Health Inequality & Welfare
Capitalism
Nicky Hart
Professor of Sociology
University of California
Los Angeles
Reducing Health Inequalities
What do we really know about Successful Strategies?
8-9th May 2009
• What is the most effective mode of social organization for
promoting population health and, by implication, reducing health
inequalities?
• Can variations in the epidemiological history of welfare state
regimes (WSR) answer this question?
• Cautionary note: Assuming there is an affirmative answer to this
question, we must not assume it would be easy to transfer successful
policy interventions from one socio-historical context to another.
Policy implies purposeful public intervention designed to achieve
defined goals; WSR implies a whole repertoire of interlinked social
institutions which have evolved over decades, even centuries,
shaped in the course of their development by democratic class
struggle punctuated by major historical events – world wars,
economic crises, cultural antecedents and upheavals – a successful
policy in one WSR may not be portable to another whose ethos is
entirely different. Policy depends on the political will, and, to
paraphrase one famous German social theorist: men make their own
policy but they do not do it under conditions of their own choosing.
Why we should expect the Welfare State Regime
concept to offer the best approach to uncovering
the secret of a healthy society?
• WSRs are alternative modes of societal modernization developed to
insulate population livelihood from the risks of market capitalism.
• He introduced the concept of decommodification to capture variations in
the capacity of WSRs to perform this function. It involves the removal of
commodity status from essential human needs, on the grounds that these
goods and services should be be subject to market exchange and profit.
• From all that we know of the relationship between material inequalities and
health over the life course, it makes sense to predict that decommodification
will be an important variable differentiating health outcomes between
welfare states.
• However, as his feminist critics were quick to point out, commodification is
not necessarily bad, it can entail liberation from dependency relations, and
as far as women are concerned, the commodification of their labor is toi be
welcomed not resisted.
Defamilization and the Fourth Regime.
•
In face of feminist challenge, Esping Anderson added an additional
concept and a fourth regime type to his typology. Defamilization
measures a WSR’s capacity to liberate individuals from dependency
on the most traditional of all welfare institutions – the family. In the
same context, he also added a fourth ideal type to his model – the
familist welfare regime associated with the Mediterranean region and
to some extent Japan.
• Applying both concepts, decommodification and defamilization, his
original conclusion was unchanged, , the social democratic regime
still emerges as the most successful mode of organizing social life to
protect human wellbeing with the added benefit of strengthening the
immemorial/ultimate purpose of social organization, the maintenance
of the flow of population through the social fabric.
• The defamilization concept is an interesting tool from the perspective
of social epidemiology because the social support typically
associated with family life is known to exert a powerful influence on
survival.
The health output of the Five regimes
• Measuring health : The risks of premature death – YPLL
1- 75 years.
• Nations included in the study
• Britannia ( Old World Liberal) England & Wales,
Scotland & Northern Ireland
• New World Liberal : USA
• Corporate: Austria, Belgium, France and Netherlands
• Social Democratic: Denmark, Norway, Sweden
• Mediterranean: Greece, Italy, Spain
• Time period 1960 – 2000
• Two Types of Gender Inequality
Female Trends in premature death
in Welfare State Regimes
So c D em
80
M e dit
B rit a nnia
C o rpo ra t e
Pyll per 1000 population all causes
E uro pe
US A
70
60
50
40
30
1960
1970
1980
year
1990
2000
Trends in Premature Male Death : All Causes 1963-93
135.00
pyll per 1000 male pop
125.00
115.00
105.00
95.00
85.00
75.00
65.00
1963
Europe
Britannia
1973
1983
Corporate
Soc Dem
1993
2000
M editerranean
US Liberal
Types of Mortality in Welfare
State Regimes
• Early versus Late Premature Death :
Potential years of life lost before and after
Age 55.
• External versus Universal Causes: The
relative significance of accidents, suicide
and violence versus aging .
Contribution of early premature death
(> 54 years) 2000
70.00
Males
Females
65.00
60.00
55.00
50.00
45.00
europe
Britannia
Corporate
Medit
Soc Dem
USA
Type I male mortality 1963-93
45.00
40.00
pyll per 1000 male pop
35.00
30.00
25.00
20.00
15 . 0 0
10 . 0 0
19 6 3
19 7 3
19 8 3
19 9 3
2000
Europe
Corporate
Mediterranean
Britannia
Soc Dem
US Liberal
Trends in Type I premature death in Welfare State Regimes
Females 1960-2000
15
So c D em
M e dit
Pyll per 1000 population all causes
13
B rit a nnia
C o rpo ra t e
E uro pe
11
US A
9
7
5
3
1960
1970
1980
year
1990
2000
Type II male mortality 1963-93
110 .0 0
10 0 .0 0
pyll per 1000 male pop
9 0 .0 0
8 0 .0 0
70 .0 0
6 0 .0 0
50 .0 0
19 6 3
19 73
19 8 3
19 9 3
2000
E uro pe
C o rpo ra t e
M e dit e rra ne a n
B rit a nnia
So c D em
US Libe ra l
Trends in Type II premature death in Welfare State Regimes
Females 1960-2000
75
70
Pyll per 1000 population all causes
So c D em
M e dit
65
B rit a nnia
60
C o rpo ra t e
E uro pe
55
US A
50
45
40
35
30
25
1960
1970
1980
year
1990
2000
Substantive Findings
• The risks of premature death declined substantially in all WSRs
1960-2000
• The Social Democratic regime charted the shallowest decline, but
this regime had a massive head start in 1960
• Gender is a major factor of differentiation: One man’s healthy
society is not necessarily one woman’s healthy society. To illustrate,
contrast the male and female trend of Britannia.
