Stigmatization and socio-economic differences in health in modern welfare states

Abstract

e have been puzzled with evidence that socio-economic differences in health are not necessarily smaller in the well-developed welfare states of Europe. With some variations, these states have egalitarian traditions aimed at redistributing incomes and the provision of collective services. It is then even more puzzling that in the most egali- tarian Nordic countries, such as Sweden, socio-economic differences in health are not necessarily smaller than in less generous countries. Recently, Mackenbach 1 provided us with a systematic overview of the possible causes of this paradox. One of Mackenbach's main conclusions is that socio-economic differences in the developed European welfare states might increasingly be based upon selection effects. The opportunities for upward social mobility, he argues, might increasingly have left behind a group of people in lower socio-economic positions that have worse cognitive abilities and more adverse personality profiles (creating an 'unhealthy' homogenization) than is the case in lower socio-economic groups in less egalitarian countries where opportunities for upward mobility are smaller. Mackenbach also evaluates the psychosocial theory for its potential to explain socio-economic differences in health in modern European welfare states and the Nordic countries in particular. Reflecting upon 'relative deprivation', he reports that the effects of 'relative deprivation' might be more substantial in countries with more possibilities and thus higher expectations of upward mobility. This might result in higher levels of frustration and stress in those (still) ending up in lower socio-economic positions. However, Mackenbach regards the hypothesis as largely specu- lative. More generally, he acknowledges the importance of psychosocial factors, such as control beliefs, for the persistence, but not for the widening of socio-economic differences in health in many countries. According to him, the harsh material circumstances of the past have been tackled in current modern welfare states, including their adverse psychosocial consequences. Although stress due to harsh material cir- cumstances might have become less common, stress induced by other societal developments might, in our view, still have contributed to the presence of socio-economic differences in health in the well-developed welfare states of Europe, as well as to their widening in many of such countries. We therefore would like to propose an additional, we think plausible, explanation for the presence of socio-economic differences in health in modern welfare states. Could it not be that in these countries, lower socio-economic groups are more often victims of stigmatization? In countries, where there are many opportunities for upward mobility and where cognitive abilities and personality characteristics are the main driving forces behind upward mobility, those who stay behind in the social hierarchy might frequently be looked upon as stupid or lazy. 2-4 We propose that processes of stigmatization should be examined in more depth, regarding their relation with socio-economic differences in health in countries that differ in opportunities for upward mobility and particu- larly in the population's belief therein (between countries). The speed with which the meritocratic legacy and the emphasis on individual re- sponsibility are getting a foothold in countries could, we hypothesize, also be related to the pattern of widening socio-economic differences in health (within these countries). Young, already in 1958, foresaw the possible undesirable consequences of the trend towards increased meritocracy: