Professor Angus Deaton, Professor of Economics and International Affairs at Princeton University, has recently published an essay that is well worth a read, titled: What does the empirical evidence tell us about the injustice of health inequalities?
Health inequalities are a matter of great moral concern. But whether we see them as an injustice, and whether and how we design policy to correct them, depends on how they come about. In this essay, I have argued that childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes. Among adults, the main priority should be the design of schemes that prevent the impoverishment that can come from ill-health, through loss of the ability to work, or through the costs of treatment. It is also important not to use health inequalities as an argument for limiting health innovations that will benefit all, though there will often be a role for public policy in ensuring that beneficial innovations spread rapidly through the population. As to the largest health inequalities of all, which come from poor health in poor countries, I believe that these cannot be regarded as an injustice, or at least not an international injustice, and that assistance from outside, while sometimes possible and effective, may also undermine the institutions that are needed to support domestic health. Finally, I believe that the recent concentration of wealth at the very top of the income distribution in the United States (and other English speaking countries) is a serious threat to well-being, through its possible long-term effects on health, education and democracy.
Meanwhile, another economist with a great interest in inequalities, Professor Gavin Mooney, has been considering some of the questions raised by Deaton.
Gavin Mooney writes:
A new paper by leading US economist, Angus Deaton, of the Center for Health and Wellbeing at Princeton University and who in recent years has investigated income inequality and health, asks the interesting question: ’What does the empirical evidence tell us about the injustice of health inequalities?’
It is to me a funny old question given that justice and injustice are value issues which would seem to be difficult to unravel on the basis of ‘empirical evidence’ or at least that alone. It is these value issues that separate inequality from inequity. Deaton suggests that ‘whether or not health inequalities are unjust, as well as how to address them, depends on how they are caused’. That is an interesting and possibly contentious thesis.
Whatever, Deaton, whose focus is the US, identifies early life inequalities and racial inequalities as unjust. That seems fair enough. He goes on to argue however that inequalities across rich and poor countries are neither just nor unjust. That seems odd to me but interestingly the philosopher John Rawls would I think take the same line.
Deaton’s argument however for coming to his conclusion on these international inequalities seems not to have much to do with any philosophical or value stance. It appears to be based primarily on his judgment (rather than ‘empirical evidence’?) that the international community cannot really do much about such inequalities (and I for one would challenge that) and therefore they are not internationally unjust (and I would challenge the logic of that).
He also claims that ‘for cosmopolitan philosophers, international health and income inequalities are injustices that ought to be corrected by the international community … and this is a task for individual donors … as well as for the World Bank [and other global institutions]’. He then states that in the real world ‘the practicalities [of correcting these inequalities] are against the cosmopolitans’.
Not only would I challenge the logic here but the assumption that Deaton seems to make that the only option to help poor countries is by this sort of donor aid.
The key question for me here is: why do such poverty and inequality continue in a world of plenty?
Might it not just be the case that it is the system of global economic governance or global political economy that is the real villain here? OK maybe Deaton means to imply that the global institutions are incapable of reforming themselves and in turn the global political economy and maybe he is right.
But given recent events in Tunisia and Egypt, maybe they will have to reform themselves. And Keynes did manage it 70 odd years ago and there might be a new Keynes waiting in the wings somewhere.
On another front Deaton does consider unjust the vast and growing income inequality in the US and particularly the very large increase in incomes at the very top of the income distribution. (He does not analyse Australia but would we be so different?)
Perhaps most interesting of all however is Deaton’s continued seeming disagreement with Wilkinson and Pickett (the authors of The Spirit Level, the book which has moved the concerns about inequality and health to a new level).
Deaton claims these authors suggest that ‘differences in income are themselves a risk factor’. He argues that the inequality that he thinks matters is what he labels ‘political inequality’. I would agree – although I would call it class.
But then Wilkinson and Pickett do write of ‘social stratification’ and I agree with them. And I’d call that class. Navarro does call it class and so I agree with him!
I wonder. Is the difference between Deaton, and Wilkinson and Pickett simply that they call class by different names? And is the difference between that trio and Navarro simply that Navarro is prepared to call a spade a spade?
More generally, in the debate about health inequalities, with respect to class, I wonder. Have we moved to a point that we ‘dare not speak its name’?
Interesting. I haven’t read the Deaton paper in full but going on this he misses what is, to me, the most striking point that the work in this field has uncovered: that individuals / groups at the top of the income scale in unequal countries are less healthy than their counterparts in more equal ones. For me THAT is the key point for health policy makers.