A book review of Inner Level by Wilkinson and Pickett

A book review of Wilkinson, R. and K. Pickett (2018). Inner Level: how more equal societies reduce stress, restore sanity and improve everybody’s wellbeing. London, Allen Lane.

By Stephen Bezruchka MD, MPH, Departments of Health Services & Global Health, School of Public Health, University of Washington


What is your world view and what is important to you, your family and friends?  To what do you want to devote your time and energy in order to change in society?

I faced that question almost 30 years ago after working as an emergency physician for decades, essentially putting bandages on people that were removed when they left the ER.  I also came to see that health in the U.S. was getting worse compared to many other countries.  As we spent more on health care than the rest of the world combined, something didn’t compute.

Happenstance, I was exposed to the concept that economic inequality in society was linked to higher mortality.  The concept was remote from treating individual patients.  Changes in income inequality required treating society.  I began teaching, writing and speaking about these ideas.  More and more killer facts emerged with the sound science to legitimize them.  Life in the United States had lost the glitter that once made me proud to be a citizen.  We were dying younger and younger than people in 30 to 60 other nations, depending on the death rate considered.  Today our chance of dying is increasing.  Unprecedented among nations this century.

The Inner Level: how more equal societies reduce stress, restore sanity and improve everybody’s wellbeing by epidemiologists Richard Wilkinson and Kate Pickett looks at aspects of society that have a socioeconomic gradient, that is where richer folk have better outcomes than those poorer.  This gradient applies to so many issues we value.  Stress, mental issues (including anxiety depression, schizophrenia, narcissism), as well as bullying, homicide, mass shootings, child abuse, household debt.  The list goes on and on.  More unequal societies have worse outcomes on the many factors we value in society.

The book is organized into three parts, what is going on in one’s mind because of economic inequality, what is going on in society related to economic inequality and finally what is the prescription needed to heal.  The chapters in each part read similarly, beginning with insightful cartoons, presenting data presented in easy to read graphs, and clear writing.  The authors point out that this is not a self-help book, but one that seeks to change the world from its current individualistic focus.  If you are like me and regularly turning to the citations for the evidence, Wilkinson and Pickett have put references in order from number 1 to 512.  This makes the foundations on which the book is built easy to track.  This is a companion volume to their previous work:  The Spirit Level:  why more equal societies almost always do better which had the US version with a slightly different subtitle:  why greater equality makes societies stronger,  perhaps watered down for this side of the Atlantic.  The American version will be released in January but those wishing to get a head start can order the book from the U.K.

What needs to be done to heal the planet?  Wilkinson and Pickett stress the need for more economic equality and a transition to a different political economic structure with worker-owned corporations.

How is this going to happen?  We are by nature an altruistic species that for most of human existence practiced vigilant caring and sharing.  That changed with the development of agriculture and a hierarchy arose.  Economic inequality, whether wealth or income, is at the highest levels in history.  To decrease it big-time requires creating awareness, and mobilizing for change.  We have to cast off the individualist mentality that has strait-jacketed us.   It won’t be easy but must be done.  The Inner Level gives you arguments for transforming society.