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Scandinavian Journal of Public Health, 2017; 45: 113–120

https://doi.org/10.1177/1403494816683878

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Introduction

At the start of the 21st century, countries around the world are faced with substantial inequalities in health within their populations. People with a lower level of education, a lower occupational class or a lower level of income tend to die at a younger age and to have, within their shorter lives, a higher prevalence of many different health problems [1].

These inequalities are not a recent phenomenon. Historical evidence suggests that inequalities in mor- tality were already present in many European coun- tries in the 18th and 19th centuries, may have narrowed during the first half of the 20th century and have been increasing again since the 1960s [2].

Paradoxically, health inequalities have persisted despite the rise of the welfare state and are not sys- tematically smaller in countries with more generous welfare arrangements [3].

In a previous paper [4] I have tried to explain this paradox by drawing on nine social–epidemiological ‘theories’ of the explanation of health inequalities. This analysis suggested that the persistence of health inequalities in modern welfare states is likely to be explained by an eclectic mix of factors, including the persistence of material inequalities at a lower, but still substantial, level, the increasing importance of consumption behaviour and non-material resources

Persistence of social inequalities in modern welfare states: Explanation of a paradox

JOHAN P MACKENBACH

Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands

Abstract Aims: Social–epidemiological explanations of health inequalities usually take the existence of social inequality as a given and ignore the fundamental questions of why social inequality exists in the first place and why it is so persistent. I review here theories of the explanation of social inequality to identify the processes and/or structures responsible for its persistence. Methods: This paper is a review of the relevant sociological literature. Results: The sociological literature suggests that what persists over long periods of time is not a specific manifestation of social inequality but a ‘meta-phenomenon’: the fact that there are different social positions, that these social positions give access to different levels of resources in some graded way and that the distribution of individuals over social positions follows rules that create inequalities in the opportunities for achieving a more advantaged social position. The durability of social inequality in this generic form can then be understood from the persistence of the underlying mechanisms and processes – for example, humans are driven by self-interest, while most objects of their striving are in short supply, therefore a struggle for rewards is present in all societies; humans are unequally endowed, therefore some are more successful in this struggle for resources than others; and the inequalities resulting from these individual level actions are structurally fixated through the intergenerational transmission of (dis)advantage, various societal institutions, and cultural factors. Conclusions: The sociological literature suggests that some mechanisms producing and perpetuating social inequality are more ‘benign’ than others. Health inequalities may be more than a consequence of social inequality and may play a more profound part by amplifying social inequalities.

Key Words: Health inequalities, social inequality, persistence, functionalist theories, conflict theories, ecological-evolutionary theory

Correspondence: Johan Mackenbach, Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail: [email protected]

(Accepted 18 November 2016)

683878SJP0010.1177/1403494816683878J.P. MackenbachSocial inequalities in modern welfare states research-article2016

REvIEW ARTIclE

114 J.P. Mackenbach

for population health, and the increasing importance of health-related selection during social mobility.

Typically, however – and this is a problem not explicitly addressed in the previous paper – social– epidemiological theories take the existence of social inequality – that is, the fact that resources are une- qually distributed over social positions – as given. They then proceed to explain how inequality in access to these resources ‘gets under the skin’, or, in more sophisticated language, how the embodiment of social inequalities occurs [5].

This is even the case in the fundamental causes theory, arguably the most sociological among the theories aiming to explain health inequalities. This theory stipulates that socioeconomic status is a fun- damental cause of inequalities in mortality in the sense that it embodies an array of flexible resources, such as money, knowledge, prestige, power and ben- eficial social connections, which can be used to avoid disease risks or to minimize the consequences of dis- ease once it occurs [6].

For this theory, the unequal distribution of these flexible resources is the starting point for the mecha- nisms generating health inequalities, but the even more fundamental question of why these resources are unequally distributed, and why this unequal dis- tribution is so persistent, is left for other theories to explain. However, this question cannot be ignored when we try to understand why health inequalities persist in modern welfare states.

