Inequality, sufficiency and health

by Chris Bertram on September 22, 2003

I’ve been working for a while on a paper that argues for a “sufficientarian” criterion for the problem of global justice. Sufficientarianism (horrible word) is the notion that what matters, normatively speaking, is not the the pattern of distribution of whatever currency we think is important (welfare, resources, capabilities, whatever…) but that everyone gets beyond a certain threshold. Not that inequality of income, say, ceases to be important because once we focus on the dimension in which we want people to achieve sufficiency it often turns out that distributive patterns impact on their ability to meet the relevant threshold.

My focus so far, has been on the capacity to function as a citizen of a democratic polity. That requires adequate levels of health, nutrition, literacy, education and so forth. Within-state income and wealth inequality matters here (and much more than between state inequality) because of the tendency of such inequality to undermine the political equality necessary for democratic citizenship. If the super-rich control much of the mass media and provide the funding that is necessary to run effective political campaigns, then the capacity of others to achieve full citizen functioning is likely to be undermined.

One of the things I didn’t know about but learnt of at the “Priority in Practice” conference at the weekend was that there is research – by Richard Wilkinson and others – that shows that other capabilities (such as for health) have a similar relationship to income and wealth inequality. According to them, to be a poor person in a rich country is to be worse off (from a health perspective) than to be a typical individual with an absolutely lower level of income in a poor country. If true, that’s a pretty striking finding (and ought to worry “those who think that to be concerned with income inequality is to focus on something inappropriate”: ).

One of Wilkinson’s collaborators, Michael Marmot, “sets out some of the findings”: :

bq. Life expectancy in China, Sri Lanka, and Kerala (a sizable state in southern India) exceeds 70 years, despite their having gross national products in 1994 of less than $1,000 per capita. Contrast this with Harlem, where there was a median family income in 1990 of $24,174 yet a probability of only 37 percent that a black man would survive from the age of 15 years to 65 (as compared with the U.S. average of 77 percent for white men ). Poor people in the United States are rich by world standards, but they have worse health than the average in some poor countries.

Marmot explores a variety of explanations of why relative (but not absolute) poverty might have these adverse health effects. I’m not going to jump in and endorse the findings or speculate too much, but this is interesting material and probably some of the more social scientific timberites know more than I do.

(Minor ideological health warning: to those in the know, I’m well aware of the problems with sufficientarianism – see “this instructive BEARS symposium”: that bears on the issue, especially the Arneson paper – and don’t mean to suggest that I endorse it as a complete theory of social justice).



Chirag Kasbekar 09.22.03 at 12:39 pm


Regarding your last point about inequality and health among the ‘rich poor’. I don’t have the time right now — got deadlines to meet! — to check out the material you point to.

Can you tell me why this has something to do with inequality rather than just poor health infrastructure, etc. among the poor in those parts?



James Joyner 09.22.03 at 1:54 pm

But, of course, $10,000 doesn’t have the same buying power in the US as in, say, China, making income an almost useless metric for cross-border comparisons. How about some sort of purchasing power parity control instead?

And, while I know almost nothing about the “sufficientarian” school, it would seem from your description that it would cover the issue of health care in Harlem. Indeed, I thought you were going in a completely different direction–that income per se or even comparative income per se isn’t the issue but rather the ability to meet threshold needs.


Chirag Kasbekar 09.22.03 at 2:02 pm

Also, is this ‘sufficientarianism’ different from some classical liberal proposals for threshold levels of collective provision to the poor — I think Friedman, Hayek and others propose something of the sort — only in degree?


jdsm 09.22.03 at 2:32 pm

The trouble with social science is that it’s big on statistical correlations and not so big on being able to explain them from a range of potential factors.

I hope the question of purchasing power parity is addressed in the findings you present – I’m sure it is, otherwise the findings are meaningless. Having said that, there could be a billion reasons to explain the differences in health and life expectancy between people in India and those in Harlem. I’m assuming people in rural India don’t go around shooting each other for one.


Chris 09.22.03 at 2:37 pm

Chirag, one of the speculations is that those at the bottome of the income distribution suffer disproportionately from things like heart disease because of the psychological effects of being in that social position, and this independently of their absolute level of income.

On the threshold question, most sufficientarianism of which I’m aware focus on achievement of a capability to achieve certain functionings that are crucial for human welfare. ADAIK, the “safety net” thresholds favoured by Hayek and Friedman are rather different in motivation, focus on income, and eschew the kind of general theory of human flourishing that e.g. Sen favours.

James. I assume that the relevant literature controls for purchasing power parity (if not that would be a grievious methodological flaw). But yes, the suggestion is that low comparative income can lead to an absolute deficit in some capability spaces. That’s been a familiar point at least since Sen’s “Poor Relatively Speaking” , and before that since _The Wealth of Nations_ .


Chris 09.22.03 at 2:44 pm

jdsm: the one article I linked to makes the point

“The low life expectancy in poor countries may be the result of starvation, infected water, and poor sanitation. The low life expectancy of people who live in poor areas within rich countries is not. The major contributors to excess deaths among men in Harlem are circulatory disease, homicide, and infection with the human immunodeficiency virus.”

