Equality And Our Health

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By Mark Lundegren

One hundred and fifty years ago, a little known philosopher and political activist named Karl Marx wrote, “A house may be large or small; as long as the neighboring houses are likewise small, it satisfies all social requirement for a residence. But let there arise next to the little house a palace, and the little house shrinks to a hut.”

Marx would go on to live and write in relative obscurity for another twenty-five years.  Only after his death in 1883 did his writings find a broader audience and inspire revolutions.  Karl Marx is of course now quite famous, or infamous, and few people who lived in the twentieth century could claim not to have been touched by his ideas in some way. 

Though Marx’s work now may be legendary, only a small number of people still read him closely any longer and many would find the suggestion offensive.  The quote I selected is but a sampling of a large body of work, one that proposes the potential for and recommends work toward the creation of a classless society dedicated to human justice.  In our time, Marx is at least a polarizing figure and often is counted as a madly idealistic and capricious one.  Many thoughtful people often disagree with his conclusions vehemently, believing Marx erred in his representations of the human social dynamics, the process of class formation, the limits of governmental action in society, and the role of individual freedom in promoting both social progress and individual happiness.

Most people today feel strongly that Marx’s work led to or at least rationalized oppressive dictatorships and widespread human suffering in the twentieth century, in the form of misguided and, ironically, unjust communist systems that paid homage to his legacy.  Many still despise Marx, in part because his ideas remain a threat to our social order and various benefits we may enjoy within it – benefits that are disproportionately allocated and increasingly so in our time.  In any case, few people today are indifferent to Karl Marx, and for this reason, most discussions of class and equality are quick to lead to references to Marxism and controversy.

It will be for a later period in history to assess Marx and his contemporaries more objectively, including liberal philosophers and activists who promoted free market systems and limited government immediately before, during, and after Marx’s time.  What is clear already, however, is that Marx was neither wholly wrong nor his adversaries wholly right in their intuitions about an ideal social order after industrialization.  In our time, in fact, an increasing body of research suggests that Marx was right to believe conditions of relative equality are essential, if not to human justice, then at least to human health and happiness. 

What it less clear, as always seems the case with Marx and other proponents of broad social change, is the optimal way to put such ideas and research findings into reliable practice.

The Case for Equality

The main question I want to consider is whether optimal levels of human health and well-being can be pursued amidst conditions of significant economic and social inequality.  While many people today are apt to believe the answer to this question is “yes,” a growing body of research increasingly challenges this idea.  Contrary to popular views in some parts of the world, this research suggests that significant social inequality, by its own nature, works to reduce human health and well-being, and is not as benign as is sometimes thought. 

This negative aspect of inequality has shown to affect the disadvantaged in society, as Marx suggested and may seem reasonable to assume.  But newer research suggests that inequality may even reduce the health of entire societies, affecting all the individuals within a society, even those who are the apparent beneficiaries of social systems that disproportionately allocate material and other benefits.

This second and newer finding about inequality proves surprising to many, but is based on detailed and generally quite reliable research into the linkage between relative social inequality and public health levels.  The result is growing consensus among researchers that inequality causes health reductions to everyone in an unequal society, not just people of lower socioeconomic status.  While it is true that the disadvantaged are likely to be less healthy than the advantaged in any society, inequality also appears to undermine the health of the haves as well as the have-nots, and everyone in between.  This new finding may seem counterintuitive at first, but becomes plausible as we begin to consider the life experiences and social incentives of all classes of people living in comparatively equal and unequal social systems. 

As we will discuss, recent research on inequality suggests at least three mechanisms cause disparities in wealth and social status to diminish the health of societies and people of all classes within them: 1) social inequality in a society can increase individual feelings of estrangement and alienation from the society, for all of its members, 2) inequality can alter our natural social environment from one that is principally cooperative to one where a sense of scarcity and a competitive ethos dominates, and 3) inequality and the competitive stress it creates can promote unhealthy and risky individual coping behaviors, again across the society and not just with the disadvantaged.  Behaviors such as drug use and escapist pastimes may reduce short-term stress in an unequal society but generally lead to long-term health and well-being reductions.  These mechanisms can be viewed as circular and compounding – the effects of inequality likely to further heighten inequality and its effects, unless there is an intervention to break this devolving cycle of reduced public health and social cohesion, or until the society collapses.

To begin a summary of the growing body of research on social inequality and its health effects, a good place to start is with the U.S. National Academies of Science, my own country’s principal body for scientific research in the public interest and a regular consultant to our federal government on policy matters.  In 2003, the Academies’ Institute of Medicine published an extended analysis of public health, entitled “The Future of the Public’s Health in the 21st Century.”  This ambitious report assessed the current and projected state of public health in the United States, both in historical terms and comparatively with other industrialized countries. 

