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Better measures of social differentiation and hierarchy are needed

Richard Wilkinson (Richard.Wilkinson@Nottingham.ac.uk), professor of social epidemiology

Division of Public Health Sciences, University of Nottingham Medical School, Nottingham NG7 2UH
Department of Health Services, School of Public Health and Community Medicine, University of Washington, Box 357660, Seattle, WA 98195-3576, USA

EDITOR—Mackenbach's editorial reads like an obituary for the hypothesis that income inequality is related to population health.1 But a substantial body of evidence of such a relation has accumulated over the past 20 years, not only in the United States but also in Brazil, Russia, Taiwan, and England. Attempts to explain away this relation are rarely relevant to more than one of the many contexts in which it occurs.

The fact that health is more closely related to income in developed societies than to differences in income between them suggests effects of relative income or social status.2 But if income distribution has its main effect through differences in social status, and individual income (or education) is a proxy for individual social status, controlling income distribution for individual income makes little sense.3 It is a difference without a distinction, and more status equality is likely to improve average health.

As with individual income, the assumption that the median income of small areas …