In this assignment you will use your research questions to guide your investigation of your chosen topic in academic sources including books and journal articles. You will conduct a critical review of the literature, including how the topic could be studied using both qualitative and quantitative methods. With quantitative studies, you should evaluate how the authors conceptualized, operationalized, and measured the phenomena they examined.With qualitative research, you should consider the patterns the authors analyzed and how they determined the social meanings they observed. The following two smaller assignments will be steps in the process of developing a literature review.Ø Identification of research topic and outline of research questionsØ Conceptualization, operationalization, and measurement
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Social Science & Medicine
Volume 58, Issue 1, January 2004, Pages 41-56
Beyond the income inequality hypothesis: class, neo-liberalism, and health inequalities ☆
David Coburn
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https://doi.org/10.1016/S0277-9536(03)00159-X
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Abstract
This paper describes and critiques the income inequality approach to health inequalities. It then presents an alternative class-based
model through a focus on the causes and not only the consequences of income inequalities. In this model, the relationship between
income inequality and health appears as a special case within a broader causal chain. It is argued that global and national socio-politicaleconomic trends have increased the power of business classes and
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resources. But international pressures towards neo-liberal doctrines and policies are differentially resisted by various nations because of
historically embedded variation in class and institutional structures. Data presented indicates that neo-liberalism is associated with
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greater poverty and income inequalities, and greater health inequalities within nations. Furthermore, countries with Social Democratic
forms of welfare regimes (i.e., those that are less neo-liberal) have better health than do those that are more neo-liberal. The paper
concludes with discussion of what further steps are needed to ‘go beyond’ the income inequality hypothesis towards consideration of a
broader set of the social determinants of health.
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Keywords
Income inequality; Class; Globalization; Welfare state; Infant mortality
Introduction
In this paper, I take a view of the relationship between income inequality and health status which is more sociological than
epidemiological. Whereas most attention has focused on the consequences of income distributions or socio-economic status (SES) for
health I discuss here the class-based production of inequalities. Doing so leads to an alternative conceptualization of the determinants of
health inequalities within and between nations to that of the income inequality perspective. The political economy approach taken links
study of the health effects of income inequality with social and class changes including the spread of neo-liberalism, the decline of the
welfare state, differences amongst nations regarding welfare regime type, and, most generally, the relationships between class structure,
economies and human well-being. This approach builds on a model developed to help explain ‘the rise and fall’ of medical dominance
(Coburn (1999), Coburn (2001)) and on the theories and findings of a number of others—particularly Navarro (Navarro, 1998; Navarro &
Shi, 2 (1999b), Navarro & Shi (2001); Navarro & Shi, 2001) but also Ross and Trachte (1990), Esping-Andersen (1990), Esping-Andersen
(1999), Lynch and colleagues (Marmot (1994), Lynch et al., 1998 (2001), Lynch & Kaplan (1999); Muntaner & Lynch, 1999; Lynch & Kaplan,
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1999), and of course, Wilkinson (1996) and the many epidemiological researchers who have focused on income inequality (see Kawachi,
Kennedy, & Wilkinson, 1999).
After briefly describing and critiquing the income inequality hypothesis I present an alternative model (Fig. 2) and empirically explore its
usefulness using available data.
The income inequality hypothesis and its critics
Income inequality and health
Analysis of the relationships between income inequalities and health has become a major focus of studies of the social determinants of
health. Within-nations income inequality plays a prominent role in analyses of SES-related health inequalities. That is, it has been found
that, everywhere, the rich live longer, healthier lives than do the poor. Moreover, the income inequality hypothesis is the dominant
approach to discussion about health inequalities between as well as within the developed nations. Elements of the income inequality
approach, such as the importance of social hierarchies, have also found their way into the health policy arena through their impact on the
new paradigm of population health (Poland, Coburn, Eakin, Robertson, & Critical Social Science and Health Group, 1998).
In: Unhealthy societies: the afflictions of inequality (1996), Richard Wilkinson argued that, amongst the less developed nations, GNP/capita is
the most important correlate of average levels of health status. However, above about $5–$10,000 GNP/capita, the point at which chronic
diseases begin to displace acute illness as the chief causes of death, Wilkinson contends that it is the degree of income inequality, rather
than national wealth which is the most important determinant of national differences in health status. It is worthwhile noting that, even
under the $5–$10,000 mark, there is a wide distribution of health for any particular GNP/capita level. Discussion of the health of the less
developed nations cannot be dismissed as the simple product of GNP/capita (Sen, Amartya, (1992), Sen, Amartya, (2000)). However,
following Wilkinson, the major focus here is on income inequality and health status within and between the 14–20 most developed
nations.
Noting that high-level British civil servants show poorer health than those even higher in the hierarchy, income inequality theorists
concluded that relative, rather than absolute income differences underlie the relationships between income and health. Hence, they
turned their attention less to material inequalities, poverty or absolute income than to psycho-social status hierarchies. Social hierarchies
are said to produce disease because of the poor self-esteem associated with lower status which, in turn, through psycho-neuro-biological
pathways, negatively influences health. Wilkinson, Kawachi, and others also contend that income inequality leads to loss of social
cohesion which produces lower health status (Kawachi, Kennedy, & Wilkinson, 1999; Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997;
Wilkinson, 1997).
Wilkinson and colleagues claim that there are two major dimensions of society, degree of hierarchy (vertical separation) and social
cohesion or fragmentation (horizontal separation) which, measuring the ‘quality of life’, determine average national or regional health
status. From an initially small collection of empirical correlations, income inequality theorists have built up an impressive edifice of
findings and explanations leading to far-reaching conclusions about the nature of human societies and the fundamental characteristics
of human nature and health. In that sense Wilkinson and colleagues built on, but went much beyond earlier empirical studies of the
relationship between income inequality and health status by Preston (1975) and Rodgers (1979). The underlying income inequality model
is shown in Fig. 1.
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Fig. 1. The income inequality model.
Criticisms of the income inequality thesis
There have been recent criticisms of the income inequality approach (e.g., Forbes & Wainwright, 2001). These have centered (1) on
whether or not the original findings are valid or exaggerated (Deaton (2001a), Deaton (2001b); Judge (1995), Judge (1996); Judge, Milligan,
& Benzeval, 1998; Lynch et al., 2001; Mellor & Milyo, 2001) and (2) whether international income inequality-health correlations are
‘artifactual’ (if the relationship between income and health within nations is curvilinear rather than linear, any decrease in national or
regional levels of inequality would ‘automatically’ lead to higher average health status—Ellinson, 2002; Gravelle, 1998; Gravelle, Wildman,
& Sutton, 2002). However, from the perspective of this paper the most important criticism, noted by a wide variety of commentators is (3)
whether the effects attributed to income inequality or to social cohesion are as much the consequence of the many social factors with
which income inequality/social cohesion correlate as they are to income-determined relative (psycho-social) status differences.
From a sociological point of view I also note (4) that the theory is one based on status hierarchies, yet nowhere are status differences or
self-esteem directly measured. There are reasons for doubting the assertion that those lower in income feel ‘disesteemed’, because status
is not uni-dimensional, there are many social hierarchies and some may attach more esteem to some hierarchies than to others.
Moreover, (5) any individual’s status and income can vary quite radically over a lifetime. There may be national variations in income and
status mobility (McDonough, Duncan, Greg, Williams, & House, 1997; McDonough & Berglund, 2002).
The original income studies examined international cross-sectional correlations amongst GNP/capita, measures of income inequality,
and health. Yet (6) even within the theory one would expect a latency period between social conditions and their effects on health.
Probably the exception is regarding infant mortality which is commonly assumed as more likely to reflect contemporary conditions than
are such chronic conditions as cardiovascular disease. Disease and death are likely due to life-long cumulative influences rather than only
to conditions in the immediate environment.