In the report, the Institute of Medicine found that, “Despite leading the world in health expenditures, the United States lags behind many of its peers” in terms of the health of its population.  High U.S investments in health care delivery, the Institute of Medicine concluded, had not produced a comparatively healthier society than other developed countries, many of whom consistently perform better on a variety of public health measures.  In the report, the Institute of Medicine questioned the wisdom of continued investments to expand health care delivery, characterizing this as an expensive and unreliable way of addressing unhealthy social conditions in any country.  The Institute went on to cast doubt on the potential for the United States to close its health gap relative to other industrial countries without a change in its overall public health strategy.

In its report, the Institute of Medicine contrasted the different social environments and public health challenges in the industrialized world, and highlighted in particular prior research on social inequity and its negative impact on public health.  The Institute concluded that “more egalitarian societies (i.e. those with a less steep differential between the richest and the poorest) have better average health.”  The Institute ended its report by proposing changes in the direction of U.S. health policy, with a new strategy centered on promoting community health (public behavior and social environment – believed to be responsible for 70% of preventable mortality). 

Though the Institute of Medicine’s findings were and may remain surprising to some, in truth they were reliably conservative and well vetted prior to publication.  The Institute’s report, in fact, reflected a now long developed and well scrutinized body of scientific evidence linking economic and social equality with lowered individual health and well-being.  As indicated before, as we examine this evidence, two clear conclusions emerge that are critical to underscore.  The first and more intuitive conclusion is that our health is more likely to be better if we are richer or have higher social status within the context of an unequal society; in other words, if we are the seeming beneficiaries of inequality.  More recent research, however, goes beyond this idea and suggests a second or less obvious conclusion: that we are likely to be even healthier if we live in prosperous but relatively egalitarian societies.

A 1999 analysis by the U.S. National Bureau of Economic Research, is one of many important examples of the first conclusion.  This study found that upper income Americans had a 25 percent longer life expectancy than their fellow citizens living in the lowest income bracket in the United States.  Another study at about the same time, this one by the World Health Organization, went on to suggest that such a negative health consequences of inequality were due less to specific income levels and behavioral differences than to social inequality more generally.  The study concluded that disadvantaged status itself – a general sense of unfairness, and the attitudes and stress such feelings engender – is enough to make the disadvantaged less well in an unequal society.

Other public health research along this line is an analysis presented in the 2004 New England Journal of Medicine.  This study concluded first that class and income differences in health levels were clear, even if still greatly unappreciated by both the public and policy-makers.  It then went on to challenge the idea that these differences were rooted in healthier behaviors among wealthier people.  The study offered data that undermined this idea and showed that “unhealthy behavior and lifestyles alone do not explain the poor health of those in lower classes.”  The researchers concluded that “even when behavior is held as constant as possible, people of lower socioeconomic status are more likely to die prematurely.”  Lower status can lead to poorer health on its own, even when there are few differences in individual behavior.

More recent analysis by researchers at Harvard University built on these and similar studies, and went on to suggest the second, less intuitive finding: that even the well-off in highly unequal social systems were less healthy than they could be.  This more recent research pointed to findings that top income earners in the United States, while healthier than the U.S. poor, were significantly disadvantaged in longevity and other health measures when compared with their counterparts in other developed but more egalitarian countries, even countries that were less wealthy overall.  This significant new finding has barely begun to be digested by policy-makers, but has far-reaching implications and will prove extraordinarily controversial when it is finally considered.

Other research supports this idea that inequality leads to negative health impacts, society-wide and across all social classes.  Researchers at the University of Nottingham in the United Kingdom, for example, found that stress levels and thus our propensity for disease were significantly higher in more unequal societies.  This pattern, they found, was true not only for the poorest members of unequal societies, but for the wealthiest members as well. Similar findings have emerged from other research.  A common conclusion is  that countries such as Denmark and Japan, both far more egalitarian societies than the United States, enjoy higher levels of health and greater longevity, across their populations, for comparable socioeconomic groups.

It was amidst these and other studies linking inequality to lower public health for all that the members of a society that U.S National Academies weighed in on new strategies to increase public health in the United States.  It is worth noting that the Institute of Medicine’s specific proposals for increased twenty-first century health did not call for aggressive income redistribution efforts to improve U.S. health and well-being.  No doubt, this was to the disappointment of some but likely to the surprise of few. 

Though the Academies’ approach almost certainly generated far fewer and less vitriolic headlines and calls for funding cuts than if it had done this, its Institute of Medicine’s findings were still a seminal event for researchers and policy advocates in the health and social justice arenas.  After all, the principal governmental research body of one of the world’s most unequal industrial countries had acknowledged not only that the country had a public health gap, but that its social environment and comparatively high levels of inequality was a prime suspect. 

Even with its more modest proposals, the Institute of Medicine and other policy makers advocating a new look at inequality and its impact on our health still generally meet with disbelief and strong opposition in the United States.  Surveying this debate over the last few years, it seems clear that our general denial and opposition to inequality discussions, in the face of increasingly hard data, has been almost exclusively on ideological grounds.  For this, we can blame Marx and the radicals that appropriated his name only so far.  The more important culprit is likely inequality itself, and its potential for compounding effects.  Once established, inequality can become a self-reinforcing and intractable problem to overcome, even with good examples around us of how cycles of inequality can be broken and the documented benefits that have come from past efforts to reduce social inequality in the industrial world.

