Comments on: Inequality, sufficiency and health

By: Joe Katzman

Joe Katzman — Sun, 28 Sep 2003 18:54:03 +0000

Why do the Chinese with a GDP of show better startistics than someone in Harlem? I’d want to look at whole bunch of things, including a look at comparable statistics from a comparable urban area in China. Bet there are poor rural areas in the USA with better stats than Harlem, too. Beyond that, I’d start with this simple observation: Harlem is a below-average economic area in the middle of a prosperous country and region. Which means there are important reasons behind that – including important social pathologies for which Harlem is infamous. Is it not reasonable to assume that those pathologies might have ripple effects on things like health and life expentacy when examined? Combine those factors with a Chinese diet that’s usually significantly healthier in its components than the American diet, and I’m willing to bet we’d explain most of the difference right there.

By: Chris

Chris — Wed, 24 Sep 2003 09:35:48 +0000

Thanks everyone. And especially thanks to Sue for responding to Sigvald. To which I’d add that we can attend to the income distribution not only by tax and welfare but also by ensuring a more equitable distribution of capital ownership – baby bonds being the very smallest step in this direction. A more income egalitarian society is likely to be one where the poorest feel their low social status a whole lot less acutely.

By: Katie

Katie — Wed, 24 Sep 2003 04:03:06 +0000

Chris— Check out Nancy Adler’s work on socioeconomic status and health. There’s an article from 1994 with a bunch of other authors called “Socioeconomic Status and Health: The Challenge of the Gradient,” and she’s also one of the editors of a recent book on the topic. One of the most interesting pieces of evidence on this issue that I’ve seen comes from a study that was done (Adler mentions it—I can’t remember the authors) looking at the health of British civil servants. Even when you’re talking about people who all had plenty to live on (and a national health system), measures of health status improved as you went up the occupational ladder of the civil service system. Adler and her colleagues do talk some about explanations—how being on the short end of inequality results in chronic stresses that build up & are bad for health, etc.

By: Sue

Sue — Wed, 24 Sep 2003 02:39:57 +0000

Chris – If you’ve read Anderson, don’t forget Scheffler’s article in Phil and Pub Aff in issue 1 of 2003. Also Jonathan Wolff’s “Fairness, Respect and the Egalitarian Ethos” from 1998 PAPA.

By: Sue

Sue — Wed, 24 Sep 2003 02:36:25 +0000

Sigvald asks "What sort of tools might the State have for adjusting or manipulating social status?" Well, social status tracks social mobility, so the point is to enable and motivate people to make choices that lead to better outcomes. Let's see, in no particular order:

Consistent, well-funded, high-quality education for everyone, low student/teacher ratios, not simply the bare minimum kids in the US get if they live in an area with low property values. Sufficientarian, in that it need not prevent parents from opting out, but with a demanding standard of what is sufficient.
Sufficient reasonably nutritious food available, some of it in schools (but provided somehow even during vacations), without shame. For all children. Hard to pay attention when hungry.
Make sure kids are not sick too often - lack of continuity stunts education. This requires aggressive management of things like asthma that disproportionately affect the kids least likely to get decent health care.
child care, birth control, etc. to lower the costs of an unwanted pregnancy, especially the lost opportunities poor women endure.
Job retraining, helping people find skilled work that has some status to it. Make this a priority, especially in parts of the UK where being unemployed is routinely expected. Give 'em the tools to improve their own social status.
Often, poor areas are also environmental disasters. Diesel exhaust, toxic industrial fumes, coal smoke, all good reasons for disproportionate illness. When surrounded by people who die young, healthy habits appear less rational.
etc.

See how many more you can think up. Instantiating respect, not through a slavish devotion to equality for its own sake, but by enabling folks to look after themselves, as political equals.

By: Sigivald

Sigivald — Tue, 23 Sep 2003 22:49:16 +0000

Also, it occurs to me that one reason why poor person health may be worse in the US than in various poorer nations is that in the US, the poor have access to plentiful cheap (and often unhealthy, though for those who care to eat healthily, there's plenty of cheap healthy food, too) food and often don't have to work strenuously for their survival. Contrasted with the stereotypical (but as far as I know roughly accurate as far as we need be concerned) vision of the poor in the third world, of a diet (due to cost and available sorts of food) such that overeating is difficult, and a generally more physically strenuous life (for example, subsistence farmers tend to be fit, because they work in the fields every day; manual laborers in factories typically walk to work - though this changes as they become more wealthy over time). While these are by no means universal among the third-world poor, I doubt I'm being inaccurate when I suggest they're very common general circumstances.

By: Sigivald

Sigivald — Tue, 23 Sep 2003 22:41:04 +0000

Chris: You bring up an interesting question in your response to Jane. What sort of tools might the State have for adjusting or manipulating social status? I agree that taxation and welfare payments are inadequate to the task… though I’m not sure the task is one the State should undertake at all, regardless of the methods involved. Nor do any likely methods come to mind, though I am perhaps simply filtering them out semi-subconsciously as incompatible with my (fairly libertarian and otherwise classically liberal) general assumptions.

