Vikas Shah, Thought Economics, January 2014
The diversity of humanity is perhaps one of the most valuable characteristics of our species. Over millions of years, we have grown into a gamut of cultures, abilities, intellects and personalities. “... inequality is the only bearable thing [in nature]," wrote Francis Picabia "...the monotony of equality can only lead us to boredom” This view of diversity is however, purely aesthetic and philosophical. The reality is that human society has created conditions whereby practically every dimension of difference becomes a tool to unify groups against each other.
History is littered with battles where the marginalised fight for recognition and equality in the face of others. Battles of gender, race, and religion have bloodied our collective hands with the lives of hundreds of millions; many of these fights still rage on today.
This century has also seen inequality manifest in profoundly deadly form- economics. We are living in a world where the top 1% of the world's population own more of our planet's wealth than the bottom 95% combined. We live in a world where billions exist in abject poverty without access to the basic food, water, shelter which the rest of us take for granted. We live in a world where hundreds of thousands of people die- of economically preventable causes- each and every day. These are not just developed vs. developed world issues, but inequalities which exist in the social-strata of every single nation, along with the physical-distances between them.
We talk of inequality as a natural phenomenon, but the truth is that it is the product of our own political, cultural and social ideals. We have in effect, sanctioned these vast gulfs to exist; albeit often we have been selectively-blind to the effects they cause. The past half-century of advance now means that our blindness may not be selective. Society is sensorially immersed in the abhorrence of inequality in all its forms. We must therefore understand not just why inequalities exist within our society but what we can do about them.
In this exclusive series of interviews, we speak to four world experts on inequality. Professor David Hulme (Founder and Executive Director of the Brooks World Poverty Institute at the University of Manchester) , Prof. Sir Michael Marmot (Director of the Institute of Health Equity, University College London), Baroness Onora O'Neill (Chair of the Equality and Human rights Commission) and Prof. Richard Wilkinson (Co-Founder of the Equality Trust). We discuss the fundamental question of why inequality exists in our society, the impact it has on our world, and what we can do to fight it.
Professor David Hulme is the founder-director of BWPI and was appointed to the role of BWPI Executive Director in April 2009. David is Professor of Development Studies, the CEO of the Effective States and Inclusive Development Research Centre (ESID) and also CEO of the Brazil in Africa Research Programme. From 2000 to 2010 he was also Director of the Chronic Poverty Research Centre (CPRC).
David's Publications include Global Poverty: How Global Governance is Failing the Poor and The Millennium Development Goals and Beyond: Global Development After 2015 with Rorden Wilkinson. Future projects include a further book on global poverty planned for 2015-16, which will examine the processes behind the post-2015 development agenda and explore the interaction between aid-based poverty reduction approaches and the sustainable development model. Among other appointments, David is currently an academician of the Academy of Social Sciences, a member of the Scientific Committee of the Comparative Research on Poverty Programme of the International Social Science Council (ISSC) and a board member of the United Nations Research Institute for Social Development (UNRISD). His most recent appointment, in September 2013, is as the vice-chair of the ERSC/DFID Poverty Alleviation Research Grants Committee.
Professor Sir Michael Marmot is currently Director of the Institute of Health Equity and MRC Research Professor in Epidemiology at University College London (UCL). Sir Michael Marmot has made seminal contributions to epidemiology by establishing hitherto unsuspected links between social status and differences in health and life expectancy. He has initiated the era of social epidemiology and paved the way for the development of a wholly new concept of preventive medicine.
He has led a research group on health inequalities for the past 30 years. He has been invited by the Regional Director of WHO Euro to conduct a European review of health inequalities. At the request of the British Government, he previously conducted a review of health inequalities, which published its report 'Fair Society, Healthy Lives' in February 2010. He was Chair of the Commission on Social Determinants of Health set up by the World Health Organization in 2005. He is Principal Investigator of the Whitehall Studies of British civil servants, investigating explanations for the striking inverse social gradient in morbidity and mortality. He leads the English Longitudinal Study of Ageing (ELSA) and is engaged in several international research efforts on the social determinants of health. He chaired the Department of Health Scientific Reference Group on tackling health inequalities.
Baroness Onora O'Neill has taught at various universities in the US and the UK. She was Principal of Newnham College, Cambridge from 1992 to 2006, President of the British Academy from 2005-09, and chaired the Nuffield Foundation from1998-2010.
She currently chairs the Equality and Human Rights Commission and is on the board of the Medical Research Council. She has been a member of the House of Lords since 1999, and is an independent, non-party peer. She served on House of Lords Select Committees on Stem Cell Research, BBC Charter Review, Genomic Medicine, Nanotechnology and Food and Behavioural Change.
She writes on ethics and political philosophy, with particular interests in conceptions of justice, in the philosophy of Immanuel Kant and in bioethics, and has published mainly in philosophical journals. Her books include Faces of Hunger: An Essay on Poverty, Development and Justice (1986), Constructions of Reason: Explorations of Kant's Practical Philosophy (1989), Towards Justice and Virtue (1996) and Bounds of Justice (2000), Autonomy and Trust in Bioethics (2002), A Question of Trust (the 2002 Reith Lectures) and Rethinking Informed Consent in Bioethics (jointly with Neil Manson, 2007).
Professor Richard Wilkinson has played a formative role in international research on the social determinants of health and on the societal effects of income inequality. He studied economic history at LSE before training in epidemiology. He is Professor Emeritus of Social Epidemiology at the University of Nottingham Medical School, Honorary Professor at UCL and a Visiting Professor at the University of York. Richard co-wrote The Spirit Level with Kate Pickett which won the 2011 Political Studies Association Publication of the Year Award and the 2010 Bristol Festival of Ideas Prize. Richard is also a co-founder of The Equality Trust.
Q: Why do poverty and inequality exist?
[Professor David Hulme] Poverty and inequality are closely related, but you must also define what you mean by each of the terms. Nowadays, in developing countries, when we talk of poverty, we are still very much focussed on absolute or extreme poverty. In OECD countries we tend to think of relative poverty- based on 60% of median-income; and that does make things very different... .
If you look at relative poverty, inequality is central to that concept. If you look at absolute poverty, then certainly some people would see it as unrelated to inequality. There are two main factors here. Firstly, scarcity of resources and secondly, the way those resources are distributed. With the absolute poverty measure, it may be possible- in some circumstances- to argue that there is a scarcity of resources. Over the last 60-90 years that argument has become more difficult to support as we are trading globally... we have more food than we could utilise... we have access to cheap medicines that treat most diseases and so on.
Poverty now can be seen as a problem of distribution... Some people are demanding more than their fair share of the world's resources.
Q: What is the true nature of equality?
[Baroness Onora O'Neill] Equality is a difficult concept and extremely abstract. It often helps us to think about it in the plural, i.e. as ‘equalities’. After all, there are many conceivable equalities that we can imagine: equal length of life, equal income, equal educational attainment and so on. To talk of ‘equality’ as if it were a mass-term is unfortunate. To talk of the concept in the plural also allows one to think through which of the equalities that one might think about is fundamental.
I don’t think we can have any serious discussion of equalities, let alone human rights, without beginning from a very abstract yet fundamental equality, namely that people should have equal recognition, i.e. everybody should count . That’s a fundamental premise for discussions on human rights or equality.
[Professor Richard Wilkinson] I am concerned with income inequality and the effect it has on society. There are very important reasons to give priority to the measurement of material inequalities as I feel that status hierarchies such as class and so on; are largely earned, and their link with animal and dominance hierarchies are about privileged access to resources.
When people talk of inequalities of status, power, wealth and so on… I think that in terms of our evolved psychology, they are basically the same thing. If you think of the status hierarchy amongst monkeys; power is about physical strength and is about the strength held by privileged access to resources. It’s not chance that status, wealth and power come together in human societies. To understand equality therefore, you have to understand monkeys and our evolved sensitivities rather than Marx.
Status is simply recognition by subordinates that you are stronger than them.
Q: Is inequality inevitable?
[Baroness Onora O'Neill] It’s inevitable that there will be inequalities in society. Perhaps your hair and my hair are not equally long… but it is unimportant to have equality in that regard.
When people say that it is inevitable that society will be unequal, they often have in mind a pretty vague, undefined set of equalities that they think could be important- and this may differ from the list of inequalities that others may consider important.
However, while equal recognition or equal respect for all persons is the most basic equality, it’s not uncontroversial to state this. Some people think this claim is not morally sustainable. They may think that other sentient animals have equal rights to human beings. So asserting that human beings and only human beings have equal moral standing or status is not uncontroversial.
The situations we are putting aside in focussing on the equal standing of human beings are some that existed in the past, and still exist today in some parts of the world, in what anthropologists or sociologists would call ‘status societies’ where the assumption is- to paraphrase George Orwell - that all human beings are equal, but some are more equal than others. Status societies assume that people of certain lineages, be it race, caste, class or gender, are going to be superior to people of other lineages.
This claim about the equality and respect we owe to all human beings is therefore a non-trivial claim.
Q: How do we define equality in the context of human rights and justice?
[Baroness Onora O'Neill] The equality of standing of all human beings is the presupposition of human rights. Human rights belong to everybody. This is an ancient idea. We have St. Paul saying “There is neither Greek nor Jew, Slave nor free…” and in many other traditions also stress the idea of the equal standing of all human beings (albeit it is often not the dominant idea).
