The Feasta Review, number 2

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Elizabeth Cullen is a medical doctor with a particular interest in public health. She currently attends NUI, Maynooth, studying the likely effects of climate change on Irish health. She is a trustee of Feasta and a committee member of the Irish Doctors' Environmental Association. She lives in Co. Kildare.

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Unprecedented growth, but for whose benefit? - page 3

ELIZABETH CULLEN

Murder rate up, other crime down

Figure 18 shows that, while the murder rate increased in the second half of the 1990s, the incidence of other crimes declined between 1990 and 2000 when allowance is made for the rise in population. (The crime data is per thousand people and uses the scale on the left while the murder rate is per 100,000 people and uses the scale on the right.) This decline in crime could have been because the potential criminals found that they had more legitimate opportunities open to them.

Prosecutions for public order offences increased by 161 %136 between 1996 and 2001. Intoxication in a public place and threatening, abusive or insulting words or behaviour were the most frequent charges and accounted for almost 80 per cent of proceedings taken in 2001. Between 1996 and 2001 the number of public order related referrals to the Garda Juvenile Diversion Programme grew by 162 per cent; almost identical to the growth in proceedings taken. The most striking change was in referrals for intoxication in a public place, which increased seven-fold. In a survey of 27 garda divisions undertaken in 1997137 by the Garda Research Unit, it was found that alcohol was a factor in 88% of public order cases, 54% of criminal damages and 48% of offences against the person.

In the light of the rise in these crimes, it is not surprising that a Garda survey138 revealed in 2002 that a quarter of people felt unsafe walking in their neighbourhoods after dark. 44% of the respondents said they felt less safe than six years previously and the same number also said that crime was rising in their areas. 84% of the respondents believed that crime was rising in Ireland as a whole. People who feel unsafe after dark are 56% less likely to be free of longterm illness139 compared to those who feel otherwise. This illustrates the link between social capital and health. Even young people were concerned. In a survey140 of 1000 people aged 15-24, 77% said in 2003 that they were concerned about the level of crime and street violence. Their level of concern was marginally higher in Dublin.

(iv) More people become homeless

The rapid rise in house prices during the boom years meant that number of people who could not afford housing rose almost fourfold between 1993 and 2002. Furthermore, the number of families assessed as needing social housing increased by 70% in the past six years141 . This figure almost certainly understates the situation. The Focus Ireland website points out that it does not necessarily include those who are involuntarily sharing with family or friends or not accessing services for the homeless. Furthermore, it states that many single people do not register for housing waiting lists as they know that will be given a low priority.

Housing lists lengthen and homelessness goes up

Figure 19 shows that the number of people who were on a waiting list for social housing rose more rapidly than previously during the high growth years. The number of homeless people, the lower line, which had been stable, also began to increase during that period.

Speaking at the launch of Focus Ireland's annual report in 2003, Sister Stanislaus Kennedy142 stated that despite government commitments to halve homelessness by the end of 2005, more people were homeless than was the case when the commitment was given in 1999. People were also spending longer periods homeless and those who were 'sleeping rough' were younger. The average time spent in B&B accommodation had shot up from twenty days in 1993 to an average of 18 months. She described the worsening homelessness figures in the wake of fifteen years of 'unprecedented economic growth' as 'nothing short of disgraceful'. The number of families on local authority housing lists had increased from 39,000 families in 1999 to almost 48,500, she said. In March 2004, the number of people sleeping rough in Dublin was reported143 to be at an all-time high.

'The recent cuts in the rent allowance system, in particular, have already made it even harder than before for most vulnerable to keep a roof over their heads,' Declan Jones, Focus Ireland's Chief Executive144 said in 2003, adding that 85% of people on the housing list were struggling to survive on €15,000 or less a year. Every budget since 1997 had seen the better-off getting more than the less well-off, he commented.

He was right. A quarter of all houses built in 2003 were second(holiday) homes. Many of these were subsidized by tax reliefs145 and their construction had the effect of pushing up land prices, making it harder for young people to buy their first home.

House prices soar and become less affordable

Figure 20 Although average incomes increased by around 73% between 1994 and 2002, house prices rose by much more than that as the graph shows. They were up by roughly 250% nationally and by 300% in the Dublin area.

B. Did the physical environment improve?

When a country's economy doubles in size, almost everything changes in some way and many of these changes will have an effect on the population's health.

(1) Air quality

(i) Nitrogen oxide emissions

The number of vehicles registered in Ireland increased by 68% between 1990 and 2001 and this contributed half of the 9% rise in Ireland's nitrogen oxide emissions146 between 1995 and 2000, bringing them up to 125,000 tonnes a year. Much of the balance came from power stations. Nitrogen oxides trigger asthmatic attacks, croup in children, and in the longer term, cause reduced lung function. They also contribute to ground level ozone, a respiratory irritant. It will be necessary for Ireland to reduce nitrogen oxide emissions by 51% by 2010 to comply with EU directives. The European Environment Agency report Environmental Signals 2002 released in 2004 finds that Ireland is not on target to achieve this goal.