There are also (7) suggestions that the relationship between income inequality and health within nations is asymptotic rather than linear
and that the shape of these relationships varies in different nations. The linear relationships previously found focused on such highly
status-oriented groups as British civil servants (Deaton (2001a), Deaton (2001b); Marmot, 1994). A recent analysis (Laporte, 2002) suggests
that, in the United States, use of general measures of income inequality, such as the Gini index, tend to obscure the strong effects of
inequalities at low income and the weak effects of income inequalities at higher income on health (cf. Kennedy, Kawachi, & ProthrowStith, 1996).
I agree with those observers who now feel that income inequality may be correlated with health but that income inequality probably
reflects or is a proxy for a variety of social conditions, operating through individual and collective, material and psycho-social pathways,
rather than income inequality being a single main cause of poorer health. For example, in the US, Muller (2002) found state educational
levels more important than income inequality. Deaton suggests that state racial composition explains away the effect of state differences
in relative deprivation on health status (Deaton, 2001b). In addition, income inequality differences among US states co-vary with a series
of other social factors from percentage of children in school to the availability of community resources (Kaplan, Pamuk, Lynch, Cohen, &
Balfour, 1996).
Rather than income inequality being the chief determinant of such societal types, I draw here on the existing literature on classes, neoliberalism and welfare regimes to point to ways in which we can begin to understand inequalities in historical and cross-sectional
perspective. In this model, income inequality is itself the consequence of fundamental changes in class structure which have produced
not only income inequality but also numerous other forms of health-relevant social inequalities. Welfare measures in turn reflect basic
social, political and economic institutions tied to the degree to which societies take care of their citizens or leave the fate of citizens up to
the market i.e., neo-liberalism. Income inequality is a consequence, not the determinant, of societal ‘types’ (cf. Nararro, 2002).
In an alternative model (Fig. 2) described below, income inequality has a place but not the central causal status given it in the orthodox
income inequality literature. This paper is thus not simply about arguing ‘against’ the income inequality thesis but is an attempt to
encompass it, and to go beyond it by opening up analysis of the determinants of health within a broader, more contextualized and more
sociologically meaningful causal model.
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Fig. 2. The class/welfare regime model.
An alternative explanation
An adequate sociological account has to help explain both historical change and contemporary variation. In what follows, I use the idea of
global capitalism as a new phase of capitalism replacing earlier forms (from Ross & Trachte, 1990) to analyse historical change and
welfare regime types (from Esping-Andersen (1990), Esping-Andersen (1999)) to account for national cross-sectional health inequality
differences. This approach is broadly congruent with a critical realist perspective (Archer, Bhaskar, Collier, Lawson, & Norrie, 1998).
To sketch an explanation—capitalism is viewed as moving through particular phases—entrepreneurial, monopoly, and most recently
global, capitalism. Each of these phases has its own set of class, economic and political characteristics. Economic globalization, as a real
force, and as ideology, brought the re-emergence of business on national and international levels to a dominant class position from the
previous phase of a nationally focused monopoly capitalism in which capital and labour had arrived at various forms of accommodation.
Contemporary business dominance, and its accompanying neo-liberal ideology and policies, led to attacks on working class rights in the
market (e.g., by undermining unions) and to citizenship rights as expressed even in the liberal (market-dependent) version of the welfare
state enacted in most of the Anglo-American nations. Labour’s lessened market power and fragmentation, and the shredding of the
welfare state also led to major increases in social inequality, poverty, income inequality and social fragmentation. I earlier (Coburn, 2000)
pointed out that neo-liberalism has doctrinal affinities with inequality and with lowered social cohesion. Neo-liberal philosophy and
policies are either unconcerned with, or positively endorse, inequalities (as encouraging work motivation, participation in markets, etc).
Moreover, they are particularly ‘individualist’ in attacking various forms of collective or state action—insisting that we face markets only
as individuals or families—that we ‘provide for ourselves’. I argue that the forceful enactment of neo-liberal ideologies and politics
exacerbates differences amongst rich and poor within the market, and, at the same time, undermines those social institutions which
might help reduce poverty or income inequalities or which buffer the effects of income inequalities on health.
