Social and economic inequality is a bad thing. Not just morally, but bad for your own health and wellbeing and for that of almost everyone else in the society in which you happen to live. Over the last two centuries, this idea has been an important strand in the work of a host of progressive political thinkers, researchers and public health activists, ranging from Ivan Illich to Beatrice Webb.

The British epidemiologists Richard Wilson and Kate Picket have now added their own voices to this select company. But they bring something new in the vast range of health and social survey data that they have collected in support of their thesis. In this sense their book is a true product of the computer age. Using official sources - which include the World Health Organization and the US Census Bureau - the authors have drawn upon over 200 separate studies to show that for modern industrialised societies, the average health, wellbeing and longevity of the population depends for the most part not upon the level of absolute poverty, nor upon the extent to which people follow government recommendations for keeping themselves well - but upon the breadth of the income divide between rich and poor. This argument is presented in a lively and clear style, illustrated on almost every other page with a scatter plot diagram that captures this thesis as it applies to a wide variety of social and health problems - including ‘mental illness’, drug and alcohol abuse, obesity, teenage pregnancy, pervasive mistrust, violent crime and premature death. The Scandinavian countries and Japan emerge with the smallest difference between top and bottom income levels and they consistently show a more positive profile in all of these areas when contrasted with Britain, America and Portugal: the set of Western countries that show the biggest earning gap between the haves and the have-nots. The main exception to this trend is suicide - which seems to be more prevalent within egalitarian countries and states. Wilkinson and Pickett explain this anomaly in terms of personal failure being that much harder to bear in more equitable (and therefore benign) societies, where the distraught may find it difficult to console themselves with the thought that their troubles might come from the world beyond their own doorstep.

If the case is compelling then what is the underlying explanation? Here, Wilson and Pickett turn to their central metaphor of the builder’s spirit level - a universal index of the degree to which large economic divisions can turn daily life into a steeplechase for security and status. A scramble that is harmful to the extent that our brains and bodies become chronically geared for fight or flight: casting us into recurring envy, resentment and gloom, eroding our immunity to infection and over-winding our internal biological clocks, so that they tick ever faster toward old age. Where deprivation is most acute, these feelings can erupt into violence, the one form of criminal conduct that is most strongly correlated with social inequality. An important message of this book is that while these physiological and psychological harms will afflict the poorest people most of all - they can and do reach into the lives of the rich. At almost any income level, it is better to live in a more equal place.

Refreshingly, Wilkinson and Pickett take aim at New Labour’s tendency to view the maintenance of good health as a largely individual responsibility but one that is also amenable to a technical fix, if only we are prepared to follow the advice of the growing number of supposed experts in psychological and behavioural techniques who are on hand in the workplace, clinic and school(i). In regard to obesity, for example, Wilkinson and Picket point out that health and social policies for treatment and prevention have sought to ‘educate people about the risks associated with being overweight, and try to coach them into better habits. But these approaches overlook the reasons why people continue to live a sedentary lifestyle and eat an unhealthy diet, how these behaviours give comfort or status, why there is a social gradient in obesity, how depression and stress in pregnancy play a role [emphasis in the original] (Wilkinson and Pickett, 2009.p.102)’. While it is unfortunate that Wilkinson and Pickett uncritically echo the general (and perhaps misguided) consensus that obesity is harmful in itself - as opposed to being a measure of the many other pernicious consequences of being poor or lowly(ii) - their general point is nonetheless well made. Cognitive Behavioural Therapy is likewise rejected as the cure for what may in fact turn out to be socially generated malaise. It is surely a sign of the confusion that reigns within the field of mental health treatment that the dust jacket of this book carries a cheerful endorsement by one of the main architects of the movement for CBT for the masses in Britain – Richard Layard himself.

This book therefore represents a strong attack upon the free-market neo-liberalist outlook that has ruled British and American policy making for the last thirty years. The authors clearly see themselves as the vanguard of a grass roots movement and they have set up a none profit making organization called The Equality Trust, in order to advance their broad egalitarian cause.