(ii) Particulate emissions

Increased traffic also led to an increase in particulate emissions. When fossil fuels are burned, tiny particles are released in the fumes, especially those from diesel engines. Because they are so small, the particles can penetrate far down into the respiratory tract and cause both respiratory and cardiovascular disease. Exposure to particulate matter is now the largest threat to health from air pollution in Western cities147 . Long-term exposure to particulate matter is associated with a reduction in life expectancy of 1-2 years and even short-term variations in particulate matter are associated with adverse health effects at low levels of exposure. Although EU legislation requires that the air should not exceed more than 50 micrograms of particulates per cubic metre more than 35 times in a calendar year, the air in some Dublin streets exceeded this level 76 times in 2000.

Vehicle numbers soar

Figure 21 shows that the number of motor vehicles purchased each year rose rapidly during the high-growth years and fell back as the rate of growth began to moderate. The result, of course, was a massive increase in road congestion.

(iii) Volatile organic compounds

Volatile organic compounds (VOCs) are released by road traffic, paints and organic solvents. Although emissions from vehicles are reduced by catalytic converters, the benefits of fitting them have been offset by the huge increase in vehicle numbers. VOCs interact with nitrogen oxides in the presence of sunlight to form low-level ozone, a respiratory irritant that also retards plant growth. Ireland needs to reduce its emissions of solvents and benzene by 37,000 tonnes from the 87,000 tonnes released in 2001 to comply with EU directives148 .

(iv) Sulphur dioxide

Sulphur dioxide is associated with asthma and with cardiac disease. It is produced largely from the combustion of fossil fuels, particularly in power stations. Ireland is now one of the three worst emitters of sulphur dioxide in the EU, releasing 131,489 tonnes in 2000. It will be necessary to reduce this to no more than 42,000 tonnes a year by 2010 if we are to comply with the UN Gothenburg Protocol and EU limits.

(v) Greenhouse gas emissions

On a per capita basis, Ireland's greenhouse emissions are amongst the worst in the world. As can be seen from figure 22, the energy demand from a growing economy caused our carbon dioxide emissions to begin to rise so rapidly in the mid nineties that by 2001 they were well over twice the 13% increase on its 1990 emissions level the country had been allocated by its EU partners under the Kyoto Protocol. These emissions contribute to the alarming build up of these gasses worldwide, and the warming they help produce will seriously affect the health of many people, particularly in the poorest areas of the world. Ireland will be affected too and we can expect to see an increase in heat-related deaths and in cases of food poisoning.

Carbon dioxide emissions increase

Figure 22 The average Irish person's emissions of carbon dioxide have tripled since 1950, rising from one tonne per person to three. It took thirty-five years to reach the two-tonne mark, and, as growth accelerated, only fifteen to add the other tonne. These emissions will have to be reduced to slow down global warming. This will require a complete restructuring of the way the economy works.

Economic growth increases oil demand

Figure 23 shows that until the mid 1990s, Irish oil consumption was below the EU average. It doubled between 1989 and 2001, while that of the EU and the world, as a whole remained unchanged. In 1996, Ireland's oil consumption per capita exceeded the EU average, and continued to rise rapidly during the high growth years. The country is now one of the most oil-dependent in the world. Source: Amarach149

Industrial and agricultural chemicals

Economic growth meant the increased use of chemicals in industry and agriculture. Although chemical production is increasing in the EU, very little is known about the health and environmental effects of most of the vast numbers of chemicals being made and used. The report of the UK's Royal Commission on Environmental Pollution150 issued in June 2003 found that only forty of the more than 30,000 synthetic chemicals currently available on the UK market have been subject to a systematic risk assessment. 'We are conducting a huge and unacceptable experiment on ourselves and the environment' Sir Tom Blundell, the Commission's chairman, said.

The Pesticide Control Service of the Department of Agriculture reported in 2004 that in 2002, 29.7% of 551 samples of food contained quantifiable residues of pesticides, and 1.3% of the total sampled had levels exceeding the regulatory limits. The investigators said they would like to increase the number of pesticides for which they were testing and to broaden the range of food products they covered.

While we may know the levels of pesticides on some fruit and vegetables, we do not know the levels of pesticides that the Irish population is carrying in its body tissues. Many pesticides and other chemicals are chlorinated chemicals and these are particularly worrying because not only are they are not easily broken down but the body is unable to excrete them and they accumulate in our body fat. Exposure to chlorinated chemicals has been linked to depressed immune systems, reduction in sperm counts, altered fertility and some adult cancers. In children they have also been associated with low birth weight, genital abnormalities and impaired neurological development. It is difficult to get an accurate picture of the amounts of chlorinated chemicals Ireland imports as there have been frequent code changes for different chemicals and the records have only been computerized since the early 1990s. It is also difficult to estimate the impact these chemicals might be having, as Ireland does not keep a national database of congenital malformations.

