Is the UK becoming more like the US, when it ought to be following the example of its Scandinavian neighbours instead? With inequalities in mortality widening dramatically in the UK and the US, this is one of the arguments made in Danny Dorling’s book ‘Unequal Health’.
Danny Dorling specialises in measuring and representing inequality so as to give the injustice new impact. The book is made up of some of the papers, cartograms, presentations, reviews, interviews and correspondence that Dorling has produced over the last several years, together with some newly written chapters. He addresses lots of big themes: global suffering, hope and despair, justice and iniquity. Dorling tries to find evidence to give hope that global suffering is improving overall, but in doing so he is forced to look beyond Europe to the measurement of mortality on a global scale. While Dorling’s overarching theme is inequality, encompassing education, housing and employment, he privileges health inequalities as the ‘worst of all’.
Dorling argues that in affluent countries we are allowing inequalities to widen to an extent that has not been seen for two hundred years. Charles Dickens’ ‘A Christmas Carol’, published 1843, highlighted the divisive effects of poverty in Victorian London. John Lanchester, in his ‘Big Fat London Novel’ entitled Capital, makes the point that the inequalities which engaged Dickens, once again characterise London life. While the disposal of sewage may have given way to first tobacco smoking and then road traffic fatalities as major health problems, Dorling argues that the breadth of the inequalities now are as shocking as they were in Dickens’ time. The UK is following the US lead in allowing the very rich to get richer, while poverty becomes entrenched at the other end of society.
In the UK and the US inequality in housing, education, employment and health is tolerated and apparently even promoted by some policy changes. The widening and entrenching of inequalities is not merely a side-effect of ‘reform’, but rather a key outcome, as with changes to housing benefit in London, making residence in the capital impossible for a whole class of people. Dorling is good on the detail of the political process and how government policy translates into deteriorating conditions for those in receipt of health services and welfare.
The Nordic model haunts Dorling’s book as an alternative to the US-style-widening of inequalities in the UK. The benefits of progressive taxation and a comprehensive health and welfare system in terms of minimising inequalities in life expectancy, mortality and other indicators of life chances are well documented.
In Sweden there is no difference in the likelihood of a poor or a rich child finishing their schooling – a remarkable achievement and an indicator of a determined policy of social inclusion. Sweden’s welfare state of the 1970s is described by David Harvey as representing ‘the ideals of a redistributive socialism with progressive taxation and a reduction of income inequality and poverty achieved in part through the provision of elaborate welfare services.’ Since the 1970s, and particularly since Sweden’s economic crash of the early 1990s, neoliberal ideology has informed a restriction of the welfare state in the name of promoting economic growth. While Sweden’s model of social democracy remains relatively generous to citizens and to those who are recognised as legitimate recipients of welfare, levels of inequality have risen nonetheless. Dorling has little to say about the effects that the ‘neoliberal turn’ has had on health inequalities in Scandinavia.
Scandinavia’s programme of out-sourcing statutory services to private provision has been lauded by the right-wing press. The private provision of tax-funded health and welfare services is represented as a pragmatic and rational response to growing health and social care bills. Liberal commentators are more willing to see the potential costs of reductions in the generosity of the welfare state and attempts to reduce the cost of service provision.
The contribution of widening socio-economic inequalities to recent civil unrest in Swedish cities has been mooted. Apparently triggered by the fatal shooting of a resident of Husby, 30 km north of central Stockholm, where 80 per cent of residents are of immigrant background, car-torching and the wrecking of public buildings spread to other cities in May 2013. Over a week of unlawful destruction of property was taken by some as evidence that a generous welfare system and immigration policy constitute a failed social experiment. In this world view, the restriction of immigration and the contraction of welfare provision, health services and social care, together with a reduction of their cost through private provision, is simple pragmatism and certainly not ideological.
Unemployment in the Stockholm suburbs where the unrest started, and among people of immigrant background in general, is higher than among the general population. Swedish formal inclusion in terms of eligibility for benefits and services is accompanied by what is called ‘institutional discrimination’ in the UK. In Sweden it is being called ‘structural discrimination’, but as yet, it is little discussed in official circles.
In Sweden where equality and social justice are proud icons of national identity, it is difficult to talk about the quiet, unofficial operation of discrimination, in the face of liberal and progressive intentions and legislation for equity. In a society where statutory efforts to include all citizens in formal welfare benefits and the national health service are so extensive, informal, institutional discrimination is shocking. A commitment to statutory and legal recourse to right the wrongs of inequality does not preclude discrimination, whether an unintentional and unintended consequence of institutional practices or as a result individual prejudice.
Dorling’s analysis of the limitations of the Nordic model with respect to diversity, immigration and inequality would be of interest.