Of course, we need to know why and whether people are sick because they’re relatively poor or relatively poor because their sick (and so for all the various other correlations).


Chirag Kasbekar 09.22.03 at 3:04 pm


Actually, since it was rather short, I did eventually skim through the article you’d linked to.

Yes, that’s what he seemed to be saying — that it could be the psychological effects of inequality.

But couldn’t this be more (or at least just as much) a question of mobility?

I’m rather sympathetic to your sufficientarianism as it seems to me, actually, but always feel the need to look very carefully at speculation on inequality.


Chirag Kasbekar 09.22.03 at 3:19 pm

Also, I think I agree with jdsm that the article’s reported findings are more interesting than its speculations.

We need more data.

On the other hand, if the phenomenon has something to do with mobility, which it could, it does raise questions about the actual level of mobility in America — at least among blacks.


Stentor 09.22.03 at 3:25 pm

The trouble with social science is that it’s big on statistical correlations and not so big on being able to explain them from a range of potential factors.

Some social science is like that. But large sectors of the social science world — such as anthropology and structuralist and poststructuralist geography — have a pathological fear of numbers.


baa 09.22.03 at 5:10 pm

Harry Frankfurt made this argument in his famous paper attacking the focus on inequality in political philosophy. He said (briefly) that everytime someone argues for economic equality, the examples that grab our intuitions are examples of *want* not of inequality. We care about the starving poor, denied the prospects of a good life, not that the principal’s house is twice as large as the teachers’ Obviously, obviously true! Long live minima!


Chris 09.22.03 at 5:28 pm

Frankfurt’s argument is ok, as far as it goes, but hardly the end of the matter. Suppose we are all above the minimum, do you really want to say that we’ve exhausted all the issues for distributive justice? Perhaps the principal uses his power to ensure that the teachers nestle just above the minimum for evermore, whilst his house gets bigger and bigger and bigger…. Unfair? There’s certainly a case to answer, and if there is unfairness it isn’t because a sufficiency condition wasn’t met.


Jane Galt 09.22.03 at 5:41 pm

You seem to be saying that the real cause of the health disparity is not actually income, but social status, for which income is a reasonable proxy in New York City. What combination of taxation and welfare payments is going to increase the social status of unskilled workers in Harlem?


Doug Turnbull 09.22.03 at 5:57 pm

It’s been a while now since I read it, but it seems to me that the “sufficeintarianism” approach is also a better answer to Rawls original position than his maximin idea.

His argument depends (again relying on fading memory) on the rationality of risk minimization, but it seems like, once you’ve reached some sifficient level, that rationale disappears and ensuring the maximum average above that then becomes the optimim society.

I’d assume someone has made this relatively obvious argument before, so apologies to anyone who has actually kept up with the arguments beyond a single class in college.


Chirag Kasbekar 09.22.03 at 6:01 pm

But again, Chris, isn’t the teacher’s plight to do with mobility?

It’s important to be clear about this, I think because acknowledging mobility brings into focus a whole different set of issues.

Then, again, I’m not saying that mobility and inequality are somehow unrelated.


Chris 09.22.03 at 6:03 pm


The main reason for my posting was actually that I don’t know the health and inequality literature so can’t be sure about what, exactly, it says. So I was rather hoping for commenters to say (A) this is the really key thing to read or (B) that stuff has been demolished by in .

I doubt that social status is the whole story, though, even from my position of ignorance, since sheer income inequality will mean that some are excluded from goods that come to be crucial for the way society works (i.e. the internet in some not-too-distant future).

I assume your question is put in good faith, btw, rather than rhetorically or semi-sarcastically. If so, then it seem to rest upon a false presupposition. Namely, that if we wanted to do something about the their low social status, taxation and welfare payments would be the only policy tools available. But why assume that?


Chris 09.22.03 at 6:11 pm


Since the teachers-principal example is a made-up story we can deploy any explanations we like and then discuss whether they are normatively significant.

But as for “mobility” I’d like you (or someone) to spell out _exactly_ what this point is (rather than simply mentioning it).


GT 09.22.03 at 6:25 pm

Very interesting.

Daniel Drezner has commented on something somewhat similar.


sue 09.22.03 at 7:16 pm

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.


Alan Schussman 09.22.03 at 7:44 pm

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.


drapetomaniac 09.22.03 at 8:17 pm

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.


PG 09.22.03 at 8:28 pm

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.


Mark Buehner 09.22.03 at 11:09 pm

“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.


Shai 09.23.03 at 2:54 am

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.


Chris 09.23.03 at 10:11 am

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.


Ratbane 09.23.03 at 7:58 pm

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.


Sigivald 09.23.03 at 10:41 pm

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.


Sigivald 09.23.03 at 10:49 pm

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.


Sue 09.24.03 at 2:36 am

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.


Sue 09.24.03 at 2:39 am

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.


Katie 09.24.03 at 4:03 am


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.


Chris 09.24.03 at 9:35 am

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.


Joe Katzman 09.28.03 at 6:54 pm

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.

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