Though considering equality’s role in public health may prove controversial in many countries, opponents have as of yet offered little in the way of hard data to counter growing evidence that social equality fosters our health, while inequality undermines it.  Reviewing the electronic record of opposing views in my country, perhaps like others, references to Marx appear often, negatively framing the topic and casting suspicion on inequality research in general.  The approach has been effective, inhibiting rigorous public discussion of inequality before it can begin.  We’ll come back to this intransigence in a moment and review some important and revealing reasons why inequality is such a difficult topic, particularly for people living within comparatively unequal systems.

While we await opportunities for more rigorous policy debates, research into the effects of inequality is both broadening and accelerating.  A number of major universities are involved and inequality research has become a fairly dynamic area in the social sciences today.  This effort is now often in the form of new interdisciplinary collaborations aimed at achieving greater understanding of the specific mechanisms that cause social inequality to lead to health reductions.  In an example of this research, one university team compared identical twins raised together and found that the relative health of each twin was closely related to their adult socioeconomic status.  Another university research group, looking inequality beyond the human sphere, found that in other primate species, less egalitarian social structures correlated with higher levels of stress hormones among socially subordinate individuals. 

As this research continues, and as past policies and interventions to reduce inequality and its negative health effects are examined and validated, a clearer general framework will emerge for assessing the optimal amount of inequality in a society.   Such assessments will of course involve value judgments, as well as an understanding of health tradeoffs, and will require extensive new political dialogue.  This dialogue, when it comes, will no doubt be against the backdrop of continued controversy, ideological attacks, and popular fears. 

Still, it is the case already that our best available science, while not validating Marx generally and especially his calls for dictatorship, does suggest that his intuitions about our personal experience of social class and material inequality were essentially correct.  In comparison, liberal thinkers of Marx’s time and our own – who propose open markets and unchecked freedom as public policies most likely to lead to the greatest good – increasingly seem naïve and optimistic, if not dangerous.  This classical liberal mindset misses much about the life experiences, aspirations, and constraints of people in both comparatively unequal and equal systems.  And, simply based on the growing body of scientific evidence, our functioning liberal systems do not lead to societies that are healthier and happier than the concrete alternatives with us already today.

Undermining liberal ideas of the individual independence and human achievement of happiness, modern inequality research suggests that, once we rise above conditions of poverty, relative income and social status are far more important to our well-being than our absolute or objective position in the world.  Scientists have found that we generally measure ourselves against those around us and the social expectations that are set for us, rather than to a fixed material or personal standard.  Our individual pursuit of happiness is thus never in a vacuum and always has important cascading impacts in the world around us.  Relative social status, in fact, can be shown to have meaningful impacts on our health and even our potential for survival in society.  Under conditions of significant social inequity, people can and regularly do drop below socioeconomic thresholds, tipping points, where our physical and emotional deprivation becomes so great that we can no longer maintain our health or function in society.

As suggested already, the impact of inequality and our individual responses to uneven social conditions go far beyond impacts to the disadvantaged.  High levels of inequality can be shown to impact a community broadly, in the interconnected and compounding ways I introduced before.  For the disadvantaged person, inequality fosters higher levels of alienation and feelings of despair.  Seemingly advantaged people, however, also feel disconnected from and threatened by those with less, and generally will work to isolate themselves from other social classes as a response to this stress.  Through these mechanisms, inequality leads both advantaged and disadvantaged individuals to feel less concern for society overall, reducing social cohesion and narrowing our social experience.  In this way, inequality is naturally predisposed to further exacerbate conditions of inequity, in particular through the feelings of disenfranchisement it engenders across a society.

A related dynamic, also for all members of an unequal society, is a general rise in the level of competitiveness in the society, as individuals and groups race to avoid becoming disadvantaged in the gradually widening gaps between people.  This conversion of society from an original community of relative equals into a race for comparative advantage, in turn, is apt to lead to the many well-documented negative consequences of human hyper-competition.  Such consequences include addiction to winning and a general disregard of others by winners, and a growing sense of scarcity (a sense created or dramatically increased by the social system itself).  Heightened competition also leads to the systematic withdrawal and increasing frustration of losers, whose numbers can inevitably be expected to increase in time as conditions of inequality benefit past winners in future social transactions. 

As social competition iterates, a continuing cycle naturally emerges of building inequity, increasing social indifference, and growing general physical incapacity to compete, as starting conditions and available resources among people increasingly widening in time.  The result is a society of reducing cohesion and higher general stress levels – one where crime, disaffectedness, civic withdrawal, and unhealthy behaviors all are increased.  These trends, in turn, drive a further distance, competition, antipathy, and inequity among people, in the compounding process we have discussed.  This iterative process of increasing inequality effects the poor most, but impacts all individuals in the society, as their sense of society is lost and as groups and eventually people are increasingly estranged from one another.

