Take the Tablets (2023)

Book Review from the August 2023 issue of the Socialist Standard

Sedated: How Modern Capitalism Created Our Mental Health Crisis. By James Davies. Atlantic £10.99.

The basic argument here is that the treatment of mental illness has been medicalised and depoliticised, meaning it has come to be regarded as a problem involving the individual concerned, rather than being part of a wider social situation. Consequently it has been addressed via increased prescription of medication, not by means of talking therapy or sociopolitical changes. This is to some degree due to the lobbying and influence of the pharmaceutical industry (drugs companies such as Pfizer). They aggressively advertise their products and even develop the patient questionnaires that GPs use to diagnose depression.

More generally, though, Davies sees it as part of a wider societal development, that of ‘new capitalism’, neoliberalism, based on deregulation of companies and a regulatory system that is closely linked to those it is allegedly controlling. Depression and anxiety supposedly cost the UK economy £12bn each year in lost productivity and incapacity benefits; this figure is from 2005, so the amount is presumably higher now. Reforming the benefit system and getting people into work was seen as vital, hence workfare and sanctions on the unemployed. Not having a job was regarded as some kind of psychological deficit, rather than being related to the ups and downs of the capitalist economy, just as problems at work were viewed as resulting from individual attitudes and difficulties, not the boring and often pointless nature of the job. The Labour government introduced a programme named Improving Access to Psychological Therapies (IAPT), but this had far less impact than claimed, with at most one person in five recovering as a result of it. In 2015 it was announced that IAPT workers would be placed in job centres.

There has been a vast increase in recent years in the prescription of antidepressants. This applies in many countries, including the UK, where the number rose from 25 million prescriptions a year in 2002 to 75 million in 2020. This has not led to an improvement in people’s mental health: far from it, as mental health disabilities have risen massively since the 1980s. When taken over the long term, many psychiatric drugs can be harmful, and it can in fact be more helpful to stop taking the drugs, even for the severely ill. Some research suggests that long-term antidepressant use can increase the risk of a person becoming depressed for life. A recent report (BBC Online, 19 June) revealed that in England two million people have been taking antidepressants for five years, despite limited evidence that a course of treatment of that length has overall benefits.

Davies notes that higher rates of prescribing psychiatric drugs occur in the poorest areas of the UK, and refers to the work of Wilkinson and Pickett (The Spirit Level, The Inner Level), which shows that there is more mental illness where there is greater inequality. He presents a powerful and convincing picture of how capitalism defines and treats mental health problems, meaning it avoids having to confront the real causes.

Paul Bennett

Blogger's Notes:

• Richard Wilkinson and Kate Pickett's The Spirit Level was reviewed in the June 2009 issue of the Socialist Standard.
• Richard Wilkinson and Kate Pickett's The Inner Level was reviewed in the October 2019 issue of the Socialist Standard.

The long and the short of it (2022)

From the June 2022 issue of the Socialist Standard

One of the great advances in the course of human history has been the increase in life expectancy. It may be argued that life was never quite as nasty, brutish and short as Thomas Hobbes once claimed, but the average human lifespan has clearly increased over the millennia and centuries, having more than doubled in the last two hundred years or so. Moreover, it is a matter of not just living longer but of doing so in a better condition too: people who reach the age of sixty now are likely to be healthier and fitter than their parents, and especially their grandparents, were at the same age. Nevertheless, there is a great deal to be said about the determinants and limits on lifespans under capitalism.

Many figures could be cited to demonstrate the improvements. For instance, in 1820 life expectancy at birth was around 29 globally, and 36 in Europe. By 1970 the averages were up to 60 and over 70 respectively. The global chances of a child dying in their first five years are down from 18 percent in the 1960s to 4 percent now. Improved health care and sanitary conditions have clearly been one of the main reasons for these changes. The germ theory of disease led to big reductions in cholera, for instance, in the nineteenth century, when proper sewage systems also resulted in far fewer deaths from typhoid. Infectious diseases have in the ‘rich world’ become less important as causes of death, while chronic conditions such as heart disease and cancer have become more crucial. In some countries, the improvements have been more recent: life expectancy in India rose from 32 to 51 between 1950 and 1968, partly caused by decline in deaths from cholera (and the figure now is 70).

