Video-Conference Forum on Inequalities, Public Health Association of BC, Canada

The Problem of Unequal Societies:

Is Canada ready to tackle the top of the ladder?

by Laura Tomm-Bonde

Award winning author, academic and researcher, Richard Wilkinson, was guest speaker in a video-conference forum hosted by the Public Health Association of BC on December 14, 2010. This forum brought people together from across BC to share knowledge and perspectives with Wilkinson, a leading expert on inequalities from Britain. Wilkinson is best known for the 1999 book he edited with Marmot, Social Determinants of Health, and more recently for the international bestselling book he co-authored with Kate Pickett, The Spirit Level: Why Greater Equality Makes Societies Stronger. The thesis of The Spirit Level underscores what many public health professionals have thought for some time about the interaction between income inequality and health. Income inequality is not just bad for those unfortunate folks at the bottom of the ladder: it is bad for everyone! Wilkinson’s main message focused on addressing those people at the top of the socioeconomic ladder rather than focusing on the bottom. We need to shift our focus, and perhaps our public health discourse, from the lower rungs of the ladder and notions of welfarism, focused on at risk and vulnerable populations, towards the higher rungs of the ladder, meaning the top wealthy.

Wilkinson supports his thesis by documenting how unequal societies have more crime, more drug abuse, more violence, more of every social pathology one can imagine. Exploring the United States in depth, he shows us how close the pattern of health and the pattern of social problems internationally fit the amount of inequality in each society. He argues that inequalities in society are divisive and socially destructive. An integral component of unequal societies, according to Wilkinson, is the drastic income divides that exist.

Income inequalities in society are problematic. The concentration of wealth in the top 1% of society threatens our quality of life because of the deepening of social class divisions. Wilkinson bases his research on the theory of social gradients. The theory of social gradients is a concept familiar to public health professionals, explained by the image of a ladder. From the bottom to the top, each ladder step indicates the socioeconomic levels where particular groups sit within society. Typically disadvantaged groups sit lower on the ladder than privileged groups. 

Wilkinson stresses the need to tackle “run-away salaries” at the top of the social gradient ladder rather than the more common public health response that focuses on those at the bottom of the ladder. While this approach may not be a new concept within public health discourse it is not something we often see done in practice. More often, public health professionals focus on target populations that address inequalities for those who are experiencing them first hand. Targeted populations are often referred to as at risk, vulnerable and marginalized people. Some people refer to this approach as welfarism.

Wilkinson’s suggestion for tackling “run-away incomes” is very much in line with notions of health equity, healthy public policy, and certainly mirrors what many were trying to communicate within the 1986 Ottawa Charter. For example, the Ottawa Charter states that building healthy public policy “combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity” (WHO, 1986). Tackling the problem of unequal societies requires us to be reminded of the classic public health monuments like the Ottawa Charter, but also requires us to consider what it might mean to employ Wilkinson’s suggestion for long-term solutions that focus on fostering greater equity within societies.

According to a recent released report from the Canadian Center for Policy Alternatives (CCPA) we are “that society” Wilkinson is talking about. CCPA’s report titled “Recession Proof” (Mackenzie, 2011) confirms the stark reality of income disparities in Canada. The author of this report interrogates the drastic divide that exists between the average Canadian and the best-paid Canadian CEOs. Canada’s top CEOs appear recession-proof with incomes 155 times higher than the average Canadian (Mackenzie, 2011).  “At the rate they earned in 2009, by about 2:30 on January 3 the average of the 100 best-paid public company CEOs in Canada already pocketed what it would take a Canadian working full-time, all year to earn” (Mackenzie, 2011). The income disparity in Canada that the CCPA draws attention to is an illustration of the concentration of wealth in the top 1% that Wilkinson warns us about.

Wilkinson’s data and the CCPA’s timely report are in some ways acting like a public health warning system that goes off during the quietness before the storm. How bad will this storm hit? Will we be prepared?

