Unprecedented growth, but for whose benefit? - page 3
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
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
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
(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
Economic growth increases oil demand
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
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
|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.
|Old age benefit||5.3%||49%|
|Lone Parent's allowance||25.8%||39.7%|
|Source: Conference of Religious In Ireland (CORI)|
Governments spend less of national income
Less Scope for Income Redistribution
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.
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
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.
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:
- 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.
- 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.
- 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.
- 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
- 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. 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.
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.
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102. 'Only 8.8% go to work by bus or train' Irish Times 16-10-03
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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
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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
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129. See ref 14 and discussed in 'Settling for less than we wanted, but more than we had' Fintan O'Toole Irish Times 20-4- 2002
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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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Growth:The Celtic Cancer,
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