By: Ratbane

Ratbane — Tue, 23 Sep 2003 19:58:56 +0000

As regarding “social mobility” may I suggest that perhaps the greatest impediment there is to this is due to dysfunctional subcultures. If one comes from a subculture in America that does not value education, the work ethic, and the need to have the ability to speak English fluently, then he or she will indeed be marginalized and upward social mobility will be difficult if not impossible. Redistribution of income can do nothing to address the inequality caused by this. If anything, to use the psychological babble of the day, we are only “enabling” the dysfunctional subcultures to continue at great cost to the country as a whole as well as to the members of such subcultures.

By: Chris

Chris — Tue, 23 Sep 2003 10:11:22 +0000

Many thanks to all who offered reading suggestions. Just a brief comment on Mark Buehner’s comment. I think you are absolutely correct to identify choice as one of the achilles heels of the sufficiency doctrine. Insofar as we aim to guarantee to everyone the capability to function at some level, we risk underwriting those who irresponsibly risk their possession of capabilities (by injecting drugs or engaging in extreme sports). That’s a point that features in the exchanges between Anderson, Arneson and others in the BEARS symposium I pointed to above. BUT …. I think it is important to distinguish between the way in which the question of choice ought to inform our fundamental principles of justice and the way in which it features in more derivative principles guiding social policy. AND people in dire circumstances not of their own making who feel that life is pointless and the odds are stacked against them often do behave irresponsibly and make bad choices. Of course, on one level we want to treat them (and for them to see themselves) as responsible, choosing agents. But to insist on and draw attention to their responsibility can (note “can”) often be an exercise in monumental bad faith by those who themselves benefit from and maintain a social system of which others are the victims.

By: Shai

Shai — Tue, 23 Sep 2003 02:54:32 +0000

There’s always Sen’s “Development for Freedom” and “Valuing freedoms : Sen’s capability approach and poverty reduction” by Sabina Alkire, although neither may be relevant to your specific question about relative differences. My memory isn’t very good, but Sen is bound to have said something about the general topic, if not directly, while the second book discusses practical application of capability. If not, criticisms of the capability approach found via the Web of Science or Philosophical Abstracts may turn up something.—John Quiggin has expressed an interest in indexes on his web log. perhaps he can tell you more about them as they occur in economics.—For my “democracy and dictatorship” class last semester there was frequent mention of indices the comparative politics crowd in poly sci departments have developed, but they tend to focus on absolute differences between nations. In all cases I’m out of my depth. I spend most of my time in the kiddie pool (popular works), and havent heard of sufficientarianism until now.

By: Mark Buehner

Mark Buehner — Mon, 22 Sep 2003 23:09:57 +0000

“The major contributors to excess deaths among men in Harlem are circulatory disease, homicide, and infection with the human immunodeficiency virus.” There is a point being missed here. The thread these three things share in common is that by and large they are products of poor decision making. Circulatory disease is a result of poor diet and excersize, the majority of homicides are drug and street crime related, and almost all AIDS cases are the result of unprotected sex. How can you compare that with infant mortality, epidemic, and starvation? Isnt there some point in sufficientarianism where financial and social status become the result of individual decision making compared to acts of god? The theory may be sound, but cant it be taken to far? Isnt keeping people from starvation, infection, and exposure about as far as society can go before personal irresponsibility starts becoming a factor? We can give free education to everyone (which we do) but we cant force people to learn to read. This seems like an outcome based philosophy, which human nature sadly rebels against.

By: PG

PG — Mon, 22 Sep 2003 20:28:59 +0000

I can't speak for Sri Lanka, but China is a communist nation, and Kerala pretty much is a communist state (also the most Christianized and educated state in India). So it makes sense, at least to me, that health outcomes would be better in nations where the little money that they do have goes to things like public health (although China's rural public health infrastructure is crumbling as the nation becomes more free market), than it would in countries like the U.S. where public health is laughable.

By: drapetomaniac

drapetomaniac — Mon, 22 Sep 2003 20:17:24 +0000

i’ve seen quite a bit of work on this, including The Health of Nations: Why Inequality Is Harmful to Your Health Ichiro Kawachi and Bruce P. Kennedy.

By: Alan Schussman

Alan Schussman — Mon, 22 Sep 2003 19:44:52 +0000

A couple of pointers: Bruce Link and Jo Phelan have done a lot of research—both original and by way of review—on the subject of inequality and health. A concise summary (pdf) of some of that work is available from the Robert Wood Johnson Foundation. Their 1995 article “Social Conditions as Fundamental Causes of Disease” does a pretty good job of laying out their arguments, and addresses issues of both mechanics (how does SES affect health, and why is it productive to consider SES instead of “intervening mechanisms”?) and the direction of causality (does SES affect health, or does health affect SES?).The article is in the Journal of Health and Social Behavior, 1995 special issue. Also consider Ross and Bird, “Sex Stratification and Health Lifestyle”, JHSB 1994, 35:161-78; and some work on education and health.

By: sue

sue — Mon, 22 Sep 2003 19:16:13 +0000

I’ve been working for a while on a paper that argues for a “sufficientarian” criterion for the problem of global justice. Oh bloody hell, not you too! (grimace, grin). Check out Martha Nussbaum’s work and pointers to other work. I’m not discounting the possible psych effects of being on the bottom of the heap, but I think there are more sophisticated causal models to explain the same thing. Ones that aren’t relevant to the objection “it’s all in their mind so we need not change the income distribution, merely change their minds.” See especially the early work at WIDER, before she left it. Contrary to an earlier comment in this thread, there is actually somevery good political science quant work on health and inequality and confounding variables like war, development, country, literacy, etc.