Book Review

The Impact of Inequality: How to Make Sick Societies Healthier

N Engl J Med 2006; 354:1329March 23, 2006

Article

The Impact of Inequality: How to Make Sick Societies Healthier
By Richard G. Wilkinson. 355 pp. New York, New Press, 2005. $27.95. ISBN: 1-56584-925-6

In this thoughtful and provocative book, the social epidemiologist Richard Wilkinson uses the results of research on health differences to explore the effects of social and economic inequalities on individuals and societies. He contrasts the extraordinary technical advances and material successes of modern societies with their social failures. Wilkinson then helps the reader examine the evidence that inequality is socially corrosive and why it is so.

Wilkinson skillfully reviews the literature on socioeconomic inequalities worldwide and their effects on death rates, the quality of social relationships, levels of violence and trust, and the degree of involvement in community life. He then presents compelling evidence that psychosocial factors such as low social status, poor social affiliations, and negative experiences in early childhood are powerful influences on health, to the extent that they trigger biologic stress reactions.

Wilkinson also argues that, although absolute material standards and levels of consumption influence the health of populations in poor countries more than in wealthy, developed countries, inequalities in social environments and psychosocial factors play a greater role in wealthy countries. But why is this so? Wilkinson submits that low social status and the relative deprivation of social interaction affect people most deeply by ranking them according to worth in comparison to others, which assaults their sense of dignity. Moreover, he asserts, greater inequalities in income create social distances among groups and promote dominance and subordination, competition for status, and poor social relationships. However, causality might also flow in the opposite direction — that is, changes in income distribution resulting from government policies, regardless of their intent, also have negative social consequences.

The U.S. population is becoming more ethnically diverse over time, and in recent years, concern about health disparities along racial and ethnic lines has received national attention. This book contributes to the current debate regarding the proposed mechanisms of these disparities. Wilkinson presents the case that, as inequality and dominance increase within a society, so does discrimination against vulnerable groups, including ethnic minorities. He argues that socioeconomic inequalities lead to social prejudice.

Inequality is also an obstacle to the attainment of sustainable economic activity within a society. Wilkinson writes that improvements in the quality of our lives depend not on wishful thinking or commitment to higher moral standards but on practical policies that affect the way we manage our economies and how large organizations use their power to influence society. He believes that the political action necessary for improving the quality of life will come only after the public understands these issues better. The Impact of Inequality is his contribution to increasing this understanding. In writing this book, he impels us to develop new approaches to bridge the inequities that divide our society and make us sick.

Lisa A. Cooper, M.D., M.P.H.
Johns Hopkins University, Baltimore, MD 21287
lisa.cooper@jhmi.edu