Neo-liberal economic globalization undermined the welfare state. But there are alternative national forms of welfare regime based on
varying national class and institutional structures (Esping-Andersen (1990), Esping-Andersen (1999)). These differentially resist
international trends towards the dominance of market-based inequalities. Welfare regimes can be categorized according to the extent to
which they decommodify citizens’ relationships to the market. Decommodification refers to the degree to which citizens have an
alternative to complete dependence on the labour market (on working for money), in order to have an acceptable standard of living
(O’Connor & Olsen, 1998). Esping-Andersen notes three major types of welfare state: the Social Democratic welfare states, showing the
greatest decommodification and emphasis on citizenship rights; the Liberal welfare state which is the most market-dependent and
emphasizes means and income testing; and an intermediate group, the Conservative, Corporatist or Familist welfare states, which are
characterized by class and status-based insurance schemes and a heavy reliance on the family to provide support (Esping-Andersen (1990),
Esping-Andersen (1999)). These countries might be viewed as strong-, weak- and intermediate or mixed-type welfare states, respectively,
although Esping-Andersen’s main point was that these are fundamentally different kinds of society.
The major examples of the Social Democratic welfare states are the Scandinavian countries such as Sweden, Norway, and Finland. The
Liberal welfare states include the Anglo-American nations particularly the United Kingdom and the United States (at one time the UK
was close to Social Democratic status). The corporatist/familist states include such countries as Germany, France, and Italy. It is
important to note that these nations represent differing ways of approaching both market and state welfare phenomena based on
differing class structures and class coalitions—they constitute distinct socio-political and not only welfare state regimes (O’Connor &
Olsen, 1998). For example, Social Democratic regimes tend to have higher overall labour force participation (particularly among women)
and stronger labour market policies aimed at full employment. Markets and states are not separate but are mutually constituted.
Within the welfare state literature, a major explanatory stream is a class or class coalitional perspective (Hicks, 1999; Korpi, 1989;
O’Connor & Olsen, 1998). Greater working class strength and/or upper class weakness and various combinations of class coalitions,
degrees of class cohesion/organization (e.g., the formation of a working class based political party) and degree of working class
institutionalization produce stronger welfare regimes or helps preserve these in the face of attack. Welfare regimes not only have causes
but they also have consequents for the class and stratification structure.
The model (Fig. 2) is one which views neo-liberal economic globalization as a new phase of capitalism. Globalization reinforced business
class power and reduced that of oppositional classes. Global neo-liberal politics and policies have increased within national inequalities
—and within nation health inequalities—partly through changes in markets (weakening unions resulting in lower negotiated
pay/benefits) and partly through attacks on the welfare state. However, neo-liberalism has somewhat different effects on different nations
because of national variations in class structure and in their institutionalized form of welfare regime.
Most previous analyses link factors in C (Fig. 2) with health or well-being (D). The model described deepens the causal explanation by
including the determinants (A and B) of access to a variety of social assets (whether individual e.g., income, or collective, e.g., universal
health care, public transportation) and other forms of inequality or deprivation. The model can encompass the fact that the health effects
of various social phenomena might have both material and symbolic dimensions. Income inequality occupies a prominent place within
this model although the question of how prominent as compared with other factors (e.g., relative or absolute poverty, housing, nutrition)
is left open. This analysis also leads to speculation that income inequality may be more important for health in more neo-liberal societies
than in others. Families or individuals in market-oriented societies have to rely on individually acquired market-related assets (such as
income) to determine the degree to which they can access health-related societal resources (private health insurance versus public
provision, private education/housing, etc). The model can also handle the possibility that the curve relating income to health may take a
different form in different societies—being more curvilinear in neo-liberal societies and more linear in more Social Democratic
societies. The major alternative to both income inequality and class-based models is that a region’s ec …
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