Yet things are not quite as bright and wonderful as is sometimes suggested. Life expectancy varies greatly across nations, and within countries on the basis of such characteristics as skin colour, education and poverty. In some cases, lifespans have been stagnating or even getting shorter. For instance, between 1990 and 2008, life expectancy for white US men without a college degree fell by three years. In general, better educational qualifications imply more years of life, and poverty of course shortens lives. In the US again, black people live on average fewer years than white people, though the gap is narrowing. Unemployment leads to earlier deaths, even when factors such as smoking and previous health conditions are taken into account.

However, in developed countries there is no simple correlation between life expectancy and average income. The US has a high average income but is near the bottom for life expectancy. People in Sweden are less well-off than those in Norway, but have slightly longer lifespans. In The Spirit Level, Richard Wilkinson and Kate Pickett argue that the determining factor is inequality, which is associated with lower life expectancy, lower birth-weights and higher rates of infant mortality: more unequal countries have worse outcomes in these (and many other) areas.

In 2006–08, life expectancy at birth was far higher in Kensington & Chelsea than in Glasgow: thirteen years in the case of men and eleven years for women. This figure is taken from Danny Dorling’s So You Think You Know About Britain? where it is suggested that premature death was in 2010 ‘the great measurer of the North-South divide’, which involved a line drawn from just north of the Wash to the Bristol Channel, with Grimsby on the northern side and Lincoln on the southern. Dorling argues that other contributory factors to a longer life include occupation, height, periods of unemployment, sleeping rough, eating fruit every day, amount of exercise, and weight. Personal lifestyle can make a difference, but a person’s social situation is clearly of great importance too.

Of course the largest differences in lifespan on a global scale do depend on how ‘developed’ a country is. According to worldometers.info, the two countries with the highest life expectancy are Hong Kong and Japan, with over 85 years each. Figures descend via the UK (over 81) and the US (over 79) to Afghanistan (just below 66), Haiti (just under 65) to the Central African Republic (54). Countries in Africa cluster towards the bottom of the list. It is hardly controversial to say that living standards, health care and access to adequate food are crucial here.

One point that applies in every country is that women on average live longer than men (just over three extra years in the UK). Quite why this should be the case is not clear. It did not hold in rich countries in the nineteenth century, and the difference in Russia is now a remarkable ten years. Various reasons have been suggested, but probably it is the combination of various factors. More men than women smoke; differences in child mortality between girls and boys may make a small contribution; biological factors can apply, such as men having more fat surrounding their organs, which increases the extent of cardiovascular disease. One interesting suggestion is that ‘women do not live longer than men only because they age more slowly, but also because they are more robust when they get sick at any age’: women spend more time in hospital than men but still live longer (article by Esteban Ortiz-Ospina and Diana Beltekian at ourworldindata.org).

There can be no doubt that capitalism impacts people’s lives in one of the most fundamental ways, namely how long you will live for. From impoverished countries with short lifespans to places where poverty and living conditions affect a person’s likely years of life, capitalism is simply bad for you. We cannot predict what will happen to life expectancy in socialism, or just what the consequences would be of increasing numbers of elderly people. But we can say that the massive global inequalities will, after a while, cease to exist. Society will be concerned to ensure that everyone leads as long, healthy and rewarding a life as possible.

Paul Bennett

Blogger's Notes:

• Danny Dorling’s So You Think You Know About Britain? was reviewed in the August 2011 issue of the Socialist Standard.
• Richard Wilkinson and Kate Pickett's The Inner Level was reviewed in the October 2019 issue of the Socialist Standard.

Happiness, Happiness? (2020)

From the December 2020 issue of the Socialist Standard

Many aspects of a person’s life can be expressed in numbers: height, weight, income, savings. But what about how happy they are? Can this really be expressed by a score out of ten and compared with how others in the same country felt a year ago or how people living elsewhere feel? That is precisely what is done in the World Happiness Report for 2020, the eighth in the series (online at worldhappiness.report). The period covered is 2017–19, and the main source of data is the Gallup World Poll (www.gallup.com). Typically, a thousand people are asked a set of questions in each country each year, and this smallish number is claimed to give reliable estimates, though no evidence for this is provided.

Let’s look at some of the findings. Countries are ranked in terms of inhabitants’ happiness, from Finland and Denmark at the top to South Sudan and Afghanistan at the bottom; the UK is in thirteenth place. There have been changes in happiness scores since 2008–12: most positively in Benin and Togo, most negatively in Afghanistan and Venezuela. More generally, in connection with the 2008 financial turmoil, it is noted that ‘life evaluations fell sharply during the financial crisis, recovered almost completely by 2011, and then fell fairly steadily to a 2019 value about the same level as its post-crisis low’.

Cities were ranked as well, from Helsinki at the top to Kabul at the bottom, with cities in Scandinavia, Australia and New Zealand receiving high scores. On average, urban populations are happier than rural ones, though this is not always the case in the developed Western world. And ‘the urban happiness advantage is considerably larger for higher educated people than for lower educated people’.

The variables used to explain scores include GDP per capita and healthy life expectancy. But perhaps more interesting are some of the other factors seen as leading to increasing happiness. What is termed ‘well-being inequality’ is of great importance: happiness scores are higher in countries and regions where well-being is more equal, suggesting that people do care about the well-being of others. Also important is the social environment, which involves having someone to count on, trust (as measured by the absence of corruption), a sense of freedom to make key life decisions, and generosity. Strong social environments help protect people against the consequences of adverse events, and reduce well-being inequality.

In general, people are aware of the importance of the natural environment and of the threat posed by climate change. In London, people greatly appreciate green spaces and also blue spaces such as rivers and ponds. Sustainable development has on the whole a positive relationship with measures of well-being. This relates to the UN’s Sustainable Development Goals (sdgs.un.org), such as eliminating poverty and hunger, achieving gender equality, providing clean water and ensuring clean and affordable energy. But two of the goals (climate action, and responsible consumption and production) were negatively correlated with well-being measures, suggesting that action here may not be so straightforward.

A final chapter asks why the Nordic countries are consistently among the happiest, in spite of the long cold winters. These countries have relatively low income inequality, but this is claimed to have in general no clear link with feelings of well-being. Here’s the conclusion: ‘The Nordic countries are characterized by a virtuous cycle in which various key institutional and cultural indicators of good society feed into each other including well-functioning democracy, generous and effective social welfare benefits, low levels of crime and corruption, and satisfied citizens who feel free and trust each other and governmental institutions’.

The report can make no claims about the coronavirus pandemic, but the site’s FAQs do note that in the past major disasters have sometimes led to increases in happiness: ‘The most frequent explanation seems to be that people are pleasantly surprised by the willingness of their neighbours and their institutions to work in harness to help each other.’

What should we make of all this? What does it show about the way the world is and the lives that people lead? For one thing, it is clear that how rich a country is has no simple relation with how happy its inhabitants are. It is true that countries ranked near the bottom are very poor, many of them in Africa, though this also includes India and Myanmar. But wealth does not explain everything, as the US is only eighteenth, just above the Czech Republic, while South Korea and Japan are 61st and 62nd respectively.

It is also interesting to compare this work with that of Richard Wilkinson and Kate Pickett, in The Spirit Level and The Inner Level. They emphasised the crucial role of inequality: the higher the level of income inequality in a country, the more problems such as shorter life expectancy, higher rates of mental illness, more obese people and less social mobility. The level of trust was another aspect studied, based on how many people agreed with the statement ‘Most people can be trusted’; higher levels of inequality caused lower levels of trust.

Trust is also covered in the World Happiness Report, though perhaps measured in a rather different way. And, as noted above, it is part of the social environment, the strength of which can help protect against difficulties in people’s lives, make them feel more secure, reduce the extent of well-being inequality and so increase scores for happiness. The sense of community could be another way of expressing this.

So in plenty of countries the present social system does not deliver reasonable rates of happiness to many, many people. In others, folk fare rather better, but this is more in spite of the competitive and inequality-based system than because of it. Health matters, but also people’s relationships with others and their sense of freedom. Many factors combine to make an individual happy, and a person’s ability to choose how they live and their relations to other people play an important role, and capitalism reduces people’s freedom in this, as in so many other areas.

Paul Bennett

Top to Bottom (2019)

Book Review from the October 2019 issue of the Socialist Standard

Richard Wilkinson and Kate Pickett: The Inner Level. Penguin £9.99.

A decade ago the authors wrote The Spirit Level (discussed in the Socialist Standard for June 2009 and December 2010). There they showed how countries with higher levels of inequality also had more problems such as shorter life expectancy, more obese people and less social mobility. In this new book they extend their analysis to mental and psychological issues (see their website www.equalitytrust.org.uk for more information).