In some ways we were comforted to learn at this forum that there are people already actively trying to address the problem of inequalities within BC. This was a breath of fresh air from Wilkinson’s dire message about unequal societies. Two members of community coalitions from Esquimalt and Surrey, BC, working on poverty reduction at the community level spoke about their campaigns to bring back a “Living Wage.” A Living Wage is defined as “the minimum hourly wage necessary for a family of four with two parents working full-time to pay for food and shelter, support the healthy development of their children, escape financial stress, and participate in their communities” (Township of Esquimalt, 2010). These two community groups are advocating for the adoption of a Living Wage policy and program in their municipalities. While creating a living wage is an example of a community driven approach to building healthy public policy it is still within the old paradigm of addressing the lower rungs of the ladder and is not quite getting at the paradigmatic shift that Wilkinson calls for.

Wilkinson’s main message, though, is much more comprehensive than the Living Wage initiative. In other ways this forum was disappointing in that there was no example of a full uptake of Wilkinson’s perspective. Components of Wilkinson’s perspective were honoured, such as community driven responses to build healthy public policy. Canadian examples that exemplified Wilkinson’s main message were entirely absent. I am still left wondering what a Canadian approach might look like to addressing the top-rungs of the ladder. Wilkinson provides countless examples of top-ladder approaches in his book, but still no Canadian examples.

I think we need to turn to people like Linda McQuaig (2010), a Canadian journalist, who co-authored the book ”The Trouble with Billionaires” for a Canadian tailored response. She outlines countless strategic and innovative tax solutions and social justice approaches that would be options for a Canadian system. McQuaig’s ideas are supported by other authors such as Vega and Irwin (2004), who argue that continuing to tackle health inequalities from the mainstream policy approach of “pro-poor” is insufficient (p. 482). In the same vein as Wilkinson, Vega and Irwin claim that factors other than income powerfully shape the social gradient. They reiterate that pro-poor approaches limit intervention to the bottom rungs of the social ladder and leave untouched the core social processes that generate health inequities.   

Whitehead and Popay (2010) also argue that to reduce inequalities requires action on inequalities in wider social determinants operating outside the health system. Cohen and Reutter (2007), like McQuaig, speak from a Canadian perspective when addressing poverty in the context of children and families. They argue that one strategic response to addressing poverty in this context would be to better prepare public health nurses with advocacy and social policy skills. They claim that nurses are knowledgeable about advocacy but are given few opportunities to practice this within the educational practice arena and lack organizational support in the workplace to fully employ this public health work. Therefore further acknowledgment of public health nurses’ potential role in social policy advocacy work is needed with the organizational support to realize their skills. All of these authors would agree that focussing on the most disadvantaged or the lower rungs of the ladder will not reduce health inequities sufficiently. We must take people like McQuaig (2010), Vega and Irwin, Whitehead and Popay (2010) and Cohen and Reutter (2007) seriously if we accept Wilkinson’s clear standpoint that we will never tackle inequalities unless we tackle the top rungs of the ladder.

With a lack of Canadian examples of top-ladder approaches, I wonder how a full uptake of Wilkinson’s perspective in public health might shift our discourse. It seems to me that a paradigm shift has yet to occur in Canada as it has in other countries. If public health puts healthy public policy at the center of our agenda, a complete transformation will have to occur in our discourses and our practice. This left me wondering what strategies and details one might employ to institute, for example, a redistribution of incomes within Canada. How might an uptake of Wilkinson’s perspective change the roles of public health practitioners such as nurses, environmental health officers and medical health officers? I also wonder how academic and research programs will need to shift their focus. If we accept Wilkinson’s message to approach inequalities from the top-down rather than from the bottom-up as the only way to truly tackle inequalities, we need to consider how to shift the traditional discourses of welfarism, pro-poor and social safety net, for example, in the overall public health movement to mirror this vision.


Cohen & Reutter (2007). Development of the role of public health nurses in addressing child and family poverty: A framework for action. Journal of Advanced Nursing, 60(1), 96-107.

Mackenzie, H. (2011). Recession proof: Canada’s 100 best paid CEO’s. Growing Canadian Center for Policy Alternatives. Retrieved from

Township of Esquimalt (2010). Living Wage Policy: Council Requests Written Feedback. Retrieved from

Vega, J. & Irwin, A. (2004). Tackling health inequalities: New approaches in public policy. Bulletin of the World Health Organization, 82 (7), 482.

Whitehead, M. & Popay, J. (2010). Swimming upstream? Taking action on the social determinants of health inequalities. Social Science & Medicine, 71, 1234-1236.

World Health Organization (1986). Ottawa charter for health promotion. Retrieved from

Published: CPHFRI, Vol 3 Issue 1, April 2011

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