Dioxins and PCBs, both chlorinated chemicals, were found in human and animal food in Belgium in 1999 and 2000. Phthalates, which have an oestrogenic effect, exceeded permitted concentrations in children's toys in Denmark in 2001 and 2002. Another class of persistent organic pollutants, flame-retardant chemicals, were found in human milk in Sweden in 2000151 .Yet Ireland has still to ratify the Stockholm Agreement on the phasing out of persistent organic pollutants. Although a survey of dioxins in human breast milk in Ireland showed low levels of dioxins and PCBs, we need to measure levels in fatty tissue as well since the level in breast milk falls in the course of each lactation as the concentration in the mother's body is reduced.

(vii) Domestic chemicals present dangers

The link between environmental estrogens and cancer is well documented. Many detergents contain alkyl phenols which mimic the female sex hormone estrogen and have been associated, along with some other chlorinated organic chemicals, with genito-urinary problems and some types of cancers. The origin of these compounds includes domestic and industrial effluents, leachate from solid waste disposal sites, agricultural leachate and urban run-off 152 . Breast cancer is the commonest cancer in women, and prostate cancer (having overtaken lung cancer) is now the commonest cancer in men, see figure 24. In other words, the commonest cancers in both sexes are hormonally related. The levels of synthetic hormone mimicking chemicals in both the water supply and in the tissues of the Irish people are unknown but some information should be available in 2005 after a study coordinated by Teagasc has been completed 153 .

Commonest types of cancer increase

Figure 24 shows that the number of cases per 100,000 people of the two commonest types of cancer - breast and prostate - have increased steadily over the past few years. Both these cancers are hormone-related and the rise could be due to the increase in synthetic hormones in the environment as a result of increased chemical use.

THE HEALTH BENEFITS OF A MORE EGALITARIAN SOCIETY

Improvements in health

Even a modest reduction in income inequality could have an important impact on population health, including infant mortality, homicide, and deaths from cardiovascular disease and cancers. Recent research from workers at the London School of Health and Tropical Hygiene indicates that eliminating socio-economic inequalities would save almost 13,000 deaths from cancer in the U.K. every five years and almost certainly save more lives in the next decade than innovative treatments154 . In Ireland, North and South, the Institute of Public Health estimates that there could be 6,000 fewer premature deaths every year if the overall death rate could be reduced to that of the highest socio-economic grouping, or 5,400 if it could be reduced to the EU average155 . And in Canada it is estimated that 23% of the years of life lost prematurely before the age of 75 can be attributed to income differences. The disease responsible for most of these deaths is heart disease as a result of social exclusion156 .

The Robin Hood Index 157 is sometimes used to measure the income gap between rich and poor. A reading of 30 on the index means that the top 10% of the population enjoys 30% of national income. Researchers at Harvard have found that the index is so closely correlated with the overall age-adjusted death rate in the US that each percentage point increase in the index is associated with an increase of 21.7 deaths per 100,000 population each year. The Robin Hood index was also positively correlated with infant mortality, cancers and coronary heart disease so much so, in fact, that the Harvard team stated that reducing inequality 30% to 25% would cut the number of deaths from coronary heart disease by a similar amount. Strong associations were also found between the index and causes of death amenable to medical intervention.

Strangely, another measure of inequality in the distribution of income, the Gini coefficient, where 0 signifies perfect equality and 100 means that one person holds all the income, does not show any correlation with health. This could have been because the coefficient gives great weight to changes around the middle of the income distribution and little to changes at the extremes.

Inequality causes reduced life expectation for the wealthy as well as the impoverished: the more unequal the society, the worse are the life chances of everybody in that society. Researchers at the Harvard School of Public Health in the US found that moving from a state with high social capital to one with very little social capital increased one's chance of low to middling health by roughly 40-70%. Indeed, the researchers worked out that if one wanted to improve one's health, moving to a high social capital state would do almost as much good as stopping smoking.

Inequality is not an accident

I want to end as I began, with a speech by an Irish political leader to a group of visiting Americans. Five months before Mr. Ahern boasted of Ireland's transformation to President Clinton, his deputy, Mary Harney, the Tanaiste, (Deputy Prime Minister) made her famous 'Berlin or Boston' speech in Dublin to a group of American lawyers. This is part of what she said:

Political and economic commentators sometimes pose a choice between what they see as the American way and the European way. They view the American way as being built on the rugged individualism of the original frontiersmen, an economic model that is heavily based on enterprise and incentive, on individual effort and with limited government intervention. They view the European way as being built on a strong concern for social harmony and social inclusion, with governments being prepared to intervene strongly through the tax and regulatory systems to achieve their desired outcomes.

Both models are, of course, overly simplistic but there is an element of truth in them too. We in Ireland have tended to steer a course between the two but I think it is fair to say that we have sailed closer to the American shore than the European one. Look at what we have done over the last ten years. We have cut taxes on capital. We have cut taxes on corporate profits. We have cut taxes on personal incomes. The result has been an explosion in economic activity and Ireland is now the fastest-growing country in the developed world.

She then went on to ask the question that I have been asking in this paper 'And did we have to pay some very high price for pursuing this policy option?' she asked. 'Did we have to abandon the concept of social inclusion?' Her answer was quite different from mine: 'The answer is no: we didn't.'

