Well-Being, Justice, and Inequality
Isaac Prilleltensky
isaac@miami.edu
www.education.miami.edu/isaac
Presented at Positive Nations Conference in Lisbon,
Portugal, Sep 29-30, 2010
Outline of Presentation
 Well-being
Definition
 Research
 Justice
 Definition
 Research
 Inequalities and Inequities in Well-Being
 Definition
 Research
 Implications for domestic and international policy and
practices

Kerala: A Community Strengths
Story
Kerala: A state in Southwest
India. The name "Kerala"
probably means "land of
coconuts."
Population: 31.8 million
Sen: Economic growth is not the whole
story. Distribution also matters a great
deal for health and human development.
Indicator
Kerala
India
Low income
countries
USA
Per Capita GDP
$
566
460
420
34,260
Adult Literacy
Rate (%)
91
58
39
96
Males (f)
68
63
59
74
Females (f)
74
64
Infant Mortality
per 1,000
12
65
80
7
Birth Rate Per
1,000
17
29
40
16
Life Expectancy
in Years
80
Processes
Well-Being in Kerala
Personal
Empowerment
Outcomes
Personal
Well-Being
Infant
mortality
Literacy
Nutrition
Life expectancy
Social
Movements
Relational
And
Organizational
Well-Being
Social support
Sense of
cohesion
Government
Action
Community
Well-Being
Tenancy laws
Nutrition in school
Distribution
Of resources
Land reform
Defining Well-Being
Wellness is a positive state of affairs, brought about
by the simultaneous satisfaction of personal,
relational, organizational and collective needs
Part I: Understanding Well-Being
 There cannot be well-being but in the combined presence
of personal, relational, organizational and community
well-being
Personal Well-being
 Sense of control
 Physical health
 Love
 Optimism
 Competence
 Dignity and integrity
 Growth
 Self-esteem
 Meaning and spirituality
 Material resources
Effects of lack of control and
disempowerment on mortality
Relational Well-Being
 Support
 Affection
 Bonding
 Cohesion
 Collaboration
 Respect for diversity
 Democratic participation
Effects of Social Support
 Less likely to have heart attacks
 More likely to resist common cold virus
 Lower mortality
 Less degree of stress
 More positive outlook on life
 Resilience
Organizational Well-Being
 Efficient structures
 Clear roles
 Monitoring mechanisms
 Planning and accountability
 Growth opportunities
 Fulfillment of needs
 Identity and meaning
Organizational Well-Being:
ERA Environments
High
Reflective Environment
High
Low
Low
Affective Environment
Low
High
Effective
Environment
Employee engagement and outcome
Employee engagement percentile
Success rate
 99
 73%
 95
 67%
 75
 57%
 50
 50%
 25
 43%
 5
 33%
 1
 27%
Engagement leads to subjective and
objective positive outcomes
“The data indicate that workplaces with engaged employees,
on average, do a better job of keeping employees,
satisfying customers, and being financially productive and
profitable. Workplace well-being and performance are not
independent. Rather, they are complimentary and
dependent components of a financially and
psychologically healthy workplace” (Harter, Schmidt &
Keyes, 2003, p. 221)
Community well-being
 Economic prosperity
 Social justice
 Adequate health and social services
 Low crime
 Adequate housing
 Clean environment
 Support for community structures
Place Matters
Male Life Expectancy by Inequality
80
78
76
74
Swed/Jap
Australia
Canada
USA White
USA Afri. Amer.
72
70
68
66
64
GINI
24.5
GINI 35
GINI
32.5
GINI 41 GINI 41
Social capital and community well-being
crime
tolerance
education
welfare
health
low
med
high
Low SC: LA, MS, GA
Med SC: CA, MO, OK
Hi SC: ND, SD, VT, MN
What Is Justice?
To Each According to His or Her Due
Sedgwick’s definition in 1922

Cardinal question of justice is whether there
are
 “any clear principles from which we may
work out an ideally just distribution of rights
and privileges, burdens and pains, among
human beings as such” (p. 274).
Miller’s 1999 condensed version
 “To each his or her due”
 Isaac’s four questions




