Social Science & Medicine 51 (2000) 1007±1008
Social change, market forces and health Clyde Hertzman* Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada BC V6T 1ZE
Keywords: Neo-liberalism; Income inequalities; Welfare state; Canada
Coburn (2000) has done the ®eld a favour by challenging us to consider how the dominant trend in global capitalist thinking and policy, neo-liberalism, aects income inequality, social cohesion and, through them, health. I share his perspective that, all things being equal, the neo-liberal social project should increase income inequality, reduce social trust/cohesion, and reduce health status. I would add to his analysis one further line of reasoning. The United Nations Human Development Report, 1999 (United Nations Development Programme, 1999) includes a graph from the Luxembourg Income Study showing the trends of market income inequality and income inequality after taxes and transfers (that is, the welfare state safety net programs) for selected OECD countries during the 1980s and early 1990s. In every country, market income inequality increased, but in several, income inequality post-tax and transfer did not go up at all, or not as much as market income inequality. In other words, the re-distributive demands on the tax and transfer systems increased in all countries, thanks to market forces, but in some countries these demands were met by the traditional welfare state programs. Ironically, this means that the potential ``profits'' in undermining the welfare state rose in those countries, in particular for citizens at the upper end of the income distribution whose taxes would be expected to fall if the tax and transfer programs were weakened.
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This fact is central in Canadian politics. Canada is one of the countries whose tax and transfer programs fully compensated for market forces (at least, until the mid1990s) while in the USA they did not. Since we are always being compared to the USA, we are now faced with the rhetoric of ``taxpayer revolt'' from upper income groups who look longingly south across the border at the lower marginal tax rates for high income families in the USA, and use them as a pretext to attack our social programs. Despite all of this, I doubt that we are about to see an end to the rise in health status, on average, in Western Europe, North America, and the wealthy countries of the Western Rim of the Paci®c Ocean. Health status has risen throughout the twentieth century despite the penetration of market forces into every facet of life, war, dislocation, and the undermining of traditional sources of social support (i.e. stable communities and extended families). It is not enough simply to attribute this to increasing wealth, since most of the world's wealthiest countries have been on the ``¯at'' of the health±wealth curve for the past 4 or 5 decades, and yet their health status has continued to improve. The argument could be made that, beyond wealth, it has been the welfare state functions (including access to eective health care) that have made the dierence. If so, undermining them could well lead to a reversal of health trends. But the welfare state programs which are under attack are only one part of the social change which has occurred during the latter half of the twentieth century, and which could help account for the ongoing improvement in health status. This social change takes many forms, and is dicult to categorize according to the traditional determinants of
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C. Hertzman / Social Science & Medicine 51 (2000) 1007±1008
health. But it is a change worth detailing and considering whether the neo-liberal social project will threaten its elements the same way that it does the traditional programs and policies of the welfare state. These are: . an end to the social respectability of religious, gender, ethnic, and racial discrimination. For the ®rst time in modern history, it is permissible to be nonmale, non-white, non-Christian, and non-heterosexual without an automatic expectation that one will necessarily be a second-class citizen. . an end to the notion that a wide range of people, in particular the young, the old, and the dependent, should be ``seen and not heard''. . an end to the notion that workers, especially men, should be prepared to give up their hearing, their breathing, their arms, legs, and backs, and, ultimately their lives at work, in order to support their families. . a general loosening of social norms and behavioural expectations and an increase in the range of lifestyles which are considered socially acceptable. . widespread access to birth control and an end to social pressures toward compulsory parenthood. . markedly increased ¯exibility in how to arrange one's life course: ¯exible entry and exit to education, late childbirth, lifelong learning, taking up scuba diving at age 70, etc. . widespread access to technologies which have egalitarian characteristics. In particular, the technologies of communication: radio, telephone, television, and the Internet have allowed mass access to forms of information ¯ow which were traditionally restricted to economic and political elites. The Internet is the most current and dramatic case. Its use by the Zapatistas to circumvent media control during the Chiapas uprising was an early example of its egalitarian use. Latterly, the Internet has been central to the international people's movement which brought the World Trade Organization to its knees in Seattle in December. Top-down ideological control of information ¯ows is next-to-impossible in the era of the Internet. I doubt that the neo-liberal social project will reverse any of these trends. At the same time, we have almost no information on their health impacts. If there is a common denominator which points towards health it is the anti-Hobbesian character of each trend. In other words, increased wealth has been associated with a range of social changes which may increase the level of ``psychosocial equality'' in society. The other line of reasoning, which leads me to believe that average health status in wealthy societies will continue to rise, comes from the fundamental contradiction of the neo-liberal social project: although it will likely undermine social cohesion and increase
inequality, successful capitalism nonetheless requires social cohesion, high levels of well-being, competence, and health among the population in order to succeed. The best description of this comes from the economic history of Engerman and Sokolo (1997). They showed how the small farm communities of northern North America outpace the plantation societies of the American South and South America in wealth creation during the 19th and early 20th centuries. The small farm communities enjoyed higher levels of income equality than the plantation societies, and fostered institutions of broad civic participation that had no place among the top-down plantation societies. These factors allowed the small farm communities to assimilate market institutions in a more benign and bene®cial way than in the plantation societies. Looking back at Kawachi's study of mortality, income inequality, and social trust among the US states (Kawachi, Kennedy, Lochner & Prothrow-Smith, 1997) shows that the (former) small farm states still enjoy lower mortality, lower income inequality, and higher levels of social trust than the (former) plantation states. What might be the net result of these con¯icting tendencies on health trends in wealthy countries over time? My best guess is that neo-liberal policies will take hold the strongest, and in the most destructive ways, in regions where civil society is weakest and income inequality already high. The result will be slow gains in average health status and widening socioeconomic gradients in health. In regions where civil society is stronger and income inequality less pronounced, the neo-liberal experiment will be more muted, health status will rise more quickly, and socioeconomic gradients in health will narrow. I fervently hope that we will have data ¯ows available to us to monitor such predictions as these over time and I thank David Coburn for opening this up in the way that he has.
References Coburn, D. (2000). Income inequality, social cohesion and the health status of populations: the role of neo-liberalism. Social Science and Medicine, 51(1), 139±150. Engerman, S. L., & Sokolo, K. L. (1997). Factor endowments, institutions, and dierential paths of growth among new world economies. In S. Haber, How Latin America Fell Behind. Essays on the Economic Histories of Brazil and Mexico 1800±1914 (pp. 260±304). California: Stanford. Kawachi, I., Kennedy, B. P., Lochner, K., & Prothrow-Smith, D. (1997). Social capital, income inequality, and mortality. American Journal of Public Health, 87(9), 1491±1498. United Nations Development Programme, 1999. Human development report (pp. 1±262). New York, Oxford University Press.