The main claim is that problems with a social gradient (those which are more common as you go down the social hierarchy, e.g. in terms of income) are more severe in more unequal societies. Thus the incidence of schizophrenia per head of population is higher in countries that exhibit greater inequality (almost three times as high in Brazil as in France, for instance). The more unequal US states have higher levels of depression. Generally, a greater degree of inequality can result in more social anxiety, which may itself be responsible for more problem gambling and risky alcohol consumption. Higher inequality can also make people more narcissistic, with an exaggeratedly positive view of themselves, which may again be related to social anxiety. More unequal countries show more bullying by children, fewer visits to art galleries and museums, and less civic participation (belonging to clubs of various kinds).

Inequality, then, is a bad thing, but it has not been a permanent feature of society: ‘throughout most of our specifically human prehistory, we lived in extraordinarily egalitarian hunting and gathering societies, in which food was shared and goods were passed between people’. Hunter-gatherers had no dominance hierarchy, and there were social constraints on alpha-male tendencies. It was the rise of agriculture that was probably responsible for the development of inequality. The social hierarchy which exists today is not the result of natural differences in people’s abilities; rather, any such differences are a product of this hierarchy since, for instance, the number of years spent in poverty can affect a child’s intellectual development.

As in The Spirit Level, Wilkinson and Pickett argue for a more egalitarian social system, or at least one where the degree of inequality roughly corresponds to that in the currently less unequal countries, where the incomes of the richest fifth are ‘only’ about four times higher than those of the poorest fifth. They argue that co-operatives and employee-owned companies can contribute to this and to the aim of a more environmentally sustainable society, with the challenge being ‘to improve well-being without growth’. There would be an end to consumerism, which is itself driven by status insecurity, and to wasteful consumption. The demands of work would be reduced, with greater leisure and so better health, both mental and physical.

The book is very informative about the extent and consequences of inequality, but achieving all that the authors envisage in a society still based on employment and production for profit would be a real pipedream.

Paul Bennett

Unequal society (2009)

Book Review from the June 2009 issue of the Socialist Standard

The Spirit Level: Why more equal societies almost always do better. Richard Wilkinson and Kate Pickett. Allen Lane, 2009.

The main theme of this book, as summarised in its subtitle, is that people living in less unequal societies almost always do better than those living in more unequal societies. This unsurprising theme is spelled out in the nine chapters in the middle part of the book dealing with the costs of inequality in various areas of life and society: community life and social relations; mental health and drug use; physical health and life expectancy; obesity; educational performance; teenage births; violence; imprisonment and punishment; and social mobility.

The first part of the book—titled Material Success, Social Failure—is an uncontroversial, even anodyne commentary on where we are now. Material success is a privilege of the minority: “the least well-off people even in the richest countries sometimes find themselves without enough money for food.”

Socialists are more likely to be interested in what the authors have to say in Part 3, A Better Society. Wilkinson and Pickett present themselves as good people with good ideas writing of the “need to create more equal societies able to meet our real social needs.” I particularly like the cartoon they reproduce of a rich, portly father explaining to his small son, “It goes in cycles, Junior. Sometimes the rich get richer and the poor get poorer. Sometimes the rich get richer and the poor stay the same.”

But the authors are really not as radical as they pretend. They like the charitable, friendly society, mutual, credit-union side of capitalism more then the openly profit-seeking side. They want a nice capitalism, not a nasty one. So when it comes to “what can be done?” they list reforms like “plug loopholes in the tax system, limit ‘business expenses’, increase top tax rates, and even legislate to limit maximum pay in a company to some multiple of the average or lowest paid.”

Stan Parker

The Levellers (2010)

From the December 2010 issue of the Socialist Standard

After his visits to Iceland in the 1870s, William Morris concluded that ‘the most grinding poverty is a trifling evil compared with the inequality of classes’. Where life was hard, there was little alternative to all being poor, but where some people were far richer and more powerful than others, that was far worse, since it was so unnecessary and deleterious. The consequences of inequality have recently been set out at length in The Spirit Level by Richard Wilkinson and Kate Pickett (published by Penguin, and reviewed in the Socialist Standard for June 2009). The authors have established a website (The Equality Trust), which is aimed at ‘the widest public and political understanding of the harm caused by inequality’.