In this review, I therefore broaden the field of enquiry into why health inequalities persist in mod- ern welfare states by reviewing theories of the expla- nation of social inequalities in order to identify the processes and/or structures responsible for the lat- ter’s persistence. As the sociological literature on this topic is massive, it is inevitable that this overview is based on existing works of synthesis without attempt- ing to independently verify the empirical basis for each of these sociological theories.

This essay is structured as follows. I start with a characterization of what is to be explained: what is social inequality and what exactly is it that has per- sisted over time until the present day? I then proceed by reviewing sociological theories of how social ine- quality is generated and of the processes and structures that make it so persistent. I conclude by discussing whether health is simply one of the many outcomes of social inequality or whether it plays an independent part in the generation of social inequality.

Durable social inequality

In a famous metaphor, Schumpeter [7] compared occupational structure with a hotel that is always

occupied, but always by different persons. Suppose, Schumpeter wrote, that there is a multi-storey hotel with the lower floors containing many people living in small, cramped rooms and higher floors contain- ing fewer people with much nicer rooms. Even if the guests are allowed to move around and change their rooms every night, at any given moment there will be guests in uncomfortable rooms as well as guests in more comfortable rooms.

I will borrow this metaphor to clarify what social inequality is and in what sense it has persisted over time. The metaphor has three elements that resemble the structure of society, each of which represents a key element of social stratification [8]: the floors rep- resent different positions in society; the different out- fits and levels of luxury of the rooms represent the resources that those positions give access to; and the allocation of guests to floors and rooms represents the recruitment of individuals into different social positions, first at birth and later when they change social position during their lives after acquiring edu- cational credentials, entering and exiting the labour market, changing occupations during their careers and gradually building up or losing wealth.

The big difference between a hotel and society is, of course, that a hotel is a physical structure, built of durable stone and glass, whereas society does not have a physical reality, but exists only in the actions and interactions of its members. A hotel also usually has a fixed number of floors and rooms, whereas the number of available positions in society is not neces- sarily fixed. But despite the non-physical nature of society, all three elements of social inequality are to some extent durable over time.

What persists over time is not the precise alloca- tion rules, nor the precise outfit of the rooms, and not even the precise number of floors and number of rooms per floor, because all of these change in smaller or larger ways over time. What persists over time is a ‘meta-phenomenon’: the fact that there are different social positions, that these different social positions do give access to different levels of resources in some graded way, and that the distribution of individuals over social positions is not random, but follows cer- tain rules that create inequality of opportunity for achieving a more advantaged social position [8].

What the defining characteristics are of the social positions that determine the distribution of resources has certainly changed over time. For example, in newly industrialized societies occupational class is the most important predictor of a person’s access to material and immaterial resources, whereas in post- industrial societies education is more important as a result of the greater importance of knowledge in all sectors of society [9]. In some European societies

Social inequalities in modern welfare states 115

there is evidence for the recent emergence of a new wealth elite as well as a new precariat, with less easily distinguishable groups in the middle, which are not a simple continuation of the social classes of the past. Although these changes illustrate that the ‘floors’ in the hotel may have been rebuilt, the structure of soci- ety is still layered to some extent, as is evident from the systematic differences between these groups in their access to a variety of resources [10].

Persistence of inequality also characterizes the distribution of resources. Economic resources, both in terms of income and wealth, are still highly une- qually distributed within society. There is good evi- dence that these inequalities are on the rise again in many countries after they had been substantially reduced in the middle decades of the 20th century, partly as a result of income redistribution and the rise of the welfare state [11]. Persistence also charac- terizes the unequal distribution of non-material resources, such as social capital (e.g. those on low incomes have smaller social networks), cultural capi- tal (e.g. the higher educated have higher levels and more varied patterns of cultural participation), polit- ical influence (e.g. those in professional occupations have easier access to political decision-makers) and even psychological resources (e.g. those in higher occupations have different scores on various dimen- sions of personality) [10,12–14].

Despite substantial upwards intergenerational social mobility as a result of changes in the economy and expansion of higher education, and despite a possible decline in relative inequality in occupa- tional or educational achievement by social origin in some countries, parents’ occupation and level of education still to a large extent predict their chil- dren’s socioeconomic position [15]. The same is true for income and wealth: inequality in income and wealth across generations may or may not have become less since the Second World War, but clearly there is still a considerable intergenerational trans- fer of material advantage [16].

