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 chal-

lenging us to consider how the dominant trend in glo-

bal capitalist thinking and policy, neo-liberalism,

a�ects 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/cohe-

sion, 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 Pro-

gramme, 1999) includes a graph from the Luxembourg

Income Study showing the trends of market income

inequality and income inequality after taxes and trans-

fers (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 pro-

grams. Ironically, this means that the potential ``prof-

its'' 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.

This fact is central in Canadian politics. Canada is oneof the countries whose tax and transfer programs fully

compensated for market forces (at least, until the mid-

1990s) while in the USA they did not. Since we arealways 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 incomefamilies 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 Wes-tern Europe, North America, and the wealthy

countries of the Western Rim of the Paci®c Ocean.

Health status has risen throughout the twentieth cen-tury despite the penetration of market forces into

every facet of life, war, dislocation, and the undermin-

ing of traditional sources of social support (i.e. stable

communities and extended families). It is not enoughsimply 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 or5 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 (includ-ing access to e�ective health care) that have made the

di�erence. If so, undermining them could well lead to

a reversal of health trends. But the welfare state pro-grams 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. Thissocial change takes many forms, and is di�cult to cat-

egorize according to the traditional determinants of

Social Science & Medicine 51 (2000) 1007±1008

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* Tel: +1-604-822-3002; fax: +1-604-822-4994.

E-mail address: hertzman@interchange.ebc.ca (C. Hertz-

man).

health. But it is a change worth detailing and consider-ing whether the neo-liberal social project will threaten

its elements the same way that it does the traditionalprograms and policies of the welfare state. These are:

. an end to the social respectability of religious, gen-

der, ethnic, and racial discrimination. For the ®rsttime in modern history, it is permissible to be non-male, non-white, non-Christian, and non-heterosex-

ual without an automatic expectation that one willnecessarily 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, theirbreathing, their arms, legs, and backs, and, ulti-mately their lives at work, in order to support theirfamilies.

. a general loosening of social norms and behaviouralexpectations and an increase in the range of lifestyleswhich are considered socially acceptable.

. widespread access to birth control and an end tosocial 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 scubadiving at age 70, etc.

. widespread access to technologies which have egali-

tarian characteristics. In particular, the technologiesof communication: radio, telephone, television, andthe Internet have allowed mass access to forms of

information ¯ow which were traditionally restrictedto economic and political elites. The Internet is themost current and dramatic case. Its use by the Zapa-

tistas to circumvent media control during the Chia-pas uprising was an early example of its egalitarianuse. Latterly, the Internet has been central to the in-

ternational people's movement which brought theWorld Trade Organization to its knees in Seattle inDecember. Top-down ideological control of infor-mation ¯ows is next-to-impossible in the era of the

Internet.

I doubt that the neo-liberal social project will reverseany of these trends. At the same time, we have almost

no information on their health impacts. If there is acommon denominator which points towards health itis the anti-Hobbesian character of each trend. In other

words, increased wealth has been associated with arange of social changes which may increase the level of``psychosocial equality'' in society.

The other line of reasoning, which leads me tobelieve that average health status in wealthy societieswill continue to rise, comes from the fundamental con-

tradiction of the neo-liberal social project: although itwill likely undermine social cohesion and increase

inequality, successful capitalism nonetheless requiressocial cohesion, high levels of well-being, competence,

and health among the population in order to succeed.The best description of this comes from the economichistory of Engerman and Sokolo� (1997). They

showed how the small farm communities of northernNorth America outpace the plantation societies of theAmerican South and South America in wealth creation

during the 19th and early 20th centuries. The smallfarm communities enjoyed higher levels of incomeequality than the plantation societies, and fostered in-

stitutions of broad civic participation that had noplace among the top-down plantation societies. Thesefactors allowed the small farm communities to assimi-late market institutions in a more benign and bene®cial

way than in the plantation societies. Looking back atKawachi's study of mortality, income inequality, andsocial trust among the US states (Kawachi, Kennedy,

Lochner & Prothrow-Smith, 1997) shows that the (for-mer) 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 ten-

dencies on health trends in wealthy countries over

time? My best guess is that neo-liberal policies willtake hold the strongest, and in the most destructiveways, in regions where civil society is weakest andincome inequality already high. The result will be slow

gains in average health status and widening socioeco-nomic gradients in health. In regions where civil so-ciety is stronger and income inequality less

pronounced, the neo-liberal experiment will be moremuted, health status will rise more quickly, and socioe-conomic gradients in health will narrow.

I fervently hope that we will have data ¯ows avail-able to us to monitor such predictions as these overtime and I thank David Coburn for opening this up inthe 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 endow-

ments, institutions, and di�erential 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.

C. Hertzman / Social Science & Medicine 51 (2000) 1007±10081008