The evidence assembled in this paper suggests that Ireland in fact has paid, is paying and will continue to pay a very high price for adopting American ways and moving closer to Boston. The table below shows where Ireland was positioned in relation to Ms. Harney's two marker countries during the high growth period she felt so proud about.

Table 8: Between Berlin and Boston

Proportion of national income received by poorest 10% of population Proportion of national income received by richest 10% of population (Robin Hood Index) Proportion of children living in households with income less than 50% of median income GDP per capita
(Dollars)
United States 1.8% 30.5% 22.5% 35,935
Ireland 2.5% 27.4% 16.8% 28,662
Germany 3.3% 23.7% 10.7% 26,233
Source: www.nationmaster.com and CIA Fact Book

Tax and budgetary policy

The move towards American levels of inequality was no accident but deliberate government policy. "A dynamic liberal economy like ours demands flexibility and inequality in some respects to function" the Minister for Justice, Michael McDowell, said in 2004. So, in spite of all the international evidence of the harmful effects of allowing the distribution of income to become more unequal, the governments of which Ms. Harney was a leading member shifted income to the better-off. As the ESRI158 stated in 2002: 'On balance, budgets over the past 10 to 20 years have been more favourable to high income groups than low income groups, but particularly so during periods of high growth. During Ireland's recent growth spurt, budgetary policy acted to reinforce income gains for the higher income groups, while involving losses for those in the lower income groups. Measured against the neutral benchmark, tax cuts raised the incomes of top income earners by more than 12 per cent over the years 1995 to 2001; but welfare increases lagged 2 percentage points behind wage growth'.

The effects of these policies are well described by Kawachi 159 even though he did not have the Irish model in mind.

The more unequal the distribution of income, the longer and harder families need to work to keep from slipping behind on the economic ladder. The greater the disparities in wealth and income, the greater the effort expended by producers of goods and services in catering to the spending habits of the rich - more space on first class seats on commercial airlines, building bigger cars, more spacious houses and so on. As the consumption pattern of the rich become more normative, the more ordinary families need to spend to keep up with the average standard of living. The harder families work to pay for lifestyles beyond their means, the less time we invest in maintaining family and community ties. The more caught up we become in competitive spending, the less regard we have for the external costs our habits impose on the social and physical environment.

In cutting taxes, Ireland was leading an international trend. Figure 25 shows that all OECD countries except Japan cut the proportion of national income that governments spent in the past ten years but that as a proportion of its 1993 revenue share, the Irish cuts were proportionately deeper than anywhere else. The result was a big increase in poverty among welfare recipients as the following table shows.

Percentage of persons in receipt of welfare benefits/assistance living in poverty.

Welfare benefit 1994 2001
Old age benefit 5.3% 49%
Unemployment benefit/assistance 23.9% 43.1%
Illness/disability 10.4% 49.4%
Lone Parent's allowance 25.8% 39.7%
Widow's pension 5.5% 42.1%
Source: Conference of Religious In Ireland (CORI)

Governments spend less of national income

Figure 25 shows that Ireland cut state spending by proportionately more than comparable nations in the period between 1993 and 2003.

Less Scope for Income Redistribution

Figure 26 The share of national income taken by the Irish government fell sharply during the high-growth years. This left the better-off with more of their earnings, thus widening the gap between rich and poor, particularly as social welfare payments were not increased in step with other groups' higher earnings. Source: John Lawlor and Colm McCarthy, "Browsing Onwards: Irish Public Spending in Perspective", Irish Banking Review

The tax-cutting strategy was deliberately designed to maintain the rate of economic growth by increasing the country's international competitiveness. So as to limit the wage increases sanctioned under the various national wage agreements, the government would undertake to cut income taxes, thus increasing the employees' take-home pay. However, as low-paid workers paid little tax, they could not benefit as much as the more-highly-paid from this arrangement. Moreover, as many of them, such as those in the clothing trade, were in direct competition with workers in low wage economies overseas, there was little scope for their employers to raise their wages directly. Others, such as those in the hotel and catering trade and in retailing, saw their wages kept down by the government-sanctioned importation of workers from Eastern Europe, India, China and the Philippines. The tax changes were one of the reasons the richest 10% of the population increased their share of the national income by about 1.4% during the high-growth years, while, as we saw in figure 6, the poorest 10% saw its share shrink by just under 0.4%.

In short, a system was created in which costs were kept down at the expense of the weakest people in society and, since the tax base had been cut, social welfare payments could not be increased to compensate. This led to the situation we noted in Table 2 - the growth of the number of employed people living on less than half the national median wage. That table also showed that the proportion of the unemployed, the sick and the old who lived in relative poverty rose significantly too.

Thus, if the Robin Hood Index works in Ireland in the way it does in Boston, this means that the cost Ms. Harney mentioned was something like 1,200 additional premature deaths a year, to say nothing of the extra ill-health, violence, stress, and social breakdown the income shift caused.