Theories of social inequality

Explaining social inequality has been at the heart of the sociological enterprise since its very beginnings and, as a result, there is an abundance of theories dealing with social inequality, including those of Rousseau, Marx, Weber, Durkheim, Pareto, Parsons, Davis, Bourdieu, Wallerstein, Elias, Tilly and many others. It is beyond the scope of this essay to review the sociobiological literature, which has documented the existence of social hierarchies in animal species other than humans [17,18]. However, the fact that forms of social inequality exist in animals with less

complex behaviour than humans suggests that these hierarchies are to some extent the outcome of univer- sal processes [19].

Two main strands of sociological reasoning on the origins of social inequality are often distinguished: a more conservative and a more radical tradition [9]. The more conservative line of reasoning is based on the premise that social stratification has a useful function in human societies because hierarchy improves group functioning. Hierarchy has been sug- gested to improve collective decision-making, facili- tate the coordination of individual action (e.g. in the form of a division of labour) and increase motivation of members to act in the group’s interest [20].

More specifically, this functionalist theory, as articulated by Parsons [21], Davis and Moore [22] and others, argues that social stratification benefits society as a whole because it gives monetary and non-monetary rewards to those who are most useful to society and therefore provides indispensable motivation for those with talent and a taste for enterprise.

How this may work for income is often explained in terms of classical economic theory: because in free markets resources will automatically be distrib- uted optimally, people in occupations that generate more welfare to society as a whole will be paid higher wages. Because individuals differ in their human capital, genetically and/or due to differences in investment in education, they also differ in their earnings [23,24]. The same mechanism may operate for other resources that are distributed on the basis of merit, such as comfortable working conditions or social prestige.

As this illustrates, sociologists in the conservative tradition do not only emphasize the usefulness and inevitability of social inequality, but also regard social inequality as at least partly arising from the proper- ties and decisions of individuals. Macro-level mani- festations of social inequality are then seen as emergent, in sometimes complex ways, from individ- ual level behaviour [25]. For example, differences between children of lower and higher socioeconomic status parents in educational achievement can to some extent be explained by theories of rational choice, which predict that in view of the resource constraints experienced by poorer families, it is irra- tional to make large investments with uncertain out- comes in the education of their children [26].

This also implies that inequality in educational achievement will be generated again and again in each new generation, as long as these individual level mechanisms continue to operate. However, the sec- ond, more radical tradition of sociological theorizing on the origins of social inequality suggests that other

116 J.P. Mackenbach

explanations are more important. In this tradition, competition or conflict is seen as the ultimate basis of social inequality. For example, according to classical Marxism, the exploitative nature of capitalism is the main motor of social inequality: those who own the means of production have the power to, and actually act to, exploit those who are dependent on selling their labour in the labour market [27].

Since the 19th century, the nature of the economy, and with it the occupational structure, have changed considerably and differences in access to resources between different groups of employees have become at least as important as those between the owners of the means of production and their employees [28]. Neo-Marxists therefore recognize a more finely graded distinction between social groups in modern societies on the basis of their ability to extract rents – that is, earnings in excess of their investments in education or the value of their efforts for society. For example, although the CEOs of large companies are formally employees, their salaries and other benefits far exceed those of other employees [29].

These material advantages or rents naturally cre- ate an interest among the beneficiaries in the protec- tion of their advantages, both for themselves and for their children. This interest is protected in subtle and less subtle ways: according to Marxism, it has led to the structural embedding of social inequality in a range of institutions (e.g. laws that protect property and an educational system that is more easily acces- sible to the children of the rich) as well as in society’s dominant culture (e.g. religious beliefs that legiti- mize social inequality) [30].

Although these two sociological traditions hold partly contradictory views on the origins of social inequality, they can to some extent be integrated as in the ecological-evolutionary theory of Lenski [9]. This theory is based on the premise that humans are driven by self-interest and that most objects of their striving are in short supply. It follows that a struggle for rewards is present in all societies. Also, because humans are unequally endowed (physically and mentally, genetically and through upbringing), some are more successful in this struggle for resources than others. However, because human societies need cooperation, there is a limit to the resulting material inequality in that the resources necessary for basic functioning will generally have to be distributed on the basis of need – this is in the interest of all. But the surplus will be distributed on the basis of power – that is, on the basis of class membership [9].

Lenski’s ecological-evolutionary theory [9] also explicitly recognizes that even though social inequal- ity in a generic sense is durable, its specific

characteristics (i.e. the nature of the social positions that determine the distribution of resources, the nature of the resources that are distributed unequally and/or the rules determining the allocation of indi- viduals to social positions) may change over time – for example, under the influence of environmental change or economic development. The largest ine- qualities in political and economic power are found in agrarian societies, whereas mature industrial soci- eties tend to have smaller social inequalities [9].

This decline in social inequality is due to a range of factors, some of which directly relate to changes in the economy, whereas others can be seen as indi- rect effects mediated by social and cultural change. These include: massively increased productivity, which makes it easier for the upper class to share resources with the lower classes; expansion of knowledge and the increased importance of educa- tion for highly specialized jobs; the necessity for the upper class of sharing authority with the middle class in technologically complex societies; the rise of democratic ideologies and the greater bargaining power of lower classes when organized in labour unions; and the expansion of the role of government and the rise of bureaucracy [9,31].

It is important to note that in both the conserva- tive and radical traditions, as well as in Lenski’s syn- thesis [9], the emphasis is on social inequality in economic resources and this is indeed a central ele- ment of social inequality. However, other theories have also acknowledged the importance of non- material resources. For example, Weber’s classical theory of social stratification makes a distinction between economic, political and symbolic (or cul- tural) resources, allowing for the possibility that social stratification systems are not uni-, but multidi- mensional [32].

Neo-Weberians have taken this a step further by recognizing the important role of social and cultural capital in reinforcing economic capital, by creating exclusionary processes that support the social clo- sure of groups that have managed to get access to the most resources [33]. Bourdieu [34] and DeMaggio [35], for example, have argued that, in post-indus- trial societies, education is the gateway to higher paid occupations and that because the education system reflects the culture of the higher classes, the cultural capital of parents determines their children’s success, so that higher education remains relatively closed to the lower classes.

Why is social inequality so persistent?

On the basis of these sociological theories, we can start to see how social inequality as a meta-phenomenon

Social inequalities in modern welfare states 117

can be durable: this requires that the processes and/or structures generating social inequality continue to be present.

At first sight, functionalist theories have good papers for explaining the persistence of social inequal- ity because they posit that all societies need a certain degree of social inequality to provide an adequate reward system. As long as there are differences between individuals in human capital – for example, in the form of physical strength, cognitive ability or motiva- tion to work – and as long as society gives higher rewards to those who are perceived to have more value to society as a whole, some individuals will end up in social positions with more access to valued resources.

There is undoubtedly some merit in this expla- nation, which has its parallel in the neoclassical economic explanation for the recent widening of income inequality in many countries: because of rising demand for highly educated labour on the one hand, and restricted supply due to the scarcity of talent and variations in educational investment on the other, wage inequality between higher and lower educated people has risen strongly [36]. Globalization, with its enhanced opportunities to employ unskilled labour in countries with lower levels of income, also plays a part [37].

Seen from the side of the individuals involved, it could be argued that as long as humans are at least partly driven by self-interest, they will strive for those social positions that give most access to valued resources and thus social inequality will continue to exist. These individual level behavioural mechanisms can have counterintuitive effects. For example, and paradoxically, it has been found that educational achievement now explains more of the association between social origin and occupational class than in the past because parents in higher occupational classes are better able to let their children succeed in the educational system. Because social origin still influences educational achievement, this apparent meritocratization actually amplifies inequality in occupational position by social origin [15].

Other more or less benign accounts for the per- sistence or even rise of social inequality in spite of countermeasures point to demographic changes that have contributed to an accumulation of advan- tage or disadvantage in the same families by changes in behaviour at the individual level. For example, in many countries there is increased educational homogamy (i.e., partners in marriage having the same level of education) [38,39]. Also, as a result of higher life expectancy, there is more overlap between the lifetimes of grandparents and grandchildren, which may strengthen the multigenerational trans- mission of (dis)advantage [40].