Nevertheless, The Spirit Level comes with certain limitations. For one thing, the discussion mainly focuses upon the effects of income differences at the expense of other kinds of inequality - including those that relate to class, race and gender and the kinds of institutional, economic and political arrangements that maintain these social distinctions. One hint that other forms of inequality might also have a bearing upon health and wellbeing is that the strongest data in support of the writers’ thesis comes mainly from comparisons of the US, Sweden, Japan and the UK. Needless to say, these are all complex societies that vary from one another in many different ways besides that of the distribution of income, and it perhaps remains for future research to identify which of these other factors might also contribute to the illness and health of their respective populations.

Furthermore, Wilkinson and Pickett perhaps also underestimate the reach and the pernicious nature of poverty in the UK and in other Western countries on the one hand, and the degree to which disease can also be traced to hazards within the general physical environment and the workplace, on the other. This last has become a growing concern in this era of deregulation and of short- term employment contracts(iii). For any such analysis of the day-to-day experience of hardship and of how it is both reproduced and intimately related to the material as well as social conditions of people’s lives, one would have to turn to the more detailed studies of writers such as Bourdieu, Davies and Hanley(iv).

On the whole, research in the field of health inequalities has studiously avoided any examination of the origins of the policies that promote these inequalities in the first place and still less of whose interests they serve and why(v) - and it is hard to avoid the conclusion that a similar lacuna lies at the heart of this volume. This is most evident in Wilkinson and Pickett’s discussion of the social policy implications of their work, in which they advocate shared ownership of production and the building up of various forms of social capital as the best ways forward. While these suggestions are laudable they also seem rather narrow, since there are many other ways of tackling inequality – the most obvious being a concerted redistribution of wealth. It may be that this omission has something to do with the authors’ apparent neglect of the word ‘socialism’ – an idea that so often seems to lurk, unmentioned and unmentionable, beneath the surface of their text. Indeed, these well meaning academics seem to think that if governments can be made to see the errors of their current free market ways then they will feel compelled to change. And yet this seems doubtful. The recent stock exchange debacle does not appear to have radically unseated the British Labour government’s commitment to the city of London and to corporate capitalism in general. Moreover, the historical record suggests that nominally social democratic governments pursue their ends first and foremost in support of narrow sectional interests and that logic, let alone compassion, usually comes quite a long way behind.

Despite these shortcomings, this book is to be welcomed because of its resolute emphasis upon the social causes of health problems, the rich variety of empirical data that is provided in support of this argument, and because of its accessible and highly readable style. Already a best seller and deservingly so - The Spirit Level has been cited in the UK Labour government’s recent Equality Bill and it is sure to become a reference point in the many debates that will help to shape the political culture of the early 21st century in Britain, and beyond.

Paul Moloney

i Furedi, F. (2004) Therapy Culture: Cultivating Vulnerability in an Uncertain Age. London. Routledge.
Furedi, F. (2009). (Second Edition) Paranoid Parenting: Why Ignoring the Experts May be Best for your Child. London Continuum.

ii Campos, P. (2004). The Obesity Myth: Why America's Obsession with Weight is Hazardous to Your Health. New York. Gotham Books.

iii Toombs, S. and Hilyard, P. (2004) Towards a Political Economy of Harm: States, Corporations and the Production of Inequality. In, Hilyard, P; Pantazis, C; Tombs, S. and Gordon, D. (Editors) Beyond Criminology: Taking Harm Seriously. London. Pluto.

iv Bourdieu, P. et al (1999) The Weight of the World: Social Suffering in Contemporary Society. London. Polity.
Davies, N. (1997). Dark Heart: the Hidden Truth about Modern Day Britain. London.Vintage.
Hanley, L. (2007). Estates: An Intimate History. London, Granta.