Education And Debate

Socioeconomic determinants of health: Health inequalities: relative or absolute material standards?

BMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7080.591 (Published 22 February 1997) Cite this as: BMJ 1997;314:591
  1. Richard G Wilkinson, senior research fellow (R.G.Wilkinson@sussex.ac.uk)a
  1. a Trafford Centre for Medical Research University of Sussex Brighton BN1 9RY

    Introduction

    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.

    A “feel bad” factor in the health divide?

    TONY WALLIS

    The existence of wide-and widening-socioeconomic differences in health shows how extraordinarily sensitive health remains to socioeconomic circumstances. Twofold, threefold, or even fourfold differences in mortality have been reported within Britain, depending largely on the social classification used.1 2 3 This series will illustrate some of the most important mechanisms involved in the generation of these differences.

    Fundamental to understanding the causes of these differences in health is the distinction between the effects of relative and absolute living standards. Socioeconomic gradients in health are simultaneously an association with social position and with different material circumstances, both of which have implications for health-but which is more important in terms of causality? Is the health disadvantage of the least well off part of the population mainly a reflection of the direct physiological effects of lower absolute material standards (of bad …

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