Praised by The Lancet, which called it a “lucid account that . . . deserves to be read by everybody interested in the politics of health,” and the New England Journal of Medicine, The Health of Nations provides powerful evidence that growing inequality is undermining health, welfare, and community life in America. The book’s prizewinning authors also make an urgent argument for social justice as a necessary vehicle for the betterment of society.
The Health of Nations is the synthesis of years of groundbreaking research on the connections between social structures and health and welfare, and one which Nobel Prize winner Amartya Sen says “has much to offer in reshaping the agenda of the debate on health care.” Now in a revised edition which includes a new afterword, it dramatically demonstrates that growing inequalities, far from being a benign by-product of capitalism, threaten the very freedoms that economic development is thought to bring about.
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Ichiro Kawachi is an associate professor at the Harvard School of Public Health and a recipient of Robert Wood Johnson Investigator Awards in Health Policy Research.
Bruce P. Kennedy was a social epidemiologist, formerly at the Harvard School of Public Health.
The Health of Nations presents evidence from many disciplines that political policies that widen inequalities in income may harm a nation's health. Kawachi, an internist turned social epidemiologist, and Kennedy, an educational psychologist, examine a number of indicators of health, such as mortality rates (with respect to which the United States performs miserably in comparison with all the other rich countries), and present arguments to show that one's relative position in society is more important than absolute wealth or income, not only when it comes to general well-being, but in terms of mortality as well. The authors contend that our "consumption cancer" has left us with huge consumer debt, limited savings, and an inequality that is posited to be the root cause of our poor health. We work longer and harder, and we have less time for our families. These factors lead our country, they argue, to higher rates of violent crime and incarceration, to the establishment of gated communities with security guards, and to the outsourcing of the care of children. With the weakening of social bonds comes a dramatic increase in the incidence of depression. Paradoxically, they suggest, if the government were to launch an effort to redistribute the wealth from the rich to the poor, the poor might not even support it: although the likelihood of upward economic mobility by the poor in the United States is lower than that in other rich countries, poorer people in this country continue to dream of being among the lucky few who win the big one. Goods that were once considered luxuries in the United States, such as automobiles, telephones, television sets, and videocassette recorders, are now near-necessities, and most people have them. Kawachi and Kennedy point out that despite rising living standards, we have not become "deliriously happy," as economists had predicted. There is little correlation between increasing income and the level of happiness in industrialized countries. We end up not "getting what we want" but "wanting what they get." According to the authors, "A notable trend during the past two decades has been the contrasting difference between massive intensification of consumption wants for material goods, but the stagnation (or even decline) of expressed needs for spiritual goods, such as a fulfilling job or happy marriage." The authors also address common misperceptions of the purported benefit of inequality: that it produces increased economic growth and productivity is unquestioningly accepted as good. In a counterexample drawn from major-league baseball, the authors show that teams are more successful when players' salaries are more equitably distributed. We work harder and longer just to keep up with our 1973 standard of living. This additional work translates into 5 to 10 more weeks of work each year for members of the American labor force than for their European counterparts. Politicians preach about "family values," but how can families prosper without time for maintenance? As a result of the orientation toward individual rather than family needs, some people see children as obstacles to individual growth. The authors point out that higher rates of crime occur when the high cultural value placed on competitive achievement clashes with widespread disparities in actual living standards within a society. Inequality is harmful, and we pay the ultimate price for it with premature deaths. Why should this book be important for clinicians and biomedical researchers? To improve health in the United States or elsewhere in the world, we must address factors that affect the health of populations but have only indirect relevance for patient care. The chapter "Politics and Health" points out that, in contrast to people from healthier European countries or Japan, Americans are less inclined to expect their government to work for the common good, as indicated by the fact that the largest "political party" in this country consists of the nonvoters. The erosion of social capital -- resulting in distrust in neighbors and unwillingness to help others -- is more prevalent where income gaps are greater. In parts of the United States where there is a greater divide, voter turnout is significantly lower. Not surprisingly, mortality rates are higher in such places as well. Clearly, the political arena is the place where doctors concerned with the health of the population must work. Stephen Bezruchka, M.D., M.P.H.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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