I think, however, that it is a mistake to state there is a ‘right to equality’. I have yet to establish what this phrase means or is supposed to mean. Human rights, however, suppose the equal moral standing of different human beings.
Then you turn to the human rights themselves. These are an extremely difficult claims, and differ from claims about equality- although a few of them could equally well be phrased as commitments to certain equalities. The ones I have particularly in mind are the right to a fair trial and equality before the law- those could be equally well seen as as equalities. Most human rights are expressed as claims, without consideration of whether everybody has the same claim. They are often therefore quite neutral on specific equalities and- indeed- sometimes, if paradoxically, assert privileges for some persons. If we use the example of The Convention on the Rights of the Child, it starts in the preamble by saying that “mankind owes the child the best it has to give”. If you took that literally, it perhaps suggests that mankind doesn’t owe anybody else anything! I don’t suppose it’s meant that way… All the same, it picks out children as having special claims, and many other documents state other such claims and priorities. More generally the human rights documents do not require very many specific equalities, and that’s why I think that in the modern period, people have thought that it is often important to say something more specific- if one can- about equalities.
The full range of human rights are a second stage that we reach after acknowledging the fundamental point of equal respect or recognition for all persons. This acknowledgement points in the first place to basic procedural rights-- such as the right to a fair trial- and then to the great slew of human rights, which is being elaborated all the time!
Suppose we had to break it down into steps. We have to first be clear about which equality we’re talking about. Once you get past the fundamental respect of all human beings, this is not obvious. Some of the equalities that are talked about are much more difficult when framed as human rights, and God knows human rights are difficult enough! They’re difficult because- as we know from the mathematical origins of the word ‘equality’, equality is a comparative notion. If we seek equality in some social or economic matter, we’re not merely looking at an individual to see if they’re getting equal share: we have to look at everyone else too to make the relevant comparisons. We can tell that a person’s right to not be tortured is being respected regardless of what is happening to other people’s right to not be tortured. But we cannot tell whether substantive a right to equality in some matter is being respected without looking at all other persons to whom that right applies.
Q: What is the current state of income inequality?
[Professor Richard Wilkinson] In many societies including Britain and the United States, you have seen similar patterns during the majority of the 20th Century. High inequalities in the early party of the century, followed by declining inequality starting in the 1930’s, a pattern which continued through to the 1960’s- bottoming out in the 1970’s before inequality began to rise again.
In many societies, we are now back to levels of inequality that existed in the 1920’s. All the progress we made in terms of greater social mobility and being less class-bound has been largely undone.
Q: How does inequality impact community life and social relations?
[Professor Richard Wilkinson] More unequal societies tend to have higher levels of violence, greater prison populations, less social cohesion, weaker community life, lower levels of child well-being, more drug problems, more mental illness and more. This has all been empirically proven.
People often find it surprising that so many seemingly different problems are connected to inequality. What we’re really saying is that problems related to social status in our society get worse as you increase the social status differential in society. The surprising thing is that it doesn’t just get worse amongst the poor but rather across the vast majority of the population.
Inequality weakens the social fabric of society and damages the quality of social relations, it also makes social status more important. In a society of inequality where some people are worth everything, and some people are worth nothing; conceptions of self-worth are heightened. We are all more worried about how we are seen, judged and how we fit into society. Class, status, status insecurity, status competition; all of these matter in a more unequal society.
Q: How do politics and commerce contribute to inequality?
[Professor Richard Wilkinson] If you look at the ‘U-Shaped’ curve in inequality through the 20th century- you can see that politics is behind this. The strength of the labour movement, social democratic parties, and any countervailing voice in society was strengthened during this period. Roosevelt himself said that we must reform to preserve. There was a sense of society and an economic system under threat. The way forward was to move to greater equality. As that voice weakened from the 1970’s onward, the income differences widened again. CEOs, bankers and so on had no real democratic constraint on what they did; and there were no countervailing voices keeping their incomes in check.
Q: How does income inequality impact social mobility?
[Professor Richard Wilkinson] It’s ridiculous to think you can create a classless society without reducing the material differences that give rise to social distances, and the cultural markers of status differentiation. The French sociologist Bourdieu, describes how people use their money for social differentiation.
It’s very clear that social mobility declines and slows in more unequal societies with higher inequalities of income; this has been empirically proven with independent data in a number of countries.
In a more unequal society, the rungs on the social ladder may be steeper.
Q: What is the relationship of equality to trust between citizen and state?