Conclusion

Essentially, by setting the achievement of economic growth rather than its citizens' welfare as its primary target, successive governments have run the country for the benefit of the economy rather than for the people. If this continues, as the 2004 CORI report, Priorities for Fairness states: 'The government's current policy focus will ensure that substantial numbers of people are condemned to live in social exclusion and substantially larger numbers of people will be forced to accept a poor quality of life for the foreseeable future'

Social welfare gets smaller share of national income

Figure 27 shows that state spending on social welfare and public service pay fell appreciably as a proportion of national income during the high growth years. The reduction in the social welfare bill was in part due to less people being unemployed but another factor was that payments were allowed to fall in relation to average incomes.Source: John Lawlor and Colm McCarthy, "Browsing Onwards: Irish Public Spending in Perspective", Irish Banking Review, Autumn, 2003

Personally, I believe that the best way to counteract income inequality and promote the nation's health would be to introduce a basic income for all Irish residents. There could be three rates, child, adult and retired. The latter rate would also be paid to those unable to work through ill-health. The adult rate would not be worth less than the current package of benefits received by people who are unemployed and the retired rate would be at least equal to the state pension. The big advantage of this sort of arrangement is that it puts everyone in society on the same side. At the moment, taxpayers see social welfare benefits as being paid out of their taxes and consequently resist higher benefit levels. Once a basic income was introduced, however, those in work would begin calling for higher basic income payments just as loudly as those who were unemployed.

It is not possible to prove the relationship between inequality and ill-health as conclusively as it is to test a relationship in the physical sciences. Nevertheless, for me, the weight of the international evidence is compelling. Accordingly, I believe the greatest public health challenge of our time is to scrap a system which puts the achievement of economic growth so far ahead of human welfare that it thinks it unimportant to keep adequate statistics to show the damage it is doing.

'We took the tough decisions and we developed a new model - the Irish model - to manage our affairs' the Taoiseach, Bertie Ahern, told the Fianna Fail ardfheis in March 2004. He continued: 'That is why Ireland today is becoming a better, fairer and more prosperous nation.'

It is hard to see how 'better' and 'fairer' could be correct. The system Mr. Ahern's government runs is depleting our true wealth - our health, our society and our environment. It must be changed. The object of our economy should be to maximize our health and quality of life. It must not be run just to generate wealth and maximize consumption purely to avert the onset of unemployment and recession.

Other people in Feasta are examining how such a change can be brought about, addressing issues such as the way money is created and the development of economic systems that are fairer to people and the planet. Meanwhile, it is to our shame that we cannot more accurately quantify the true price that we paid for allowing the Celtic Tiger the free run of our land and that our leaders can still get away with boasting about the progress they and their tiger have made.

Recommendations

Our economic system, by polarizing income distribution in the interests of economic growth, is the greatest single threat to everyone's health and wellbeing, not just that of the least well off. Income inequality is also a threat to our physical and social environments, which also affect our health The great rise in feelings of stress in the years coinciding with our economic boom, the increase in suicide, the increase in perinatal mortality in babies born into families on lower incomes, the increase in alcohol abuse, the rise in obesity, the increase in drug use, and evidence for the need to reduce our levels of pollutants in the environment, all indicate that something is going seriously wrong.

Here is what I believe needs to be done to correct the situation:

  1. The effects of changes in income distribution on health and well-being need to be measured much more carefully. Irish statistics are totally inadequate at present. We need regular census data on income, income inequality, occupation, social position and health. The Hospital In-Patient Enquiry System should collect such information and disease registries should be established to do so too. The section on income categories in the provisional census form for the 2006 census is welcome, but 60,000 euros as the top income level in a country where income is polarized is a little low.
  2. We also need to measure other indicators of health such as the levels of industrial chemicals in our bodies and the prevalence of depression, asthma, diabetes and other illnesses, on a regular basis. We need to ask meaningful questions about health in the census, and we also need to encourage other countries (not all in the EU) to follow suit.
  3. While the government is committed to reducing absolute poverty, it only monitors relative poverty and, as the latter has such a grave impact on health, this needs to change. The National Anti-Poverty Strategy must not only adopt the targets160 outlined by its working group for reducing the disparities of health between rich and poor but also carry out a Health Impact Assessment for the economic system as a whole.
  4. It is necessary to look again at health education, which currently tends to focus on the individual's health behaviour rather than the social determinants of health. Research has shown that health behaviour, though not unimportant, has a relatively small impact on overall health inequalities.161
  5. The introduction of a basic income should be seriously considered as a way of reducing inequality and rewarding work that the present economic system does not appreciate. As James Robertson says in Transforming Economic Life, A Millennial Challenge 162 , what we need is 'a vision of a people-centered society in which the amounts that people and organizations are required to pay to the public revenue are based on the value they subtract by their use or monopolization of common resources; and in which all citizens are equally entitled to share in the annual revenue so raised, partly by way of services provided at public expense and partly by way of a citizen's income. The citizens of such a society will be more equal with one another in esteem, capability and material conditions of life than now'.
  6. 6. Finally, we need to examine the reasons why our economic system needs continuous economic growth if it is not to collapse. The study should include the problems associated with creating money by lending it into circulation rather than putting it the economy in other ways.

