Medical Writing Health Economics and Market Access In the Bookstores

Volume 22, Issue 3 - Health Economics and Market Access

In the Bookstores

The Spirit Level

Ever had a ‘ping’ moment? This book might have been mine. I'm not a natural pessimist, but Western society today seems less cohesive and people more materialistic, stressed, unhealthy, and unhappy than in times gone by. Wealth and status seem to be valued above everything else. Consumerism is seemingly unstoppable as the world hurtles towards an Armageddon of its own making. My personal views are not that uncommon, as discussions with friends and family show. Why we are in this situation and what can be done about it is less obvious. What I really need is someone to join up the dots …

Wilkinson and Pickett, both UK-based academics with economics and epidemiology backgrounds, present a compelling ideological argument, apparently underpinned with copious economic and political evidence. They hypothesise how material success has led to social failure and back this up with statistical meta-analyses of international (23 of the world's 50 richest countries) and US-based (50 American states) socioeconomic data. Graphs – with advice on how to interpret them – are used to convey key outcomes messages. The graphs mostly show income inequality (x-axis) in relation to various health and social outcomes (y-axis) with a regression line to show the ‘best fit’ relationship.

The outcomes are broadly defined as community life and social relations (including trust, women's status, and spending on foreign aid); mental health and drug use (including mental illness, mental distress, and use of illegal drugs); physical health and life expectancy (including infant deaths); obesity (both adults and children); educational performance (including literacy scores, high school drop out, and 15-year olds aspiring to low-skilled work); teenage pregnancy (both births and abortions); violence (including homicide and children's experience of conflict); imprisonment and punishment (including prisoner numbers); and social mobility.

Most of the negative health and social outcomes, it seems, are more prevalent in more unequal societies, and the positive measures (levels of trust between members of the public and women's status [as a combined index of women's political participation, employment, earnings, and social and economic autonomy]) show higher values in more equal societies. This is apparently true both internationally and in the US. The authors claim that the relationships are too strong to be dismissed as chance findings; the differences between more and less equal societies are large, and these differences are applicable to whole populations rather than subgroups. The conclusion is ‘… that greater equality usually makes most difference to the least well-off, but still produces some benefits for the well-off’.

The individual outcomes are combined into a single index of health and social problems, shown in relation to income equality, in Figure 1.

Figure 1: Index of health and social problems in relation to income inequality.

Click to view

The findings are balanced to an extent by limited discussion of whether or not inequality plays a causal role, and other possible explanations. In this 2010 edition of The Spirit Level, the authors address the critics of the original 2009 edition in a new chapter and add evidence that came to light after the spring of 2008 – when they finished writing the original book – and overwhelmingly supports their findings.

So, what can be done to iron out inequalities when political will is seemingly lacking? The authors assert that ‘greater equality can be gained either from using taxes and benefits to redistribute very unequal incomes or by greater equality in gross incomes before taxes and benefits, which leaves less need for redistribution’, indicating multiple routes to greater equality.


  1. Melton DA, Daley GQ, Jennings CG. Altered nuclear transfer in stem-cell research – a flawed proposal. N Engl J Med. 2004;351(27):2791–2.
  2. Byrnes WM. The flawed scientific basis of the altered nuclear transfer-oocyte assisted reprogramming (ANT-OAR) proposal. Stem Cell Rev. 2007;3(1):60–5.
  3. Elliott C. White Coat, Black Hat. Adventures on the Dark Side of Medicine. Beacon Press, Boston; 2010.



Message from the President
Thirty-seventh EMWA Conference, 7–9 November 2013, Barcelona, Spain
Announcing the Geoff Hall Memorial Scholarships
Health economists and medical writers: Collaboration or collision?
Early benefit assessment of new drugs in Germany: Framework for submission of dossiers by pharmaceutical companies
NICE guidance on health technologies and the role of editors
European network for health technology assessment – EUnetHTA
Guest Editorial: Medical writing and health economics/market access: A health economist's view
Results of the 2012 EMWA salary survey
Successful document collaboration in a virtual team
Profile: An interview with Blanca Mayor Serrano on the state-of-the-art of health literacy in Spain
What can twitter do for me?
In the Bookstores
Journal Watch
The Webscout
Regulatory Writing Developments in paediatric regulation
English Grammar and Style
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Manuscript Writing
Out On Our Own
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  • Victoria White (Tampa, Florida, USA)
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