[Baroness Onora O'Neill] It seems to me that the promise (not always the achievement!) of modern conceptions of the state is it that the citizen is indeed seen as subordinate to the state, but equally subordinate with all other citizens. That is to say that the state exists so that nobody shall be above the law. The issue of nobody being above the law, and everybody equally under the law, is a fairly straight-forward corollary of the concept of respect for all persons. There have been many societies that have different laws for different sorts of people. The modern world has vestiges of that, for example the treatment of women in Saudi Arabia (albeit you see it in many other places too…)
The question is… does there have to be subordination to the state? You then get deep into political philosophy… What are we saying when we say that we are ‘equal under the law’? If we are to have law there must be enforcement, so there has to be an enforcing agent or body. The state is a very distinctive enforcing agency because of its territoriality… However, it’s quite difficult to imagine dispensing entirely with agencies that have a territorial basis.
What we need a state to do, above all else, is secure the rule of law. I think the rule of law is even more elementary than human rights, for it means that nobody is above the law. The first challenge for states is what has been called ‘the problem of the over-mighty subject’, and it is a problem that recurs in different forms. There are many states in which individuals or groups have carved out positions that mean that they are in effect above the law. An example might be drug cartels or warlords within certain states, and wherever some are above the law there is a fundamental threat to other citizens.
Q: How does poverty manifest in the developed versus developing world?
[Professor David Hulme] If you look at poverty in a very poor part of Africa or South Asia, you are seeing catastrophic malnourishment... people whose mothers and grandmothers were underweight and undernourished; passing on that genetic heritage of problems. If you look at the UK, USA and elsewhere- malnutrition in such extreme forms is much less likely, albeit there will be some people who simply may not be able to access services to help them.
Developed and developing world poverty are also connected through phenomena such as migration; a fact that becomes awfully clear with incidents such as the 300 bodies of African migrants washing up at Lampedusa, after they had tried to cross the Mediterranean for a better life in Europe.
Q: How has urbanisation impacted poverty and inequality?
[Professor David Hulme] In most of the rich-world, we are 90-95% urbanised. Poverty in those societies is largely concentrated into urban areas albeit when you look there are discrete forms of rural poverty- often from populations that have been left behind and may not be connected to the modern economy.
In developing countries, you have high rates of urbanisation but great differences. Latin America is majority urbanised, South Asia less so, and Africa much less. South Asia and Africa are urbanising quickly, and the poverty in urban areas is very different and must be measured and understood differently. Many people in urban areas have access to higher incomes, but the costs of things like water, transport, accommodation and so on are much higher.
The thing that bothers me about the urbanisation of poverty is that most of the ideas, policies and data we have are based on rural poverty. That's the way it used to be! It's rapidly urbanising now, and many of our ideas are no longer appropriate for those changed environments.
It's very sloppy that we still use phrases like developed and developing world. I've been working in development for almost 40 years, and while early in my career I could see the distinction; now it's not so clear. Where would you place China and India by those measures? The differences are also visible within countries. In a recent book by Amartya Sen, he described India as 'islands of California in a sea of sub-Saharan Africa....' I'm not sure that's right, and it's rather pejorative of Africa... but some parts of India such as central Bangalore or Hyderabad could well be anywhere in the rich-world, albeit with Indian cultural features. When you get further out into Uttar Pradesh for example, a Dollar could be a lot of money for someone... In the US you see similar patterns. In a place like Washington DC, you find areas that are the capital of the most powerful country in the world; with everything a member of the elite could want. A block or two later, things are very run-down. You will find people with real problems, just a hundred yards away you are in a different world.
Q: How do events such as financial-crises, climate change and so on impact poverty and inequality?
[Professor David Hulme] Climate change events are certainly having an impact on poverty. I work with Bangladesh a lot and although you can't link any event.... we can say that climate variability has increased and the frequency of catastrophic events like cyclones are no longer once or twice in a lifetime, they may be three, four, five times. That's a big difference, and can wipe out entire communities and prevent them rebuilding.
Financial crises are also catastrophic, but they impact in different ways. In many ways the 2008 collapse knocked Europe much more than parts of South Asia; they were insulated by virtue of not being as integrated with the global economy to the same degree- certainly financially.
Q: What are the greatest challenges and opportunities for poverty reduction?
[Professor David Hulme] When you look at poverty in a global context, you see two very different narratives. The first being that things are very bad... particularly in Africa and South Asia... children are going hungry and so on. If you look at the data however, you see the second narratives. Things are getting better... and have been getting better. If you look at the agricultural sector, things have been getting better for most of humanity. In the past 30-40 years, life expectancy has also been improving. In Bangladesh where I do a lot of work, the country was previously seen as a 'basket case'. Life expectancy has been increasing by 1-2 months a year, that's phenomenal.
The concerns come from the fact that we now have enormous technological and organisational capability, which simply did not exist in the past. If one applied those resources in only a marginally different way; perhaps just re-applying 1-2% of global GDP... you could reach those bottom 1-2.5 billion people. You could improve their lives quite markedly.