Acknowledgements.

I am greatly indebted to Richard Douthwaite for his help with this article. I would also like to thank Andrew Butt for preparing the graphs and for his helpful comments on the data and its interpretation. I am grateful too to the Garda Press Office and the Central Statistics Office for their help and for the trouble they took in preparing figures for me.

Footnotes

1. Remarks made by Bertie Ahern to President Clinton and members of the Oireachtas, Guinness Storehouse, Dublin, 12 December, 2000

2. Central Statistics Office, Statistical Year Book, 2003

3. 'Ireland ranks as the most globalized of 62 states due to exports', Irish Times 8-1-2003

4.'Three out of four report life is more stressful' Irish Times 9-10-2001

5. SLAN survey Department of Health 1999

6. 'Student Futures' from the Amarach website www.amarach.com

7. 'Celtic tiger did not improve quality of life, study finds' Irish Times 9-11-2002

8. Policy Implications of Social Capital No. 28 NESF, Dublin, Table 8.1, p.100

9. www.amarach.com

10. Urban-rural differences in the occurrence of female depressive disorder in Europe--evidence from the ODIN study. Lehtinen V. et al Soc Psychiatry Psychiatr Epidemiol, June 2003 vol.38(6) pp283-9

11. 'One in 3 Dublin women hit by depression' Sunday Times 22-7- 2003.

12. Eurobarometer 57

13. Eurobarometer 47

14. 'Mental illness study results 'frightening'' Irish Times 9-1-2004 and 'Young men face 'frightening suicide risk'' Irish Independent 9-1-2004

15. As 9

16. Monitoring Poverty trends in Ireland, Results from the Living in Ireland survey ESRI, Dublin, 2003 Policy research series No 51

17. State's engines for tackling poverty are failing those on the margins' Irish Times 25-8-2000

18. CORI website 19-7-03

19. Irish Banking Review Summer 2004 page 7

20. Monitoring Poverty Trends in Ireland Results from Living in Ireland survey 2001 ESRI

21. Helen Johnson, Director Combat Poverty Agency Press Release 7-10-2003

22. '2.8 billion euros needed to help socially excluded- SVP' Irish Times 11-11-2003

23. 'A League Table of Child Poverty in Rich Nations' UNICEF June 2000

24. 'Poverty eroding quality of family life'. Combat Poverty Agency, Dublin, 2002

25. Health of our Children, report of the Chief Medical Officer, Department of Health, Dublin, 2002.

16. PHD expert says 'data observatory needed of health' Medicine Weekly 26-11-03

27. Adverse socioeconomic conditions in childhood and cause specific adult mortality: prospective observational study Davey-Smith G. et al, British Medical Journal 1998 316:1631-1635

28. Socioeconomic determinants of health: Stress and the biology of inequality Brunner E. British Medical Journal 1997 314:1472.

29. Implications of European Public Health 2001 page 41 Institute of Public Health in Ireland

30. Central Statistics Office Statistical Year Book 2003

32. 'A career choice that makes no economic sense' Irish Times 30-7-2003

33. As 31

34. Monitoring Poverty Trends and exploring poverty dynamics in Ireland ESRI PRS41 pages 89-90

35. 'A mechanism converting psychosocial stress into mononuclear cell activation' Bierhaus A. et al Proceedings of the National Academy of Sciences February 18, 2003 vol. 100 no. 4 |

36. Stress and peptic ulcer: life beyond helicobacter Levenstin S British Medical Journal 1998 316 538-541

37. 'Self reported stress and risk of stroke' Truelson T. Boysen G. Stroke 2003 34 856

38.' Does stress cause cancer? There's no good evidence of a relation between stressful events and cancer. Mc Gee R. British Medical Journal 1999;319:1015-1016

39. Chronic stress and age-related increases in the proinflammatory cytokine IL-6 Kiecolt-Glaser J et al Proceedings of the National Academy of Sciences 22-7-2003 Vol 100 No. 15 9090-95

40. 'Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. Kivimaki M. et al British Medical Journal 2002 325:857-860

41. 'Depressed patients have higher heart risk' Irish Medical News 8-3-2004

42. 'Life-course exposure to job strain and ambulatory blood pressure in men' Landsbergis P. et al. American Journal of Epidemiology 2003 157 998-1006

43. 'Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study' Everson et al British Medical Journal 1997 314 553 -558

44. As stated Dept. of Health Website Health Statistics Jan 2004 Section B

45. Eurostat 2003 as reported Irish are top of EU baby league Irish Times .6-3-2003

46. 'Irish look forward to longer lives' Irish Times 24-6-2004

47.' Martin boasts of success in fighting killer disease' Irish Times 24-2-2004

48. The Ecology of Health, Schumacher Briefing No.3 Green Books. Totnes 2000, page 10

49. Richard Wilkinson, Unhealthy Societies, Routledge London, 1997

50. Richard Wilkinson, 'Income distribution and mortality: A 'natural' experiment', Sociology of Health and Illness, vol. 12, No. 4, 1990, pp. 319-412.

51. The Health of Nations: Why inequality is bad for your health, Ichiro Kawachi, New Press, New York 2003

52. For a contrary view see Mackenbach 'Income inequality and population health' British Medical Journal 2002 324 1-2

53. R. Douthwaite, The Growth Illusion, Lilliput Press, Dublin 2000 page 102

54. Wilkinson R. 'Class mortality differentials, income distribution and trends in poverty', 1921-1981 Journal of Social policy vol 18, No. 3, pp.307-35G.D. Smith, et al, 'Socio-economic differentials in health and wealth. Widening inequalities in health - the legacy of the Thatcher years', British Medical Journal, 1993, Vol. 307, pp1085-6. from The Growth Illusion Douthwaite R. Lilliput Press 2000 page 108

55. 'The height and weights of adults in Britain' Knights I. 1984 cited in The Growth Illusion, Douthwaite R. Lilliput Press, Dublin, 2000 page 108

56. 'Two-tier system puts poor to the top of sickness list' Irish Times 1-12-00

57. 'The Health of our children' Department of Health 2002

58.'Inequalities in Mortality 1989-1998' Institute of Public Health in Ireland

59. Personal communication 10-3-2004

60. 'Inequalities in Health Hard facts' TCD Department of Community Health and General Practice 2001

61. 'The child is father to the patient' The Economist June 14th-20th 2003 page 85-86

62. 'Trend analysis and socio-economic differentials in infant mortality in the Southern Health Board, Ireland (1988-1997'). Ryan CA et al. Irish Medical Journal 2000 Oct 93(7) 204-6

63. 'Quality of Life in Europe An illustrative report European Foundation for the Improvement of Living and Working Conditions' page 55

64. 'Inequalities in Perceived Health: A report on the All Ireland Social capital and health survey' Dublin Institute of Public Health in Ireland 2003 Balanda K. Wilde J.

65. 'Ireland's drink problem' Professor Ian Robertson Professor of Psychology TCD Irish Times 10-12-02.

66. 'Suicide rate in adolescents trebles in just one decade' Medicine Weekly 1-10-03

67.' Suicide level higher than RTA deaths' Irish Medical News 30-9-2003

68. 'Ireland has second highest suicide rate worldwide among young males' Medicine Weekly 26-11-03

69. 1 October 2003 Medicine Weekly

70. 'Suicides being under-reported' Irish Medical Times 16-8-02

71. 'Suicide rates don't show full extent of despair' Irish Medical News 7-1-2

72. 'Rate of suicide in young females has doubled in past ten years' Medicine weekly 13-3-02

73. 'Blame everything on the box' Irish Times 1-11-02.

74. '55% of young people know of peer suicide attempts' Irish Times 20-9-03

75. 'One fifth of adolescents at risk of developing psychiatric disorder - Mater study' Medicine Weekly 19-2-2000

76. 'Teenage girls top new parasuicide tables' Medicine Weekly 16-10-02

77. 'Pre-teen depression rise alarms doctors', Sunday Times 16-5-04

78. '4.5 million euros allocated for suicide prevention' Medicine Weekly 25-2-2004

79. 'Mental Wealth' Consumer Choice August 2003 page 319

80. Interim report of Strategic Task Force on alcohol Department of Health 2002 page 5

81. How much do we drink? Irish Times 21-11-03

82. 'Time to ban alcohol advertising, minister' Irish Times 10-3-2004

83. 'Irish Drinking Culture-The results of drinking and drinking related harm - a European Comparison' Department of Health 2003

84.'Conference told of increase in binge drinking' Irish Times 10-10-02

85. Department of Health 2002

86. 'Teenage Alcohol, Smoking and Drug use in the Mid-West region' Mid Western Health Board 2003

87. 'Drinking and drugs drive teachers out of the classroom' John Walshe Irish Independent 6-4-04

88. 'Current trends in substance misuse in Ireland' Irish Psychiatrist Vol 5 Issue 1 Feb/Mar 2004

89. 42% of 14 year olds 'consume alcohol' Irish Times 14-11-03

90. O'Neill M et al 'Adolescent Alcohol Misuse- searching for a solution' Irish Medical Journal October 2003 Vol 96 No 9279-280

91. 'Study links obesity to social classes' Sophie Blakemore, Birmingham Post 2-3-04

92. 'Obesity and cardiovascular disease' Daly S. and O'Shea D. Irish Medical Times 8-8-2003

93. 'Reducing obesity rates by half could cut cancers by 36,000' Medicine Weekly 17-3-04

94. 'Body Mass Index and Overweight in Adolescents in 13 European Countries, Israel, and the United States' Lissau I et al Arch Pediatr Adolesc Med, Jan 2004; 158: 27 - 33.

