40 years on, we know that it is chronic stress that lies at the heart of our vulnerability to poor health; stress is related to such a wide range of diseases that its effects look like more rapid ageing.
We also now know that the most potent generators of chronic stress are embedded in the social fabric, in our lives and relationships with one another. Three aspects stand out above others: the damaging effects of low social status, whether that is due to poverty, racism or any other cause; the quality of care in early childhood; and the strongly protective effects of friendship and social integration.
Relationships matter so much because other people can be our best sources of security, comfort and cooperation or our worst rivals. Just as bad relationships are highly stressful, friendship is relaxing and restorative. We have evolved an extraordinary sensitivity to relationships, because getting them right has always been crucial to our survival.
Experiments have shown that it is threats to self-esteem or social status, where other people can judge us negatively, that most reliably raise our stress hormones. These feelings are so potent, causing anything from fury to stomach-clenching shame. Even simple experiments have shown they have serious consequences, including slower wound healing and weaker resistance to infection.
Stress responses evolved to help us cope in brief emergencies, but if we worry for weeks and years, our health and wellbeing suffer. To understand what is going on, it helps to think about monkey dominance hierarchies. They are essentially bullying hierarchies, held together by fear, with the strongest at the top and the weakest at the bottom. Low-status monkeys have more biological signs of stress, including high levels of blood-clotting hormones which increase the risk of heart disease. Low social status has exactly the same biological consequences in humans. And it isn’t only our bodies that are affected, low social status also shapes how we think and feel. Psychologists have repeatedly shown that people score much less well on tests of ability if the experiment contains even a subtle reminder that they belong to a category of people who are thought to perform less well.
Beyond physical health, low social status and poor relationships with other people also contribute to most of the other problems associated with relative deprivation – including worse mental health, lower educational performance among school children, loss of social cohesion and the increase in violence triggered by disrespect, loss of face and humiliation.
We all want to be valued and appreciated: being looked down on, shamed or rejected is agonising. The experiences of low social status and racism are deeply stigmatising. To be treated as inferior, to be devalued and thought less of – whether on grounds of class, ethnicity, sexuality, or gender – is intolerable.
The coronavirus pandemic has again exposed our health and economic inequalities, just as the death of George Floyd again exposed the awfulness of racism. It is good that current public debate is turning to the possibilities of “building back better” rather than simply returning to the status quo.
So what can be done to ensure our health and resilience? The key is that class and status, prejudice and discrimination are strengthened by larger income differences. As George Bernard Shaw said: “Inequality of income takes the broad, safe, and fertile plane of human society and stands it on its edge,” with the result that some people are valued very much more than others. The rich are made to seem more superior and the poor more inferior, inequalities in health and in young people’s life chances increase, while social mobility slows.
The picture could hardly be simpler: almost all the problems that we know are related to social status within our society get worse when status differences are increased. If we want a less dysfunctional society and a healthier population, building back better means addressing the scourge of income inequality.
• Richard Wilkinson is a researcher in social inequalities in health. He is emeritus professor of public health at the University of Nottingham