The people who control resources in the world... the world's most powerful people... tend to be reluctant to see things renegotiated. A good example of this can be seen in the pharmaceutical industry. Firms are beginning to be more reasonable now, but the fact is that hundreds of thousands of people died in the developing world simply because of the insistence of these firms to hold onto patents in ways that made drugs inaccessible. Perhaps if they had different business models, they could have made drugs more accessible and even made more profit along the way.
In those parts of the world where you have the greatest concentrations of poor people, you also tend to be able to do the least about their situation. You are faced with bad governance, weak states, poor public service delivery and more. It's very difficult to get states to function effectively and even harder to improve public service delivery. Where you most need poverty reduction, it's the most difficult to actually do it!
[Baroness Onora O'Neill] We have made tremendous progress, and we will make more, but one has to go about it very carefully.
Discrimination is an interesting concept in this regard. Discrimination is making a decision on the basis of irrelevant considerations. For example, if you are an employer and you give a job to somebody because you like their looks or because they’re your cousin- that consideration is not relevant to their likely job performance, and the decision is one that is based on unlawful discrimination. We often call it nepotism in the latter case.
Discrimination is always based on using an irrelevant basis to make a decision. In this country we’ve picked out certain characteristics as a focus for specific equality duties and reminded ourselves that it is particularly wrong to discriminate on the basis of those characteristics. They include gender, age, race, disability, sexual orientation and so on. These are not of course the only irrelevant characteristics by which people discriminate. For example, if you were interviewing to fill a job and thought “hmm… he’s a Yorkshireman, I’m not hiring him!” – that would be discrimination and… by the way… unlawful discrimination.
When we talk of discrimination, it’s important to recognise the lawful discrimination that you and I practice every day, and how it is different from unlawful discrimination. Unlawful discrimination is making a decision on the basis of something that is irrelevant. When you appoint to a job, and look at competence and experience and other characteristics that are relevant to the job… but not at the gender of your applicant, their ethnic origins, age and so on…you are making a decision on the basis of relevant characteristics, and that sort of discrimination is lawful.
I’m old enough to remember advertisements that would say, “Wanted! Van Driver! Male, between 20-30…” It sounds quite funny now…
Q: What is the link between equality and health?
[Professor Sir Michael Marmot] We see big inequalities in health within and between countries. Within countries; inequalities in health are shorthand for the systematic differences in health between social groups. If those groups are defined by some measure of socio-economic position such as education, income, occupation or the socio-economic characteristics of where they live, then those social inequalities relate to people’s socio-economic position.
The worse health of the poor, disadvantaged, vulnerable and marginalised groups is exactly what we mean by health inequality. It’s not that these groups are impacted by health inequality but rather that their worse health is- to some extent- the definition of health inequality.
Within a country, health follows a social gradient. It’s not only the poorest that have the worst health, but in fact ; the lower the status- the worse the health. It’s a gradient that runs from top to bottom. When people think about inequalities in health they usually think of disadvantaged, poor and marginalised people having worse health- and indeed they do. The gradient shows that it’s not confined to that. The greater the degree of advantage, the better the health and the greater the degree of disadvantage, the worse the health.
This is important; it changes the way we think of our explanations. If you think poverty is the problem, you will deal with poverty. If inequality is the issue, so that people in the middle of the social hierarchy have worse health than those above and better health than those below… that’s not poverty, but- I would argue- that it is due to social conditions not limited to poverty.
Inequalities in health are the result of social and economic inequalities in society.
Q: How does health inequality manifest within society?
[Professor Sir Michael Marmot] Life expectancy is often used as a shorthand for this. We plotted life expectancy in England by local area, and found that within one London borough (Westminster); there is an 18 year gap in male life expectancy between the worst off part of the borough and the best off part of the borough.
In Glasgow, there is a 28 year difference in life expectancy between those in the poorest and richest parts of the city. In the USA, there is a 20 year difference in life expectancy between the worst and best off counties.
In England, we have also analysed life-expectancy and disability-free life expectancy. The social gradient for disability free life expectancy is much steeper than life expectancy on its own. In other words; the disadvantage of quality of life increases more than length of life as you descend the social hierarchy. It’s morbidity as well as mortality that we must look at.
In the developed countries, for most specific causes of death (with a few noble exceptions such as breast cancer which appears to be more common in higher status groups, and colon cancer which appears to have very little socioeconomic distribution) the lower you are, the higher the risk.
Q: What are the economic and social impacts of health inequality?
[Professor Sir Michael Marmot] Health and health inequality are a manifestation of the way a country organises its affairs. For example; when we first looked at health across Europe and examined the communist countries of Eastern Europe versus the non-communist countries of Western Europe, the gap in life-expectancy between them was increasing. After the collapse of communism, there was an 18 year gap in life expectancy between Russia and the richer countries of Sweden, Israel, Iceland and so on. That’s a manifestation of economic and social realities in countries.