95. 'One-third of 4-year-olds overweight, study finds' Irish Times 25-3-2004

96. 'Five year European diabetes study announced' Irish Times 10-1-04

97. 'Child obesity is no longer just 'American problem' Sunday Tribune 3-3-03

98. 'Warning that Ireland 'will drown in diabetes''. Irish Medical News 7-10-03

99. 'Irish children are health 'time-bomb'' Irish Medical News 2-10-03

100. 'Environment 'key to obesity'' Irish Times 6-11-03

101. 'Irish children are health 'time bomb'' Medicine Weekly 24-9-03.

102. 'Only 8.8% go to work by bus or train' Irish Times 16-10-03

103. 'Children's diabetes clinic halts intake due to demand' Irish Times 23-12-2003

104. 'GPs indicate obesity has increased their workload' Medicine Weekly 7-11-03

105.'42% of females 'always trying to lose weight' Irish Times 20-10-03

106. Personal e-mail from BodyWhys, an organization dealing with eating disorders, 4-11-03

107. 'Task force planned to target obesity' Irish Times 25-12-2003

108. ''Fat tax' no way to tackle obesity' - expert Irish Times 18-6-4

109. Statistical release, Quarterly National Household Survey, 30-5-2002

110. 'Medical card holders sicker than others' Irish Times, 6-12-2002

111. 'Health level 'better' for non-medical card holders' Irish Times, 28-3-2000

112. 300,000 patients on anti-depressants Irish Times 18-5-2004

113. Annual report of the National Cancer Registry 2002

114. 'The Policy Implications of Social Capital', National Economic and Social Forum report No. 28 p. 30

115. As 49

116. 'Social capital, income inequality, and firearm violent crime' Kennedy BP et al Soc Sci Med 1998 Jul;47(1):7-17

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118. Social capital, income inequality, and mortality Kawachi I. et al American Journal of Public Health 1997 87 1491-8

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120. As 9

121. As 64

122. Address to AGM of Irish Doctors' Environmental Association, Crumlin, 14-2-04

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124.As 9

125. As 64

126.

127. Personal communication 17-7-2004

128. Poverty Today, No 2, p. 3, Summer 2003, Combat Poverty Agency

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130. As 64

131. Trends in crime and their interpretation Home Office Research Study No. 119 (1990) from page 141 Field S. Douthwaite R. The Growth Illusion, Lilliput Press, Dublin, 2000

132. 'FG describes figures as 'national emergency' Irish Times 4-4-03

133. As 49, page 156

134. 'That was then, this is now; Change in Ireland 1949-1999', CSO, Dublin 2000.

135. 'Sharp rise in murder rate could be linked to increased drinking' Irish Times 29-10-02

136. 'Public order offences in Ireland' page 21 National Crime Council 2003

137.'Think before you drink: Alcohol policy: A public health perspective' August 2003 Department of Health page 88

138. '25% feel unsafe out walking at night' Irish Times 2-10-02.

139. As 64

140. '77% worry about crime, street violence' Irish Times 20-9-03

141. 'Housing need' Cornerstone page 2 Issue No. 15 2003

142. 'Homeless figures 'a disgrace' says Sr. Stanislaus' Irish Times 24-7-03

143. 'Figures show 237 homeless people sleep rough in Dublin' Irish Times 25-3-2004

144. 'State needs €1b for homelessness crisis, says Focus' Irish Times 27-11-03

145.'Housing: A growing trend towards inequality' Burns M. Working Notes Issue 48 June 2004

146.Environment in Focus EPA, Dublin, 2002.

147. Europe's environment: the third assessment European Environment Agency, Brussels, 2003

149. As above

149. 'Ireland's alarming reliance on oil' Gerard O' Neill in Before the Wells Run Dry, edited by Richard Douthwaite. Feasta and Tipperary Institute, 2003

150. www.rcep.org.uk

151. National Resources Defense Council www.ndrc.org website 10-4-04

152. 'The mutagenic, carcinogenic and genotoxic potential of oestrogenic chemicals from Irish effluents' Kathryn Quinn, Dr. Cepta Brougham, Athlone Institute of Technology

153. 'Cancer and endocrine disrupting compounds' Medicine Weekly 14 -1- 2004.

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155. 'All-Ireland report highlights socio-economic obstacles still facing health services' Medicine Weekly 27-7-01.

156. www.yorku.ca/wellness/heart.pdf"

157. 'Income distribution and mortality: cross sectional ecological study of the Robin Hood Index in the United States' Kennedy BP et al British Medical Journal 1996;312:1004-1007

158. 'The distributive impact of budgetary policy: A medium term view' Tim Callan, Mary Keeney, John Walsh, ESRI Dublin, 2002.

159. The Health of Nations: Why inequality is harmful to your health Kawachi I. Kennedy BP. New Press New York 2002

160. The targets are the reduction of the gaps between the lowest and highest socio-economic groups by at least 10% for circulatory diseases, cancers, injuries and poisoning by 2007. There are also targets for reducing the gap in life expectancy and the gaps in birth weight.

161. Quality of life in Europe an illustrative report, European Foundation of the Improvement of Living and Working Conditions, Dublin, page 59

162. James Robertson Transforming Economic Life: A Millennial challenge Schumacher Briefing No. 1 Green Books, Totnes, 1998.

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