The book’s subtitle, Why Equality is Better for Everyone, suggests the main thrust of its argument. The authors begin by discussing the relation between economic growth and standard of living on the one hand, and life expectancy and happiness on the other. As might be predicted, a low standard of living in a country means low life expectancy (fifty years or less), and an increase in per capita income means people living longer (to over seventy years). But there comes a point at which the relationship disappears, and the wealthiest countries (such as the USA and Norway) do not have greater life expectancy than the rather less rich (like Greece and Germany). A similar point holds for the proportion of people who describe themselves as ‘quite happy’ or ‘very happy’: the first stages of economic growth lead to people being happier but those in the richest countries are no happier than those in the slightly less rich.

But things are different when comparisons are made within one country. In the US, for instance, those living in better-off areas do live longer than those in poorer areas. And for a whole set of health and social problems, Wilkinson and Pickett use a very wide range of data to argue that the more unequal countries have more of the problems. The rates for mental illness, to take one example, are far higher in the US and UK than in less unequal countries such as Germany and Japan.

In addition to mental illness, the problems covered are: levels of trust, life expectancy and infant mortality, obesity, children’s educational performance, teenage births, homicides, imprisonment rates and social mobility. For thirty ‘advanced’ capitalist countries, the level of inequality is measured by the ratio of the income of the top to the bottom 20 percent (so the top includes many slightly better-off workers). To compare inequality across US states, they use a more complex measure called the Gini coefficient. In each case, they do not just record the correlation between inequality and the extent of the problem, but also discuss why such a correlation should hold. And countries tend to perform badly on all the measures if they do badly on one:

“If…a country does badly on health, you can predict with some confidence that it will also imprison a large proportion of its population, have more teenage pregnancies, lower literacy scores, more obesity, worse mental health, and so on.”

Let’s look more closely at some of the problems. The level of trust is measured by how many people agreed with the statement ‘most people can be trusted’. In Portugal only 10 percent agreed (!), in Sweden 66 percent. The proportion in the US who agree has fallen from 60 percent in 1960 to under 40 percent in 2004. It is quite a commentary on the nature of capitalism that so many people do not trust others. As Wilkinson and Pickett say, ‘High levels of trust mean that people feel secure, they have less to worry about, they see others as co-operative rather than competitive.’ And inequality causes lack of trust, rather than vice versa.

As for obesity, a greater proportion of adults and children are overweight in more unequal countries, and this correlation is stronger for women than for men. Lack of exercise and reliance on fast food are the main causes here, and unemployment also tends to lead to weight gain. A more tentative argument is that people suffering from stress respond to food by accumulating fat around their middle as well as by comfort eating. It had not previously occurred to me that Socialism would drastically reduce the extent of obesity, but maybe it will.

In the case of violence, the general argument is that it is in most cases triggered by humiliation and loss of face when people feel they are disrespected or looked down on. Shame and lack of social status (in terms of education, income, housing, etc) can make us all resentful, even if relatively few will react with violence. And ‘increased inequality ups the stakes in the competition for status: status matters even more’. Many research studies have shown that violent crime (especially homicides and assaults) is positively linked with inequality. In the US, 72 percent of juvenile murderers grew up in homes without fathers, as family breakdown leads to inter-generational cycles of violence.

In the book’s final part, Wilkinson and Pickett set out their ideas for ‘a better society’. Some of the general points here are perfectly fine, such as recognition of the importance of friendship and mutual help: ‘human beings have a unique potential to be each other’s best source of co-operation, learning, love and assistance of every kind’. From a long-term historical point of view, the current highly unequal societies are exceptional, since the vast majority of humans have lived in extremely egalitarian societies.

What they argue for, of course, is a more equal kind of social system, in the belief that this will improve the quality of life for all. However, they stand not for Socialism, but for a less unequal form of capitalism. There are different roads to greater equality, say the authors, but they all need to address the basic cause of inequality, the institutions that employ us. So the solution they advocate is for employees to own and control the companies that employ them. Workers might then vote for the chief executive to earn ten times the average wage (thus reducing but not eliminating inequality).

Yet this leaves the wages-prices-profit system of capitalism untouched. Most people will still have to work for wages, companies will still have to make a profit, workers will lose their jobs when the company can no longer make a profit from their labour power, the environment will still be desecrated in the search for cheap raw materials and higher profits. The waste of capitalism, with its banks and credit cards and accountants and ticket-collectors, will remain, as will the causes of wars.

It is clear that slightly less unequal versions of capitalism are possible, but also that they do not put an end to social problems, as even the more egalitarian versions still have them. It will take a socialist society to do away with the grotesque inequalities of capitalism and its inherent problems.

Paul Bennett