Immorality of inaction on inequality

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j556 (Published 08 February 2017) Cite this as: BMJ 2017;356:j556
  1. Kate E Pickett, professor of epidemiology,
  2. Richard G Wilkinson, honorary visiting professor
  1. Department of Health Sciences, University of York, York, UK
  2. Correspondence to: K E Pickett kate.pickett{at}york.ac.uk

Our collective failure to reverse inequality is at the heart of a global malaise

Each year, at its meeting in Davos, the World Economic Forum produces a report on global risks, highlighting the biggest challenges the world is facing and the connections between them. Inequality entered the list of global risks in 2012, and in 2017 rising income and wealth disparity ranked as the most important trend likely to determine development across the world over the next decade.1 Oxfam also issues reports on inequality at Davos—in 2014 shocking the world with its estimate that the 85 richest people in the world owned as much wealth as the poorest 3.5 billion; this year reporting that just eight men own the same wealth as the poorest half of the world.23

During the 20th century inequality in most rich countries fell almost continuously from the 1930s to the 1970s and then increased dramatically from the 1980s with the dominance of neoliberal economics.4 This widening inequality has been dominated by top incomes growing faster than others. Meanwhile, inequality between countries has fallen, and some countries, most notably in Latin America, have managed to reduce income disparities.

Inequality matters because, as a robust and growing body of evidence shows, the populations of societies with bigger income differences tend to have poorer physical and mental health, more illicit drug use, and more obesity.5 More unequal societies are marked by more violence, weaker community life, and less trust. Inequality also damages children’s wellbeing, reducing educational attainment and social mobility.

The differences in population health between more and less equal societies are often large. Among developed countries, mental illness and infant mortality rates are two or three times as high in more unequal countries; teenage birth rates and homicide rates can be 10 times higher. These differences are so large because inequality affects the majority of the population not just a poor minority, and the scale of income differences within a society immerses us all more deeply in issues of status insecurity and competition. A growing literature also highlights the effect of inequality on status anxiety, depression, narcissism, self enhancement, and addictions.6

Inequality is implicated in other global risks that concern the World Economic Forum, from fiscal crises to profound social instability, increasing polarisation of societies, increasing national sentiment, and even climate change and environmental degradation.1 This is because of the ways in which inequality drives consumerism and overconsumption. Economists have also identified the negative effect of inequality on economic stability and growth, as well as on reducing poverty.

You might think that evidence of harm, alongside the growing concerns of world leaders, academics, business, civil society, and government would be enough to turn this problem around. But from our perspective as social epidemiologists working on inequalities, the record on tackling health inequalities does not inspire optimism. Decades of research has led to a consensus among public health academics and professionals that we need to tackle the structural determinants of health if we want to reduce health inequalities; yet this has not happened and health inequalities have not diminished. In many cities in the UK and US, for example, we continue to see life expectancy gaps of five to 10 years, and occasionally 15 to 20 years, between the richest and poorest areas.

The long term failure, even of ostensibly progressive governments, to tackle these glaring injustices is perhaps one of the reasons why public opinion has swung so strongly away from the established political parties.7 And the public’s sense of being left behind will only be exacerbated by the negative health effects of austerity, which are starting to emerge in our health statistics.8

The economist Tony Atkinson, who died last month, devoted his life to the study of inequality. Two years ago he published his recommendations on how to reduce inequality.9 They ranged from a code of practice for pay above the minimum to a top tax rate of 65% and a child basic income. We could do him no greater honour than supporting his proposals. However, just as the downward trend in inequality during the middle decades of the 20th century was driven partly by the countervailing voice of what used to be called the Labour movement, effective political action today will also depend on the development of powerful grassroots movements.

During the last generation, economic growth ceased to improve health, happiness, and the quality of life in rich countries. Now, more than ever, we need an inspiring vision of a future capable of creating more equal societies that increase sustainable wellbeing for all of us and for the planet.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare we are trustees of The Equality Trust.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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