortality rates between 1960 and 1995, the percentage differences between the mean infant mortality rates for the two contrasting regime types, the Social Democratic and the Liberal, are substantial.
Mortality rates, number of people alive at ages 45/65 and PYLL
What about other measures of health status? Most to some degree reflect infant mortality and there is great overlap amongst measures; they are not independent estimates of health. The relationships may also be highly influenced by latency or lag effects. Nevertheless, to permit comparison with previous studies I report here on the class/welfare regime hypothesis and a variety of measures of national health status.
Examining regime types as categorized by Navarro and Shi or Korpi and Palme (data
Conclusions
A class-based model of the relationships between inequalities in health within and between nations has been described by setting income inequality and health linkages within a broader conceptual framework. This model places income inequality and social cohesion within a radically different causal sequence to the orthodox income inequality approach and suggests that many other material factors, and their interpretation or imputed meaning, rather than simply income inequality, are central
Acknowledgements
The Social Sciences and Humanities Research Council Grant No. 410-1998-0838 helped support this project. The School of Public Health and the Department of Sociology at La Trobe University, Melbourne, sponsored me for a Visiting Fellowship June–July, 2002. Some of the ideas in the paper had their origins in discussions within the Critical Social Science and Health Group at the University of Toronto. Many thanks are due to Bessie Gorospe and Larry Nieva for help in the numerous revisions of this
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Earlier versions of this paper were presented in the Department of Sociology, University of Western Ontario, at the International Sociological Association World Congress in Brisbane, Australia, July, 2002 and at the School of Public Health at La Trobe University, Melbourne.