There’s also an enormous cost associated with health inequality and people becoming prematurely ill and dying. This occurs in the form of real costs such as healthcare costs, lost taxation, lost productivity and so on. This is quite apart from the theoretical costs of lives lost and so forth.
Q: What are the key challenges and opportunities in health inequality in the developed and developing world?
[Professor Sir Michael Marmot] There are six domains which are the key causes of health inequalities and in which action could reduce health inequalities. These are:
1. Early child development
2. Education and lifelong learning
3. Employment and working conditions
4. Everyone having the minimum income necessary for a healthy life
5. Healthy and sustainable places to live and work
6. Taking a social-determinants approach (pricing of cigarettes, alcohol and so on)
There are barriers all the way through these factors. In early child development; poverty causes a massive adverse impact. In some countries, we’re simply not reducing child poverty as much as we should. We see that if you use the fiscal system of transfers and tax, you can have an enormous impact on child poverty. The decision not to use taxes and transfers to reduce child poverty has enormous negative impacts on society. We also know that a key determinant to the outcome of education is what happens before kids get into school. Countries like the UK and USA as recent OECD figures show, do very badly in terms of maths, science and so on at ages 15/16. Employment and working conditions are important too. We are seeing a hollowing-out of the workforce with people having well-paid jobs in the financial and digital sectors, and then low-paid menial jobs in the service sector. We have to answer the question as to whether we care enough to do things differently… A minimum income for healthy living is critical. Look at a country like Britain where a majority of people in receipt of housing benefits are in work. They are not paid enough to rent accommodation! They’re not paid the minimum to live a healthy life and they wouldn’t be able to do so unless they got housing benefits. We have to organise our affairs to enable people in low paid jobs to rent their accommodation. This does not have to be done by the tax payer through the benefits system.
In the developing world, all six of these areas are highly relevant. If you take some of these however, you must understand the context. If you take the need for healthy living and working conditions, in the developing world we’re still talking about having clean-water and shelter. In the developed world, that’s not the conversation anymore. We also know that in the developing world, one of the best interventions to improve child-health is the education of mothers. We talk of education in rich countries… but in poor countries the importance is no less vital.
We have to decide that organising our social and economic affairs to promote the well-being of the whole population is a priority.
Q: Is access to healthcare a basic human right?
[Professor Sir Michael Marmot] Access to healthcare is absolutely vital for any society. Not only is access to healthcare a basic human right, but health itself is a human right. The highest attainable standard of health is a human right; and that will only be determined to some extent by access to healthcare.
It’s not a lack of healthcare that determines inequalities in health, that’s down to social and economic conditions. It’s a lack of healthcare that determines what happens when you get sick. We don’t want to add the insult of a lack of healthcare to the injury of getting sick in the first place.
Q: To what extent business and commerce impact health inequality?
[Professor Sir Michael Marmot] The New York Times recently did a series where they compared the cost of a hip replacement in Boston and Brussels. It was several times higher in the US than Belgium! These are both developed countries with high-quality medical care, and- in fact- surgeons were using the same bit of hardware! To the extent to which people must bear the costs of their own healthcare, factors like this will be barriers.
More generally, corporations are vitally important- and for at least three reasons. Firstly.. they produce things! Let’s say for example you’re a food company, you can produce healthy or unhealthy food. We all have to eat, and the majority of the world’s population now live in cities. We are therefore absolutely dependent on the quality of the foods produced, marketed and sold by the food industry. Second… they’re employers. When a factory collapses in Bangladesh, you have a very dramatic manifestation of the fact that industry has a responsibility to the health of its workers; the nature of working conditions really matters. Thirdly… Industry is a stakeholder in society. They can have a positive impact in terms of employment and so forth, or they can be bad by polluting and so on.
Quite apart from the healthcare sector producing drugs and diagnostic equipment, wider industry plays a critically important role in health.
Q: What are the biggest challenges facing health inequality in the future?
[Professor Sir Michael Marmot] Good health, bad health and health inequalities are manifestations of the way we organise societies.
If you look at the global financial crisis and how countries have or have not responded to it, we can see an amplification of what was going on pre-crisis. The hollowing-out of employment for example; we don’t manufacture in rich countries anywhere near to the extent we did, we have exported those jobs… and have exported them with adverse working conditions. Those of us lucky enough to live in rich countries get cheap clothes and cheap consumer goods precisely because the people producing them are being paid very little and work in adverse conditions which will damage their health.
A major challenge is to figure all this out! How do you make the good side of globalisation become a greater force for good than the bad side of globalisation is a force for not-good. These are major challenges we face in the future.
Q: What are your views on the concentration of wealth in society (and the redistribution of wealth)?