Looked at another way, widening individual incomes and life experiences increase distances between people in society, making consensus and social harmony ever more difficult.  The result is greater stress for all involved, making members of the society even more individualistic and anti-social.  Unchecked, the result can be a destructive cycle of increasing alienation, a breaking down of consensus-based social order, increasing reliance on rules and law enforcement, and then still more alienation and social stratification. 

Increased competitiveness and competitive stress also have been shown to lead to more a myopic outlook among all the participants of a society, reducing intelligence and encouraging acceptance and rationalization of the status quo.  In the face of inequality and hyper-competition, at a personal level we may each genuinely think and believe that only others are disadvantaged, even as the social environment gradually and objectively degrades, even as the entire society suffers a general breakdown in harmony, health, and well-being.

Equality And Freedom

In discussions with others, a common objection to arguments for promoting social equality is actually not ideological at all.  Instead, it involves personal concerns about the potential for losses in freedom and social mobility, through public policies aimed at reducing community and individual inequities.  This is a legitimate concern, one often expressed in terms of quality of life, both because we all value our freedom and because of the strong case that human freedom is essential to human progress and adaptation generally.  Our very strong innate feelings and fears about losing our freedom, in addition to those about giving up wealth and privileges we may enjoy in existing conditions of inequality, make discussions about equality and our health quite difficult at first. 

Such concerns are particularly true in our time and, depending on where one lives, often quickly lead people into ideological stances and intransigence, given the recent and predominately negative Marxian legacy of totalitarian political structures and inequitable redistribution schemes.  In my own country today, anti-communist feelings and strong associations with the idea of reduced freedom and political oppression, enter into almost every conversation of social equality.  One might have previously hypothesized that the vast material abundance of the early twenty-first century would make social equity discussions easier, but our recent world history and the basic dynamics in our human nature, particularly when we live amidst inequality, competition, and feelings of scarcity, work against this quite strongly. 

Since giving up something we have and value is often harder than living without something we don’t yet possess, equity discussions remain and may always be uphill journeys whenever some have more than others and are asked to reduce such differences.  Compounding this, when a competitive, fearful, and status conscious (extrinsic) mindset has been strongly established in a population through significant inequality, equity discussions are made even harder.  Each of these phenomena are key elements in the dynamic that causes inequality to work on itself to promote or reinforce still greater and more intractable conditions of inequality.

It is no secret that the United States remains home to some of the world’s most strident objections to public policies aimed at promoting equality, especially equality of outcome (as opposed to equality of opportunity, a distinction which incorrectly presupposes the two are not substantially correlated).  As I have suggested, across much of my country, thoughtful discussions inequality cannot yet take place.  Here, there is a palpable and historically grounded fear of social policies that promote an agenda of social and economic equality.  People often view such policies as a corrupting and unnatural force, one that is inherently prone to reduce freedom and opportunity.  Perhaps, as equality research accumulates and successful social policies are proven over time, this fear will dissipate, but for now it is a very difficult situation for people seeking to address the health impacts of inequality. 

The United States is of course not alone in this.  As is the case in many societies, past and present,  there has been and remains today a deep cultural conservativism that makes discourages discourse about progressive social change.  Strangely, this outlook is strongest among societies with the highest levels of inequality of wealth and power – and thus those societies with the greatest risks for people of all classes to fall behind others.  On the other hand, we can also see that it is the more egalitarian industrialized countries of our time that are the most progressively minded societies of the world.  This is an important development of our time, one that is generally recognized but the reasons for this difference are not yet widely understood. 

In truth, once we examine these more egalitarian, socialistic industrial countries, we almost immediately can see the greatly diminished risks of social backsliding for people of all classes, with much smaller individual fears of loss of one’s social position.  I will suggest it is for this reason, above all others, that people there live generally far freer, more gregarious, and much healthier lives than their counterparts in more unequal, and thus generally more pressurized and stressful, industrial societies.

In the socially progressive countries of continental Europe, for example, people work much less and have significantly more free time for personal pursuits and holidays than their counterparts in the more individualistic, competitive, and unequal countries.  People there have closer ties to family and friends, even if these ties are increasingly eclectic.  These people also generally have far less concern about obtaining the basic necessities of life and functioning in society, or achieving and maintaining an “acceptable” social status. 

In these more egalitarian countries, we should expect and do in fact find a far freer social environment and more relaxed individual attitudes.  This very different experience of daily life in egalitarian societies is quite important, and is foundational to understanding how social structure drives the higher health and quality of life measures that we see.  This link between social experience and public health is often greatly unappreciated, with important implications for health and social policy.  To be candid, the easier life and more relaxed social attitudes of continental Europe are an enigma to and often actively discounted by people living in the more precarious and conservative conditions of high inequality and social competition.

