Wilkinson RG. Health inequalities: relative or absolute material standards? British Medical Journal 1997;314:591-5

This is the first in a series of eight articles in the BMJ looking at factors affecting the relation between deprivation and health. It is an overview of the relationship between socioeconomic status and health that argues that it is relative rather than absolute material standards that matter. That is, the direct (physiological effects of chronic mental and emotional stress) and indirect (stress-related smoking, drinking, eating "for comfort") effects of differences in psychosocial circumstances associated with social position account for the health disadvantage seen among lower socioeconomic groups. The evidence for this comes from three sources. One is that there is a close relationship of health with income (or other measures of socioeconomic circumstances) within countries, but not between countries, indicating the influence of relative income rather than absolute material standards. The second source is the finding that it is income inequality, not absolute income that is associated with mortality. Wilkinson suggests the third reason is the presence of the epidemiological transition, namely that stage in a country's economic development after which further improvements in material standards have less influence on health, and the diseases of affluence in poor countries (coronary heart disease, stroke, hypertension, obesity) become diseases of the poor in affluent societies. Biosocial mechanisms postulated to account for this include the effects on social cohesion, and chronic stress emanating from social status differences. 

Abstract

That mortality in developed countries is affected more by relative than absolute living standards is shown by three pieces of evidence. Firstly, mortality is related more closely to relative income within countries than to differences in absolute income between them. Secondly, national mortality rates tend to be lowest in countries that have smaller income differences and thus have lower levels of relative deprivation. Thirdly most of the long term rise in life expectancy seems unrelated to long term economic growth rates. Although both material and social influences contribute to inequalities in health, the importance of relative standards implies that psychosocial pathways may be particularly influential. During the 1980s income differences widened more rapidly in Britain than in other countries; almost a quarter of the population now lives in relative poverty. The effects of higher levels of relative deprivation and lower social cohesion may already be visible in mortality trends among young adults.

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Keywords

• economic growth
• epidemiologic transition
• health inequalities
• income
• income inequality
• international
• life expectancy
• material deprivation
• mortality
• psychosocial factors
• redistribution
• relative deprivation
• social cohesion
• socioeconomic status
• stress