[Professor David Hulme] Lets remember, the mega-philanthropists such as Bill Gates only find themselves in the position to give so generously because of the extraordinary concentration of resources and wealth they have been able to amass.
There are two angles to look at situations like this. The first is to make a case to the self-interest of those who are doing extremely well, and to make them realise that it is in their interest to consider whether or not those concentrations of wealth are giving them (and particularly their children and grandchildren) the world that they want. When I speak to the very wealthy, they are often horrified at the idea of leaving or giving enormous sums of money to their kids. They see that as being incredibly damaging and disempowering, they often feel that it can cause a lack of focus and drive in their lives... You can also look at what societies the wealthy are creating for themselves. If we look at the USA, UK and Latin America, you are seeing the emergence of gated communities- and one has to ask the residents if this is the sort of community they really want to live in. Wouldn't they rather be in a more open and friendly community? It's a bit like the Truman Show... it's a very heavily managed world, and misses the best parts of life.
There is also a moral and norms based argument for wealth redistribution which looks at the fact that the economic system we've set up is allowing certain people to have excessive access to resources. Yes you should be rewarded for patents, breakthroughs and so forth... but not by concentrating so much wealth in the hands of so few.
Most of the growth in the past 20 years of the USA hasn't been concentrated in the top 5% or even the top 1%, but rather the fraction of a percent of individuals who are not only able to get these assets under their control, but also to get laws changed through lobbying to enable them to do so, and to reduce their taxes.
When you're looking at the finances of what reduces poverty, the real secret is domestic tax. If you look at the poorest African countries and see what we need to get them working; you see AID projects, philanthropic projects and more... but the real task is getting the taxation system working so that the country has resource to pay for education, infrastructure and health itself, but while also giving a political settlement whereby the elites take on some responsibility for taking their nation and society forward.
Q: How effective are our current development and poverty reduction paradigms?
[Professor David Hulme] There's a real need for innovation as our existing paradigms are not working well. They are very much focussed on AID; which has two fundamental problems. Firstly it is effectively the rich giving to the poor- creating a subordinate relationship... and secondly, it's very short term and unpredictable. The important tasks such as state-building are long-term jobs. They require relationships that are developed over many years.
We've known this for 20-30 years. The idea of 3-5 year programmes when it comes to getting governments working, tax systems working, people working.... simply cannot work. We must move to 15-20 year frames of thinking.
Q: How do forms of wealth re-distribution such as charity aid in the fight against inequality?
[Professor Richard Wilkinson] Society shouldn’t' depend charitable giving. It’s never enough to deal with the problems of poverty, unemployment, homelessness, poor healthcare and so forth. To combat these problems we have to have a system where we all contribute proportionately to our incomes. That’s ultimately what the tax system is for, and it’s quite wrong to depend on charity in this regard.
We shouldn’t be thinking about whether inequality is good or bad for things like that. We must provide together for these things. We mustn’t depend on the good-will of a few people to keep other people from being homeless.
Q: What is the role of business and economics in creating an equitable society?
[Professor Richard Wilkinson] You can reduce income differences either through redistribution (taxes and benefits) or by reducing income differences before tax; I think you need to do both.
On the taxes and benefits front, the most urgent thing is to deal with tax avoidance and tax-havens; both by businesses and individuals. If an individual or business creates financial arrangements for the sole purpose of avoiding tax, then those arrangements should not be allowed.
On the income differences before tax, we see the runaway top incomes and income ratios within companies have expanded enormously. If you take the biggest 350 American companies, the ratio of incomes of CEOs to production workers were 40:1 in the late 70’s and 80’s. By early this century it was 200-400:1. That is a lack of democratic constraint, and we have to build that in.
The next great project for the emancipation of civilisation is the democratisation of the economic sector. We must back all forms of greater economic democracy whether this is in the forms of mutual, employee-cooperatives, employee-share-ownership social enterprises and more. They cannot be token things, but they have to allow real power.
Companies do the essential work of providing goods and services, but also quite unnecessarily become systems of concentrating power and wealth quite undemocratically. Many of our world’s companies are bigger than countries in terms of their economic turnover, and the power they exert on the global stage.
It looks as though more democratic companies work at least as well, if not better than their less democratic counterparts. There are other benefits too. More employee engagement turns a company from being property to a community, and allows for more even redistribution of wealth- and not just income.
In the future I hope we even have more consumer and community representation in companies. There is no reason why companies should be systems to concentrate wealth and power so undemocratically.
Q: What would be your message to the next generation in their attempts to make our world more fair and equitable?
[Professor David Hulme] You have to be optimistic. If you look short-term at the world's problems, it's easy to despair.... You have to look at the longer-term data. Incomes are getting higher, even the poorest parts of the world are seeing less children dying, lives getting longer, and more.
You have to think of those technical skills and political ideas that will allow you to contribute to the world, and your own society.