By comparison, my own countrymen in the United States are often far more fearful, conformist, materialistic, and cynical than their northern European counterparts.  They assume and will hold vehemently that there is more freedom and opportunity in the United States than in Europe, and are led to think in this way by our mass media, politicians, and the widespread selective consumption of social statistics.  People of all classes generally share in this pervasive view, this common sense, despite compelling observable conditions and reliable data suggesting the reverse is actually true and that many societies in the world today offer greater freedom.  A recent Brookings Institute study, as an example, found that intergenerational class mobility was noticeably higher in relatively egalitarian countries like Norway, Finland, and Denmark than the United States, the presumed epitome of social mobility and meritocracy.  Other comparative research suggests that continental Europeans are happier too, in addition to enjoying the significantly better health and longer lives as we have discussed already. 

In my country and other more competitive-unequal industrial societies like Great Britain, the available data and observable facts about life within more egalitarian countries have not yet permeated the public domain.  These domains, in fact, are far more closed and prejudiced than many of the people inside these unequal societies may realize.  Within these competitive spheres, a Panglosian attitude often dominates, a general public sentiment that their system is the best of all possible outcomes.  This view is held despite the pressing issues, untapped opportunities for progress, and quality of life gaps that come into clear relief  as one compares actual social conditions across different societies.  Because this view, rationalizing the unequal social system, is so pervasive and strong across a diversity of countries with high levels of inequality, it is safe to assume selection forces are actively shaping these views within the population.

A regular protest in my country against such comparisons of modern industrial societies, and to the model of more egalitarian socialist countries, is that, while these societies may preserve basic freedoms and provide a high quality of life to their populations, they still greatly stifle creativity, initiative, and innovation.  The socialist countries, the thinking goes within markedly unequal societies, are simply less interesting and energetic places in which to live.  This is believed to be true, in large part, because people in more egalitarian societies do not have economic incentives to engage in innovative behaviors and, as a result, it is assumed that stagnation and a more stultifying social environment sets in. 

Of course, when we look for this idea in fact, we see that there are actually few signs of this social petrifaction in the countries I speak of.  Our socialist industrial societies, in truth, often possess some of the most innovative and creative people and organizations in the world.  Many of the most valued items and tends of modern life have been created and produced under conditions of relative equality, particularly when we include Japan in our calculations.  Moreover, it is clear on inspection that these countries generally offer a richness of social life that is often lacking or now rapidly disappearing in less egalitarian and more individualistic industrial countries like the United States and Great Britain.

Fundamental to understanding this gap between the theory and reality of actual life in socialist countries, I believe, is a reconsideration of the classical liberal hypothesis that economic and other extrinsic incentives are essential to motivate humans, including human creativity and innovation, and human altruism.  While external rewards may explain motivation and behavior in conditions of pervasive poverty (and in poverties of pervasive conditioning),  once societies and individuals reach above such base conditions, we can observe that acts of creativity, innovation, and benevolence become increasingly valued in themselves.  They are values intrinsically, as esteemed ends and complete sources of meaning and satisfaction on their own. 

In other words, as people develop out of actual or perceived conditions of scarcity, our presumed original state in liberal theory but perhaps our resulting one instead, we can observe that individual action is increasingly pursued for its own sake and often to instantiate deeply held personal values.  Here, the liberal paradigm, and its libertarian and generally materialist social agenda, breaks down.  An alternative are newer ideas about human action and motivation.  Increasingly, research suggests it is more commonly for its own sake, and that there is natural human valuation of community and social harmony.  Both ideas are predicted by evolutionary theory and better describe observable conditions in the world today, especially outside of hyper-competitive societies and those in conditions of extreme poverty and war.  They increasingly call into question pre-industrial and pre-Darwinian conceptions of individualism, the primacy of extrinsic rewards, and achievement of social harmony through competitive social structures, with their inevitable and ever increasing result: social inequality. 

Perhaps the most difficult problem we face today in moving past old ideas and improving social health is simply beginning – convincing people of  the need and opportunity for progress through reductions in social inequality.  In truth, even small changes to remove inequality and positions of social advantage are difficult to discuss and implement in unequal societies, once created and allowed to become deeply imbedded in the lives and thinking of a people.  As discussed before, the removal of an advantaged social position can be a painful process at a personal level, engendering feelings of loss that an individual may never fully resolve.  This problem is exacerbated by conservative mores, more common in competitive-unequal societies, and conditioning that links happiness to economic and other extrinsic rewards.

On the other hand, once the movement to a more equal society is begun, there is the real prospect of accelerating and compounding progress in the direction of health and cooperative life as well.  Individual memories of past social positions are likely to fade in time and actions to de-emphasize extrinsic rewards and sources of motivation can enable new and more intrinsic motivations,  equally reinforcing within the society as the benefits of equality and new opportunities for action become clearer.  With progressive change, there is the prospect of a yet another threshold point, this one involving the systematic tipping of societies from a competitive-unequal structure to more cooperative and socialistic ways of life, ways of life that ultimately prove more satisfying and healthy in the lives of people. 