However, conflict theories also go some way to explaining the persistence of social inequalities. First, not all the individual level mechanisms men- tioned here are as benign as it may seem. One does not need to hold a black view of human nature to acknowledge that the pursuit of self-interest by the better-off often directly or indirectly harms the less well-off, and that they know it. Few highly educated people are prepared to send their children to socially mixed schools, but most instead choose to maxi- mize the opportunities of their own children by sending them to socially homogeneous schools with better educational outcomes. Rich people use their higher incomes to buy the best house in the best neighbourhood they can afford to maximize their own well-being, the safety of their families and access to the best facilities, thereby indirectly con- tributing to residential segregation and welfare losses for poorer people [41].

It has also been shown that the recent explosion of income inequalities in many countries cannot be explained from market forces alone and that a shift in power relations also plays a part. Managers of large companies have increasingly come into a posi- tion in which they determine their own earnings, thereby increasing the degree of rent-seeking behav- iour [37].

And, of course, at the individual level, a person’s material and non-material inheritance is a given, which implies that people’s starting points in life are hugely different. Although countries differ in their degree of intergenerational transmission of disadvan- tage, social origin is still very much a determinant of cognitive ability, educational achievement and subse- quent social position and life trajectory, partly as a result of the active striving of well-off parents to transmit their advantages to their children [42].

Once a hierarchy is established, it is reinforced by psychological processes. Power transforms individual psychology such that the powerful think and act in ways that lead to the retention and acquisition of power. Status generates expectations for behaviour and opportunities for advancement that favour those with a status advantage. Hierarchies are also rein- forced by the psychological tendency to rationalize the social structure of the status quo [43].

Although the durability of benign and less benign individual level mechanisms may explain part of the persistence of social inequality, structural factors are likely to play a major part as well. People entering the labour market usually do not themselves create their jobs, but, in Schumpeter’s terms [7], enter a hotel room that for them is a given, as part of the occupa- tional structure in which the economy operates. The distribution of rewards over these occupations is also

118 J.P. Mackenbach

not decided on a case-by-case basis, but part of long- standing agreements and regulations.

It is also not difficult to still see various forms of exploitation underlying social inequality. Over the past decades there has been a clear shift in the bal- ance between labour and capital to the advantage of the latter and, as a result, wages have risen much less than company profits. This is partly due to the fact that ideological changes have led to declining union membership and to less income redistribution by governments [11].

Residential segregation is another structural factor that helps to perpetuate social inequality. Children growing up in poor neighbourhoods have less school readiness and achievement and more behavioural and emotional problems, probably through a range of pathways (institutional deficiencies, less support- ive social relationships and less favourable social norms and collective efficacy) [41].

Cultural factors may also contribute to the dura- bility of social inequality. We already briefly men- tioned Bourdieu’s theory of social distinction on the basis of cultural capital, which reinforces the relative closure of the educational system to children from lower social classes [34]. Ambition and other tastes for educational and occupational advancement are dependent on cultural factors such as time prefer- ences and role models. Children from lower class families may have self-fulfilling beliefs due to dis- crimination and may be discouraged by the negative expectations of teachers and other elements in the dominant discourse [16].

Clearly, then, the persistence of social inequality rests on the durability of the underlying mechanisms operating at the individual level, be they benign or less benign, as well as on the durability of institu- tional arrangements and cultural factors in which social inequality has to some extent become fixated. This also explains why the modern welfare state has not been able to eliminate social inequality: it has softened some of the sharper consequences, for example, by reducing the prevalence of absolute and relative poverty [44], but has only marginally affected the many underlying mechanisms and structural factors.