• Among males, the social democratic charts the most progressive
course; but Britannia also charts a progressive trajectory. .
• For females, the familist Mediterranean regime is the surprising
success story, charting low rates of type I mortality and the most
progressive decline of type II. The familist regime does not enjoy a
reputation as a female friendly society yet it emerges as the most
propitious epidemiological environment for women .
Social Democracy & Deviant Denmark
Denmark makes a significant negative
contribution to the sluggish performance of social
democracy in the 2nd half of the 20th century
In 1960, Denmark recorded rates of premature
death below the European average but above the
social democratic norm, the gap between
Denmark and the other representatives of this
regime type widened each decade , by 2000,
Denmark displayed the highest relative risk of
any nation.
Circulatory 1993 - Denmark and other Nordic
Cirrhosis 1993 - Denmark and other Nordic
50.00
Rate of PYLL
25.00
2.50
0.00
0.00
1-4
15-24
5-14 15-24 25-34 35-44 45-54 55-64 65-74
DenmarkAge Group
other Nordic
25-34
35-44
Denmark
Lung Cancer 1993 - Denmark and other
Nordic
45-54
55-64
65-74
Age Group
Other Nordic
Breast Cancer 1993 - Denmark and other
Nordic
Rate of PYLL
25.00
Rate of PYLL
Rate of PYLL
5.00
0.00
0.00
15-24
25-34
Denmark
35-44
45-54
55-64
65-74
25-34
35-44
Age Group
Other Nordic
Denmark
45-54
55-64
Age Group
Other Nordic
65-74
The disciplining dimension of welfare capitalism
• This example also underlines an important but neglected ingredient of
WSRs, the fact that they exert an important disciplining function, and,
perhaps, the greater the redistribution, the greater need for social
discipline if the ideological integrity of the system is to be maintained.
• Note also, the necessity and the utility of taking a long run view to
understand the importance of the various factors impinging on
population health status in different places.
• From the trend in the social democratic regime, we can see that this
regime had already made remarkable headway improving population
health status before the Golden Age of the Welfare State. Ironically,
the decline of mortality slowed down in this period when the policies
which today characterize this mode of social organization were being
established. As we have seen , Denmark goes some way to explain this
unexpected finding, and exploring the reason reminds us the
importance of long standing cultural influences directly impacting
upon health while also furnishing an hospitable normative
environment for institutional reform and development. In northern
Europe, especially, temperance was an important element in the
modernising project and one of the cornerstones of social democracy
Explaining Danish Deviance
• From all that we know of the class gradients in health, there are no grounds
for doubting the benefits of the redistributive policies of the type pioneered
by Social Democracy
• At the same time, the WSR is not the only factor, other structural
influences are at work shaping population health status and we must be
aware of them in assessing the health generating capacity of a WSR.
• How does Denmark differ form her neighbors? The proximate factor in
Denmark’s relative disadvantage is cigarette smoking, why did Danish
women turn to the cigarette with greater intensity than the women of
Sweden or Norway. Possible factors include urbanization, male smoking
culture, but I suspect the most significant is the legacy of Temperance.
• Of the 3 social democratic nations, Denmark was alone in not embracing
temperance with attendant legislation to civilize drinking behavior as the
society modernized. Sweden by contrast, introduced the most rigorous
controls to discipline the population in this respect. The absence of a
temperance legacy may explain the resistance of Danes to anti-smoking
propaganda and the toll of mortality that followed.
• This reminds us that that we should not overlook the important civilizing
mission of the ‘policy makers’ who made social democracy. Temperance
was a strong element in the social ideology of Nordic social democracy, I
believe it is an important component of the early epidemiological
advantage of Scandinavia.
Final Point: The Importance of Cigarette Smoking
for Health Inequality
• Cigarettes is a versatile accessory to modern life, in its time it has served
as a style icon, a badge of adulthood, a symbol of liberation a source of
pleasure not to mention, a handy self administered device for managing
stress. For sociologists, it has even been put forward as a proxy for social
class.
• It is a very important factor in the widening health inequalities, it explains
the bulk of the widening gradient in health inequality within and between
nations. Ironically this is a public health triumph with a downside for
health inequality.
• Smoking explains the contrary experience of male and female trends in
Britannia and for the relative disadvantage of Denmark.
• It is also a factor, by its relative absence, in the advantageous
Mediterranean female trend.
• Cigarette smoking signifies the claim of autonomy even in contexts of
extreme constraint, it reveals that part of the cause of health inequality is
the extension of the freedom to choose.