The European societies I have mentioned already, and Japan, serve as living and self-sustaining examples of this prospect in action.  These countries operate with often very different priorities and attitudes than their less equal counterparts, create quite different life experiences and inceptives for their people, and appear just as involved in compounding social cycles, but in this case toward greater health and happiness, and with the prospect of greater social cohesion and sustainability over time.  That each of these societies have made this transition to more egalitarian life is a lesson for people living in unequal society, even if many began this change only after the ultimate failure of unequal and competitive society – war and social collapse.

In thinking about the mechanics of such change, it is worth noting that within these more equal societies, there are far fewer opportunities for display of affluence and social advantage, either in the nature of economic equality itself and because such displays are actively discouraged by social conventions and mores (yet again suggestion selection forces, but this time of a different sort).  For both reasons, the inequality that does exist is far less evident and incentives to pursue or display social advantages are greatly reduced. 

In a reverse of our earlier discussion, when looking at the functioning of these more socialistic countries, equality can be seen to work on and reinforce itself much in the way that inequality does, but in this case encouraging community and social cohesion.  The hypothesized and actual results are societies that are much less competitive and extrinsically oriented over time, and with general affluence, societies that are increasingly progressive, creative, open, and healthy.  These societies offer and promote an environment that is less stressful and, though while still counter-intuitive for many today, often more intelligent, creative, and productive in those human domains most likely to produce social goods, as opposed to objects of envy and display.

When I speak with colleagues and friends from Northern Europe and Japan, I of course get a richness of views that goes beyond social theory and the superior health and wellness statistics of these countries.  But their views make obvious that they are as comparatively healthy and well as global health statistics suggest.  In truth, people from these societies do complain about social policies and instances of excessive regulation.  They still worry about unequal treatment and perhaps are too accepting of their social order and the status quo.  Many even become wide-eyed when talk turns to the American West and the great expanses of land there.  But dramatic natural landscapes and healthy human communities are two different things, though certainly not mutually exclusive ones. 

Equality And Social Policy

If we are willing to consider the idea that creating more equal societies is likely to lead to more supportive and engaging social environments and healthier people, and even potentially to people who are freer and more creative, it is worth considering the tools of social policy available to promote social equality.  These policy tools generally have been proven in practice in various industrial societies already and can be reliably expected to promote the social changes we have discussed.  Overall, their effect is to change social values and priorities: limiting destructive hyper-competition and downplaying extrinsic and relativistic motivators in the social environment.  the goal of this is to move societies toward more cooperative and sustainable operating models based on motivation primarily through intrinsic rewards and fulfillment of natural human values.

Progressive income and/or consumption curbs – though unequal social status involves more than unequal income levels, the central role of income disparity and the personal incentives it creates in establishing and then driving social inequality cannot be overlooked.  Income inequality, in the daily experiences of people, fosters a generally competitive and extrinsically-oriented social environment.  It divides communities of people into differing economic classes, reducing social cohesion and promoting feelings of alienation among all members of a society and leading to unhealthy coping behaviors.  The combined effect, as we have discussed, is a circular phenomenon, with threshold levels of inequality working to fuel ever greater inequality, reducing our health and creating a path to eventual social collapse. 

Because of the danger and likelihood of this dynamic emerging in any society, both formal and informal barriers to high disparities in income and wealth, as well inhibition of conspicuous consumption and displays of status, are central in limiting social inequality and its negative consequences.  Such barriers are ideally implemented in advance of significant income inequality, but can be used to break existent cycles of accelerating social devolution in societies that are already significantly unequal.  The general formula for such barriers has been proven in the various socialistic counties we have discussed, though no doubt can be improved upon based on the experiences of these countries.  Key formal constraints include progressive income, consumption, and inheritance taxation.  Informal constraints should be used in tandem, but probably will not succeed in tipping to the society toward a more egalitarian and healthier equilibrium without formal limits on income and consumption levels (disincentives on the pursuit of high income and consumption). Informal actions include encouragement and advocacy of communitarian mores and values, and mass media and educational reforms as outlined below.

Mass media reforms –perhaps the most important informal catalyst of competitive-unequal cycles in societies today is the mass media.  Modern mass media both reflect and shape individualistic and communitarian standards in industrial society, and their ability to promote and reinforce stereotypes and values deserves special treatment.  In my own country, like most industrial democracies, discussion of potential limitations on public speech and media content can be controversial, but the reality is that all modern societies regulate media content, even if in different ways and to varying degrees.  Media content in modern industrial societies is also strongly driven by the demands and incentives of the host society, and therefore is implicitly limited and controlled by these demands.  In comparing media content in the world today, it appears clear that such content can be expected to remain fixed in character and general scope until the underlying social environment and incentives change, or are made to change.  Mass media is thus a tool of social policy and values, generally reinforcing the social order, but capable of changing and driving change.  This underscores the importance of actively shaping media content as part of any agenda of social progress.

On this point, many are apt to argue that the modern media merely reflect society and its natural preferences, and deserve to be left to operate with minimal constraints.  Much like calls to leave alone economic entities devoted to the consolidation of wealth, this position on media regulation is generally either naive or self-serving, and in any case is not supported by the facts.  In truth, all producers of public media begin from a worldview or agenda that less than perfectly encompasses the general society.  Such views or goals more often actively drive a particular set of values and goals, rather than the public good.  Public media content also has been demonstrated to be highly influential on social attitudes and behaviors, and not just correlated with it, driving society as much or more as reflecting it.  For these reasons and looking at media management across different societies, a two-track approach is again likely the best approach to promote progressive social change: 1) formal regulation of public media content that promotes unhealthy and anti-social behavior, and 2) informal efforts to raise public and media awareness regarding the nature of media content, including its social impacts and implicit biases, and to promote alternative and progressive forms of media content. 

New educational approaches – in addition to altering social environments and their underlying incentives to favor cooperative life, via the formal and informal means we have just discussed, important opportunities for progress exist in the reform of education systems, especially in highly competitive-unequal societies.  Like the mass media, educational content and the structure and mission of our educational institutions both reflect and can actively shape the larger social environment.  In highly unequal countries like my own, our educational systems generally constrain people and prepare us for roles in our specific and less than optimal form of society (the people adorning this social environment with a universality it does not deserve, expressly rationalizing their own place and patterns of conduct in the world). 

In truth, educational quality in my country varies widely, our schools generally reinforce class identity and the dominant social mores and ideologies that foster inequality, and educational curricula are often far more reactive and vocational than people realize and may be desirable.  Still, in spite of these significant shortcoming, exceptional people still do emerge from our educational systems, people who are able to break the bonds of class, ideology, and social stereotypes, and live freer and more engaged lives than the ones they are prepared for by our educators.  It is in these exceptions, I propose, that the direction for needed educational reforms lies today.

We should begin by asking what is it about these exceptions – people who find a way to live relatively independently of the dominant ideas and persistent traditions of their time, who can look at themselves and their social environment more objectively and freely – that makes them able to achieve this.  Curiously, studies of people who reach this status suggest no clear correlation with income, background, education level, occupation, or social environment.  Closer observation, however, does reveal a common process that occurs at a personal level and in very personalized ways.  Through whatever mix of predispositions and experiences, these exceptional people have found a way to make a transition from being primarily socially-oriented and externally-directed to a state that is principally internally directed and motivated by self-selected values and ideas.  This finding is not new and extensive work has been done in this area to validate and explore this general process. 

Such self-directed or self-actualizing people often report much more engaged experiences and higher life satisfaction than their more externally and traditionally directed counterparts.  In reaching toward and maintaining this more engaged state, self-actualizing people share three important attributes.  The first attribute is an ability to look beyond their immediate physical environment and social norms to achieve new perspectives and envision new potential in the world.  The second attribute is their advancement of personally engaging and emotionally-charged values and priorities, including selection of a life mission, however formally or informally this is done.  The third attribute is the general organization of their life to fulfill this mission, using a variety of strategies and whatever resources they can find.  Underlying this process is repetition of this progression in an iterative way, improving personal clarity, coherence, and efficacy over time. 

In a very real sense, these self-actualizing people succeed at breaking barriers of perception that often constrain people within their own times and lives.  Such people generally (perhaps strangely for some) live in ways that are both more individualized and more universal than most people of our time.  Importantly, they also often live less competitively and less concerned with status and extrinsic goals than more externally oriented people.  My use of the terms self-directed and self-actualizing may mistakenly be translated as selfish and therefore anti-social personalities, but research shows clearly that this is a mistaken notion.  Studies of self-directed people suggest they are often highly altruistic and cooperative, centered in our natural social emotions and frequently committed to principled life and self-transcendent goals, even as they pursue what may be highly individualized life missions. 

To understand this seeming contradiction, it is worth considering that self-chosen values and principles often can be fulfilled in a great many ways, unlike life lived according to the often more narrow confines of fixed external ideals and roles.  Self-directed or self-actualizing people are thus often more adaptable and less likely to experience chronic stress and frustration than people who are more externally motivated.  Because of this, they are less subject to the many unhealthy attitudes and behaviors, and the potential for neurosis, that chronic stress and frustration can engender.

A generation or more of research and analysis now exists on this topic, one which modern educational institutions in many societies struggle to digest and utilize, but perhaps most urgently in strongly unequal and competitive societies.  It is likely the case that these institutions, like their host societies, are still bound by the traditions they encourage and the systems they use to manage people in their care.  If there is a formula to foster breakthroughs to self-directedness and self-actualization, it is deceptively simple:  1) promote increased comfort and practice in reflection, including observation of one’s own perceptions and inner dialogue, 2) build awareness of our foundational values and commitments, with the awareness that these may change over the course of one’s life, 3) develop self and world awareness to a threshold point, where one realizes and begins to act from the idea that all fixed views are limiting and ultimately indefensible, and that continual learning and growth is implicit in all free life, 4) mobilize our commitment personal authenticity, to action in the world to fulfill one’s values and heightened personal awareness (this last step to include intensive focus on vocational skills development). 

