Health, poverty and social exclusion
A dual causal pathway
Much of the evidence on the relationship between income and health seems to point to a non-linear relationship, at least at the individual level, indicating that the association is much stronger when income is low (Deaton, 2003). Whether it is absolute income, or poverty, that matters, rather than relative income, or rank, a non-linear relationship with health indicates that reducing income inequality will improve overall health, as the health gain enjoyed by the worse off outweighs the deterioration suffered by the better off. Moreover, when a country reaches the level of wealth at which average income has negligible effects on overall health, improvements could still be achieved by reducing income inequality. And this is independent of any direct effects that income inequality may have on health (Wilkinson, 1996). The evidence would appear to strongly support the case for redistributive policies, and for policies to fight poverty, in a country like the UK. This would not just improve the health of the worse off, and likely reduce inequalities, but it would also improve overall population health. However, redistribution tends to produce its effects in the long term, and may have an opportunity cost in terms of reduced growth and average income. In the short term, health policy measures to improve the health of the worse off tend to require disproportionately large investments, and measures generally aimed at improving population health tend to have a greater effect on the better off, making the simultaneous achievement of a narrowing of inequalities and of an improvement in overall health difficult, if not impossible.
If the broader concept of social exclusion is considered, the case for policies targeted at the worse off appears strengthened. Poor health is a determinant of social exclusion along all its dimensions (Burchardt et al, 2002) as it imposes limitations in consumption, production (directly and through unemployment) and political and social participation. Poor access to health care, often associated with poor health, also contributes to social exclusion as an aspect of limitations in consumption, although one that does not derive primarily from low income. The hypothesis of a dual causal pathway between social exclusion and health is supported, for instance, by evidence on the impact of unemployment on health and mortality; and on the association between health and social networks, voting inequality and participation in unions.