Psychosocial and material pathways in the relation between income and health: a response to Lynch et alBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7296.1233 (Published 19 May 2001) Cite this as: BMJ 2001;322:1233
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Re: Marmot and Wilkinson on Income Inequality, Social Cohesion and
While presenting a superficially persuasive argument I believe there
are sound reasons to remain sceptical about the relationships between
income inequality, social cohesion and health as proposed by Marmot and
Wilkinson. Among these reasons:
1. The authors talk frequently about 'relative status' - yet they measure
mainly income inequality. But income inequality as objectively measured,
surely has a somewhat contigent relationship with 'perceived status' which
is the factor presumed to be important. Moreover, the authors never state
or measure 'who are the Joneses' that is, to whom do individuals and
groups compare themselves? If the psycho-social is as important as these
authors assert, then the relationships between income inequality and
perceived status must be less straightforward than the authors assume.
2. There are a variety of bases of status not necessarily directly
income related. Academics pride themselves on how many articles they have
written. The religiousi display various degrees of 'holiness'. Status
may depend on characteristics other than income. Moreover individuals may
show various degrees of congruence or incongruence between various
possible bases of status. An individual's income, educational level, and
occupational prestige are often not congruent, one might have a high
income yet relatively low prestige. Occupational prestige scales, for
example, offer a number of examples of such possible incongruities.
3. The authors fail to look at income inequality in context or
examine possible factors which might produce both higher income inequality
and lower social cohesion (hence the income inequality - social cohesion
relationship is spurious). That is, both income inequality and social
cohesion in contemporary societies may be the product of some third factor
(e.g.. the welfare state - itself a product of struggle between classes
etc). Quite clearly, for example, countries which show more income
inequality are almost always those higher in welfare state efforts and
effects. Income inequality and social cohesion are part of larger social
structures and factors.
4. In places the authors postulate a theory of society based on
social psychological speculation about basic evolutionary human traits.
One knows how societies form and interact because of what 'human nature
is'. Yet such arguments do not explain variations in social forms
historically and cross-sectionally.
5. Ignoring context. Marmot and Wilkinson fail to show how or why
income inequalities among countries vary because they have a view of
stratification which emphasizes socio-economic status but ignores class.
But, class struggle, for example, can be viewed as partially determining
levels of SES - and - also forms of society (most recently, for example,
the 'rise and fall of the welfare state') contributing to higher or lower
Hence, it would be highly premature, on the arguments presented, to
collapse health differences in the advanced nations solely onto
differences in income equality and/or social cohesion.
Finally, the use of the term 'neo-material' to encompass simply
physical characteristics of the environment misinterprets the historical
materialist tradition in which central 'material' factors are indeed
particular modes of production and particular forms of social
relationships (for example, classes).
Department of Public Health Sciences,
University of Toronto,
Toronto, Canada M5S 1A8
Competing interests: No competing interests