First Question: Who Or What Is Each?
Second Question: How Do We Decide What Is
Due A Person, Family, Or Group?
Third Question: Who or What is Responsible
for Distributing Resources and Obligations?
Fourth Question: How Do We Decide what is
Due From a Person, Family, Group, or
Institution?
Second Question: How Do We Decide What Is Due A
Person, Family, Or Group?
 Dominant ideology
 Alternative ideology
 Ability
 Ability
 Effort
 Effort
 Needs
 Rights
 Opportunities
 Power
The role of context
 context should determine what criterion or
criteria must be preferred in each case
 In social conditions of inequality, we must
accord preference to needs over ability
Context of Relative Equality
 Under conditions of relative equality, where
the gap between classes is not very
pronounced, it is possible to favor effort
over needs.
Context of Plenty of Opportunities
 In a context of plenty of opportunities for
everyone, it is possible that ability and effort
will be the preferred choice.
Justice Out of Context
 Societies aspiring to justice must seek equilibrium
among all criteria
 When context of inequality calls for need and
equality, but culture favors effort, it’s because
privileged groups benefit.
 As a result, group interests that influence the
choice of allocation pattern often disregard the
context-specific situation.
Context Minimization Error
 “Practitioners “should pay more attention to
the community contexts of human behavior.
Conditions in neighborhoods and
community settings are associated with
residents' mental and physical health,
opportunities, satisfactions, and
commitments.” (Shinn and Toohey, 2003,
Annual Review of Psychology).
Synergy of Justice and
Well-being
How Justice Influences Well-Being
Well-Being  Justice
Well-Being is
enhanced by
Self-determination
Justice is enhanced, and contributes to
well-being, by the power, capacity, and
opportunity to
Experience voice and choice, participate
in decision making
Caring and compassion
Experience nurturing relationships free of abuse
Equality and freedom
Benefit from fair and equitable distribution of resources
and burdens
Ecological Model of Well-Being
Sites of Well-Being
Individual
Relational
Organizational
Communal
Environmental
Objective signs
health
networks
resources
social
capital
low emissions
Subjective
Signs
efficacy
voice
support
belonging
safety
Values as
source and
strategy
autonomy
caring
participation
diversity
protection of
resources
Justice as
source and
strategy
My
due/Our
due
Your
due/Our
due
Its due/Our
due
Their
due/Our
due
Nature’s
due/Our due
When Is Inequality in
Well-Being Inequitable?
(question posed by Daniels, Kennedy, and Kawachi, 2000)
When inequalities in well-being are avoidable,
unnecessary, and unfair (Dahlgren and Whitehead, 1991)
Do inequalities in well-being exist?
 If so, are they



Avoidable
Unnecessary
Unfair
 Let’s examine the evidence…….
Colombia: Happy but Dead
 Highest rate of murders per capita in the world
 Highest number of kidnappings in the world
Colombia 5181 in 7 years
 Mexico 1269
 Brazil 515
 Venezuela 109
 Severe under reporting
 Colombians report highest level of satisfaction 8.31 (out of 10) in the
world in the 90s

USA
List of Best Nations (Newsweek, Aug 2010)
Finland
2. Switzerland
3. Sweden
4. Australia
5. Luxembourg
6. Norway
7. Canada
8. Netherlands
9. Japan
10. Denmark
11. United States
1.
Colombia # 62
Metrics for Best Countries Survey
 Education (TIMMS and or PISA)
 Health (Healthy life expectancy)
 Quality of Life (Gini coefficient, gender gap, extreme
poverty, homicide rates, pollution, unemployment)
 Economic dynamism (GDP, innovation,
diversification, business friendly laws, bankruptcy)
 Political environment (freedom house rating, global
peace index, political risk)
From Gallup Poll
President-Sarkozy.aspx
http://www.gallup.com/poll/103795/WellBeing-Report-Card-
Life satisfaction and per capita GDP around the world
From: J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:
J Econ Perspect. 2008 April 1; 22(2): 53–72.
doi: 10.1257/jep.22.2.53.
Each doubling of GDP is associated with a constant increase in life satisfaction
From: J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:
J Econ Perspect. 2008 April 1; 22(2): 53–72.
doi: 10.1257/jep.22.2.53.
Contradictions between objective and
subjective criteria of well-being
 "neither life satisfaction nor health satisfaction can
be taken as reliable indicators of population wellbeing, if only because neither adequately reflects
objective conditions of health.” (Deaton, 2008, p.
70)

J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:
J Econ Perspect. 2008 April 1; 22(2): 53–72.
doi: 10.1257/jep.22.2.53.
 “life-satisfaction is higher in countries with higher GDP
per head.
 “it is not true that there is some critical level of GDP per
capita above which income has no further effect on lifesatisfaction.”
 Data reject the Easterlin paradox, according to which
happiness does not go up after certain income level.
 (Deaton, 2008, J Econ Perspect. Author manuscript;
available in PMC 2009 May 11. Published in final edited
form as: J Econ Perspect. 2008 April 1; 22(2): 53–72)
Do inequalities in well-being exist?
YES!!!!!
 If so, are they