As we look at our educational systems today, especially those in our most unequal and competitive societies, it is revealing how poorly aligned these systems are with this proposed process of guided personal development.  With this benchmark, we can see just how focused these systems are on driving conformity and girding the student for hardship in competitive space.  With this insight, we also can begin to assess how much could give way to enable new priorities and a sustained commitment to making exceptional, self-directed people less the exception.  Let me add that such change is made doubly hard when educators work from the conditions of stress and diminished health that pervade unequal society, and the strong external demands that arise when social backsliding is a real threat in our lives.  In truth,  nothing less than wholesale educational reform is needed, in every society in the world today, to better make use of our new, modern understanding of the self and to enable new personal growth amidst the advanced society around us.

Other steps toward communitarian society – though progressive income and consumption barriers are the brakes that begin a halt in the direction of community breakdown from competitive-unequal social systems, enabling and creating impetus for the other measures I have outlined, certain additional governmental policies have been shown or are likely to aid devolving unequal communities to make the turn to create more egalitarian and healthier futures.  These include: 1) ensuring social safety net programs, in conjunction with the educational reforms I have suggested,  to ensure people meet basic life needs during periods of transition and to enable life choices less driven by short-term economic demands, 2) workplace regulation to allow ensure occupational health, as well as adequate flexibility for people have sufficient time to attend to family and community issues, 3) election reform to reduce the need for and limit the potential of candidates to appeal to moneyed interests of all types, and 4) drug dependency programs, to mitigate this unfortunate and long-term part of human coping in competitive and alienating social settings, and to promote the transition to life in healthier and more humane social environments.

Equality And Our Individual Lives

In this extended survey of contemporary research findings regarding social equality and our health, we have considered the implications of this research and the extent to which these findings are at odds with often firmly held beliefs about social equality and the human social environment more broadly.  Our method has been to examine studies of the different socioeconomic and health outcome data of two basic types of industrial societies – socialist-egalitarian and individualist-liberal – and to consider how the incentives and life experiences of people living in these environments might explain the fairly significant health and longevity differences between these two forms of society.

These research findings and my own conclusions about the dynamics of these contrasting social systems are sure to both fall on deaf ears and engender controversy in many quarters of sharply unequal countries like my own.  They may well even engender vitriolic attacks by some, so deeply engrained is classical liberal thinking into the fabric and beliefs of many unequal countries today, and so great are popular fears in these societies regarding the prospect of a move to more socialistic or communitarian constructions for the future.  And yet the data and obvious and observable differences in the reality and quality of life in our socialist industrial countries today, when compared with more unequal and hyper-competitive industrial societies, simply is what it is.

Since we can expect old habits and beliefs to change only generationally, even with compelling data and persistent advocacy for measures to promote greater social health and well-being, individual action and responsibility for our own lives and health will remain an imperative for many years to come.  This is true in all countries since none are yet ideal, though faster progress is clearly the case, if we are to achieve more optimal health and more open life in our lives today. 

To these important ends, four opportunities for individual action come to mind when thinking about the challenge of creating and promoting healthier life in the times and social systems that we must live within in our time:

  • Values – we each can begin with our own values and life patterns, reflecting on the extent that they are externally driven or consciously and freely chosen.  We can examine the relative place that health and wellness have in the values we express with our priorities, attitudes, and actions.
  • Environment – we can seek out social settings of comparative equality and cooperativeness, especially life and work communities that are more supportive, open, creative, and health oriented.  This may be a hard challenge, or a relatively easy one, depending on where and how you live today.
  • Community – we all can and should build and rebuild our social networks, adding new friends and fostering the well-being of those already in our lives, since we cannot be optimally healthy in isolation or with a social network that actively diminishes our health and ability to fulfill our values.
  • Advocacy – we can promote health and wellness through the techniques I have written about elsewhere.  In today’s discussion of comparative health in the industrial world, we should not lose sight that all societies today have a health or a vitality gap.  In working to close this gap through individual and social change, we both promote the health of both ourselves and others, two inextricably linked phenomena.

To end somewhere near where we began, consider that in a society populated by people with generally poor health, few may realize that this state of affairs, though the norm, is neither natural nor optimal, in all but the meanest environmental circumstances.  But if one person, or a group of people, achieve new levels of health, this accepted state of affairs will shrink to sickness.  With compassion, persistence, and ingenuity on the part of the healthy, this sets the stage for dramatic social change.

Looking beyond the labels, ideologies, and fears of our own time, perhaps you too can see that great new social progress is possible, through a new commitment to human health and well-being.  Perhaps you can see this transformative potential, in our midst, even the possibility that we will create whole new societies dedicated to human vitality and development, societies that we can not even yet imagine. 

Our task, in this time, is to begin to imagine them.

Mark Lundegren is the founder of HumanaNatura.

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