Your values will tell you how to piece the challenges together, and optimism will give you the energy to continue.
[Baroness Onora O'Neill] The most important thing to think about is how to link your ideals to your judgement of what’s feasible. It’s not enough to have noble ideals if you don’t work out who will have to do what for whom.
If we’re to have an effective and realistic translation of equality and human rights into life, we have to answer this question at each stage. You can’t just wave the banner of ‘Equality of X’ unless you’ve worked out who’s going to have to do what….
It’s about the actions you take, not simply the attitudes you have….
[Professor Richard Wilkinson] Increasingly people feel that we are here to serve the economy, rather than the economy being here to serve us. We have to think very hard about the society we want to move towards; and how we can guarantee a higher quality of life and greater sustainability.
People often regard consumerism as a sign of the basic acquisitive desire of humans, but it’s not. It’s a very alienated social desire. What we’re trying to do with consumption is speak well of ourselves to other people. It’s about identity, self-image and so on; and how you paint self worth in other people’s eyes. We express it in terms of money and consumption because we’ve lost those face-to-face community relations. Even in the last century, there were very settled communities, but recently we’ve seen these relationships break down. We’re now meeting more and more people each day, and are faced with this background zeitgeist that some people are worth so much, and others so little. This creates a recipe to exacerbate social anxieties about self-worth, confidence, self-esteem and so-on. At the other end you also get the problems of narcissism; the social-evaluative threat, the rise of greater self-enhancement and self-engrandisment…
I do often feel that the reason that kids drink before the go out, take ecstasy, and so on is to enable them to relax with friends. The anxiety of whether you’re dressed right, or whether you’ll be able to say anything interesting to the people you’ll meet is real; it makes social contact an ordeal and not a pleasure
We’ve got to the end of what increased material consumption can do for the quality of our lives and we have to now think about our social environment.
It’s inevitable that if you have 200 years of economic growth, that at some point it will have done its job…. In the developing world, they still need that economic growth but for the rich world, increasing growth is not bringing us any greater quality of life- some may even argue it is following the law of diminishing returns.
Since society became sentient to the cultural phenomenon of political ideals, there has been an intuitive sense that equality is worth fighting for. We are acutely aware that logically equality does not exist apart from the abstract realm of mathematics; but something tells us that intrinsically equality is a good thing. Whether this is part of our natural human condition, or something ingrained in us by culture is a matter for debate- but many of the most profound unifications of people for a single purpose have been manifest in the name of equality.
World War II was the most widespread war in history, involving the vast majority of countries in the world. In 1943,at the height of this epic battle, Sister M. Jane Frances Ferguson submitted a profound dissertation on, The Philosophy of Equality, seen through the lens of a conflict that had the real potential to end the world. "In the midst of a war whose fundamental issue is proclaimed to be the survival of democratic society, an examination of one of the basic concepts of that society is not only timely, it is imperative..." she wrote, continuing that, "...a war that engulfs humanity has justification only if it touches humanity at its very core. Equality, being one of those essential human relations of which democracy is conceived, an attack upon the latter is not merely an attack on a method of government, it is an attack on something fundamentally human."
Sister Ferguson also noted the profound significance of equality as a socio-political concept. "The conception of men as individually equal has repercussions in the whole of social life..." she wrote, "So profound is the influence of this notion that we do not hesitate to say that it has shaken to its very foundations the whole structure of the state. Indeed, any permanent and durable structure is impossible in the presence of a principle which, emphasizing the absolute character of the individual to the neglect of this social structure, destroys the basis of fraternity and extinguishes any true liberty.... society, whatever else its character, has an intrinsic urge to achieve an ordered and unified whole. It is possessed of something more than a herd instinct, something nobler than mere arithmetic union, something more rational than blank uniformity. It demands organisation, and whatever involves organisation, involves in turn a structural or hierarchical order, a subordination of the less to the greater, of means to an end: and wherever there is subordination there is bound to be inequality."
Her observation of subordination is significant. Much like the moral and philosophical precepts of good and evil, one must measure relative to the other; insofar as intuitively we know what is good, by knowing what is equal and vice versa.
To put this in context of equality, we are not stating that all things should literally be equal- as that would be a fallacy, as by any measure- we are all- by our diversity- unequal. Equality in a human context is more of a moral concern; it is a statement of what differences we do or do not decide are morally permissible in society.
By any measure it would be hard to argue that equality has not become a platitude in our world, perhaps because it is easier for us to deal with it in that context. The fact remains however, that while differences will always exist... it cannot be morally permissible for a society to exist where each individual who is born does not have equality of consideration and opportunity. If people are at least given that benchmark, they can then as holders of individual agency, decide how they flourish from there.
As John F. Kennedy once said, "...if we cannot end our differences, at least we can help make the world safe for diversity."
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