Avoidable – YES, because social arrangements such as a good
public education and equitable distribution of resources can avoid
inequitable outcomes
Unnecessary – YES, because social arrangements in certain
countries show that equity in well-being does not come at expense
of human and social development, on the contrary. A NO answer
is usually based on personal interests of doctors, insurance
companies, or other interested parties claiming that the capitalist
system and high levels of quality are based on competition
Unfair – YES, because people with limited opportunities in life, due
to circumstances outside their control, have to suffer due to no
fault of their own. This is especially true in the case of poor
children, whose poor level of education is associated with many
negative health and well-being outcomes.
Part II: Promoting Well-Being
Domestically and Internationally
From
 Deficits
 Reactive
 Arrogance
 Individual blame
To
 Strengths
 Prevention
 Empowerment
 Community Change
Time and place of interventions
Collective
THIS IS WHERE WE NEED TO BE
Quadrant IV
Examples:
Food banks, shelters for homeless
people, charities, prison industrial
complex
Quadrant I
Examples:
Community development, affordable
housing policy, recreational
opportunities, high quality schools
and accessible health services
Reactive
Proactive
Quadrant II
Quadrant III
Examples:
Skill building, emotional literacy,
fitness programs, personal
improvement plans, resistance to
peer pressure in drug and alcohol
use
Examples:
Crisis work, therapy, medications,
symptom containment, case
management
Individual
THIS IS WHERE WE ARE
Focus and engagement in interventions
Strength
THIS IS WHERE WE NEED TO BE
Quadrant I
Quadrant IV
Examples:
Voice and choice in celebrating and
building competencies, recognition of
personal and collective resilience
Examples:
Just say no! You can do it!
Cheerleading approaches, Make
nice approaches
Detachment
Empowerment
Quadrant II
Quadrant III
Examples:
Voice and choice in deficit reduction
approaches, participation in
decisions how to treat affective
disorders or physical disorders
Examples:
Labeling and diagnosis,
“patienthood” and clienthood,”
citizens in passive role
Deficit
THIS IS WHERE WE ARE
Strengths, Prevention, Empowerment,
Community change
The
Grameen
Bank
1960s
Lesson #1: Strengths
We all have strengths
We all need to be treated with
respect
We all need to be given a chance
9/7/1854…Removing the Handle of
London’s Broad Street Pump
Lesson #2: Prevention
 “No mass disorder, afflicting humankind,
has ever been eliminated, or brought under
control, by treating the affected individual”
 HIV/AIDS, poverty, child abuse, school
drop out, addictions, powerlessness are
never eliminated one person at a time
 Must focus on prevention to reduce the
incidence of psychological, behavioral, and
social problems in children and youth
Determinants of Health
(by percent contribution)
100%
5
10
90%
80%
15
70%
Environmental Exposures
60%
30
50%
Medical Care
Social Circumstances
Genetic Predispositions
40%
Behavioral Patterns
30%
20%
40
10%
0%
McGinnis
et. al., 2002
Determinants of Health

http://content.healthaffairs.org/cgi/content/full/21/2/78
US Spending on Health
National Health Spending (2005)
Government Public Health
Activities
100%
90%
$56.60
$126.80
$143.00
80%
Investment (Research and
Equipment)
70%
60%
50%
Government
Administration and Net
Cost of Private Health
Insurance
40%
$1,661.40
30%
20%
Personal Health
(Hospital/Clinical
Services, Nursing Home,
Home Health Care,
Medical Products)
10%
0%
$1,987.80
Per Capita Total

Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S.
Department of Commerce, Bureau of Economic Analysis, and U.S. Bureau of the Census.
Too much reaction, not enough prevention
Investments in Reactive vs. Proactive Interventions in Health and
Community Services (Nelson et al, 1996; OECD, 2005; de Bekker-Grob et al., 2007)
100
90
Investments in
Prevention:
80
Italy 0.6%
70
USA 3%
60
50
Netherlands
4.3%
40
Canada 8%
30
20
10
0
Reactive
3/24/2016
Preventive
Prilleltensky
61
Ratio of Benefits to Costs (Lynch, 2007,
page 19)
18
16
14
12
10
8
6
4
2
0
Abecedarian
CPC
Perry Age 27
Perry Age 40
Strengths, Prevention, Empowerment,
Community change
Lesson #3: Empowerment
 Identifying the external source of
oppression in life can be empowering
 Empowerment is a means and an end in
itself
 Empowerment can be a tool for social
change and personal healing at the same
time
Strengths, Prevention, Empowerment,
Community change
Lesson #4: Community change
 “The psychotherapist, social worker or social
reformer, concerned only with his (her) own
clients and their grievance against society,
perhaps takes a view comparable to the private
citizen of Venice who concerns himself only with
the safety of his own dwelling and his own ability
to get about the city. But if the entire republic is
slowly being submerged, individual citizens
cannot afford to ignore their collective fate,
because, in the end, they all drown together if
nothing is done.” (Badcock, 1982)