Had more radical redistribution measures been taken, then social inequalities might have been reduced more effectively, but the welfare state has never had such revolutionary goals. On the con- trary, its rise reflected a compromise between the interests of employers and employees, between the labouring and the middle classes, and between dif- ferent political ideologies [45]. It therefore should not come as a surprise that its redistributive and other effects have been modest.

connection with health inequalities

The persistence of social inequality – in the form of a virtual hotel with different floors determining the levels of luxury of the rooms and with implicit or explicit rules for allocating guests to rooms – is a nec- essary condition for the persistence of health inequal- ity. It is not in itself a sufficient condition, but it is easy to see how health inequalities almost follow automatically from social inequalities: humans have an innate drive for survival and for avoiding illness and thus will inevitably use some of the resources that their social position provides to pursue these goals [6].

A more intriguing question is whether health ine- qualities are only a consequence of social inequality or whether they play a more profound part in the generation and persistence of social inequalities. Over the past decades, research into health inequali- ties has become an ever larger part of the total research effort devoted to social inequalities as a result of the enormous amount of research money available for health-related studies [46]. However, there has been little communication between this new field and the wider field of sociological enquiry into social inequality and there has consequently been little attention to the possibility of connections at a deeper level.

Let me list a few mostly speculative options as hypotheses to be tested in further study. First, because health has become so highly valued in mod- ern society, one may wonder whether it has not also become a defining characteristic of a person’s social position, alongside the more conventional character- istics of education, occupation, income and related variables such as sex, ethnicity and neighbourhood of residence. Some sociological studies have indeed started to treat health status as one among many dimensions of inequality [12]. Although this may not be helpful for those who want to explain inequalities in health from the processes and structures involved in social inequality, it could also be argued that there is no theoretical reason to a priori separate health from other social phenomena and thus to entertain the idea that the persistence of health inequalities partly explains the persistence of social inequalities.

Second, and well-recognized in the social–epide- miological literature, health certainly plays a part in the allocation of individuals to social positions, one of the three central elements of social inequality. Although the contribution of health-related selec- tion to total health inequality remains uncertain and debated, health-related social selection has been shown to operate over the life course: children with physical or mental health problems have less good

Social inequalities in modern welfare states 119

educational outcomes than their healthy peers; adults with health problems are less likely to be upwardly socially mobile and more likely to experi- ence a loss of income; and elderly people who have experienced health problems during their lives have less opportunity to accumulate wealth than those who have not [47–49]. One could perhaps argue, borrowing terminology from the fundamental cause theory, that health is a flexible resource that can be used to create social advantage [50]. Thus whereas social disadvantage causes health disadvantage, the latter may, in its turn, aggravate social disadvantage, creating vicious circles [51].

Third, if social inequality helps society to function smoothly, as functionalist theories stipulate, one may start to wonder whether health inequality also has some usefulness for society. Is receiving a few extra years of life and having to spend less years of life with disease and disability not an enormous bonus on top of the other rewards for perseverance in education and excelling at one’s job? Of course, to be effective as an incentive, these health benefits would have to be widely known by the general public, either con- sciously or unconsciously, but some recent studies do suggest a fairly widely diffused awareness of health inequalities (between the poor and the middle class – less so between the middle class and the rich) [52].

Fourth, if social inequality is the outcome of com- petition for scarce resources, as conflict theories imply, health inequality is among its most dramatic outcomes, with disease and premature death being the losers’ fate. This is certainly also part of the story, as the example of tobacco or junk food shows: it is in the interest of those who have invested their wealth in the tobacco and food industries to continue to sell unhealthy products to those who do not have the knowledge, the self-directedness or the money to buy healthy products. Health inequality then is indeed the ultimate outcome of power relations, as Marxist scholars suggest [53].

But could health inequality somehow also strengthen these power relations? Perhaps because the ill-health of the poor and those with a low level of education helps to further shift the balance of power towards those who already have more of everything? Or because ill-health leads to social exclusion through a loss of work and the necessity of remaining ill to avoid the loss of one’s disability benefit? The higher prevalence of depression in lower socioeconomic groups has been interpreted as a form of adaptive behaviour that strengthens social inequality by mak- ing lower status people refrain from competition [54]. Also, it has been argued that states of depres- sion and anxiety are behaviour patterns necessary for the maintenance of hierarchy in social groups [55].

These are difficult questions to answer, but I sug- gest that health inequality is more than a conse- quence of social inequality and plays a more profound part by amplifying social inequality in various ways that deserve further study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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