Well-Being, Justice, and Inequality
Isaac Prilleltensky
www.education.miami.edu/isaac
Presented at Positive Nations Conference in Lisbon, Portugal, Sep 29-30, 2010
Outline of Presentation
Well-being Definition Research
Justice Definition Research
Inequalities and Inequities in Well-Being Definition Research
Implications for domestic and international policy and practices
Kerala: A state in Southwest India. The name "Kerala" probably means "land of coconuts."
Kerala: A Community Strengths Story
Population: 31.8 million
Sen: Economic growth is not the whole story. Distribution also matters a great deal for health and human development.
Indicator Kerala India Low income countries
USA
Per Capita GDP $
566 460 420 34,260
Adult Literacy Rate (%)
91 58 39 96
Life Expectancy in Years
Males (f) 68 63 59 74
Females (f) 74 64 80
Infant Mortality per 1,000
12 65 80 7
Birth Rate Per 1,000
17 29 40 16
Well-Being in Kerala
CommunityWell-Being
RelationalAnd
Organizational Well-Being
Personal Well-Being
Tenancy lawsNutrition in school
Distribution Of resourcesLand reform
Infant mortalityLiteracyNutrition
Life expectancy
Social supportSense of cohesion
Personal Empowerment
Social Movements
Government Action
Ou
tcom
esP
roce
sses
Defining Well-Being
Wellness is a positive state of affairs, brought about by the simultaneous satisfaction of personal, relational, organizational and collective needs
Part I: Understanding Well-Being
There cannot be well-being but in the combined presence of personal, relational, organizational and community well-being
Personal Well-being
Sense of control Physical health Love Optimism Competence Dignity and integrity Growth Self-esteem Meaning and spirituality Material resources
Effects of lack of control and disempowerment on mortality
Relational Well-Being
Support Affection Bonding Cohesion Collaboration Respect for diversity Democratic participation
Effects of Social Support
Less likely to have heart attacks More likely to resist common cold virus Lower mortality Less degree of stress More positive outlook on life Resilience
Organizational Well-Being
Efficient structures Clear roles Monitoring mechanisms Planning and accountability Growth opportunities Fulfillment of needs Identity and meaning
Low
Low
High
Hig
h
HighLow
Effective Environment
Affective Environment
Reflective Environment
Organizational Well-Being:ERA Environments
Employee engagement and outcome
Employee engagement percentile
99 95 75 50 25 5 1
Success rate
73% 67% 57% 50% 43% 33% 27%
Engagement leads to subjective and objective positive outcomes“The data indicate that workplaces with engaged employees,
on average, do a better job of keeping employees, satisfying customers, and being financially productive and profitable. Workplace well-being and performance are not independent. Rather, they are complimentary and dependent components of a financially and psychologically healthy workplace” (Harter, Schmidt & Keyes, 2003, p. 221)
Community well-being
Economic prosperity Social justice Adequate health and social services Low crime Adequate housing Clean environment Support for community structures
Place Matters
Male Life Expectancy by Inequality
64
66
68
70
72
74
76
78
80
GINI24.5
GINI 35 GINI32.5
GINI 41 GINI 41
Swed/Jap
Australia
Canada
USA White
USA Afri. Amer.
Social capital and community well-being
low med high
healthwelfare
educationtolerance
crime
Low SC: LA, MS, GAMed SC: CA, MO, OKHi SC: ND, SD, VT, MN
What Is Justice?
To Each According to His or Her Due
Sedgwick’s definition in 1922
Cardinal question of justice is whether there are
“any clear principles from which we may work out an ideally just distribution of rights and privileges, burdens and pains, among human beings as such” (p. 274).
Miller’s 1999 condensed version
“To each his or her due” Isaac’s four questions
First Question: Who Or What Is Each? Second Question: How Do We Decide What Is
Due A Person, Family, Or Group? Third Question: Who or What is Responsible
for Distributing Resources and Obligations? Fourth Question: How Do We Decide what is
Due From a Person, Family, Group, or Institution?
Second Question: How Do We Decide What Is Due A
Person, Family, Or Group?
Dominant ideologyAbilityEffort
Alternative ideologyAbilityEffortNeedsRightsOpportunitiesPower
The role of context
context should determine what criterion or criteria must be preferred in each case
In social conditions of inequality, we must accord preference to needs over ability
Context of Relative Equality
Under conditions of relative equality, where the gap between classes is not very pronounced, it is possible to favor effort over needs.
Context of Plenty of Opportunities
In a context of plenty of opportunities for everyone, it is possible that ability and effort will be the preferred choice.
Justice Out of Context
Societies aspiring to justice must seek equilibrium among all criteria
When context of inequality calls for need and equality, but culture favors effort, it’s because privileged groups benefit.
As a result, group interests that influence the choice of allocation pattern often disregard the context-specific situation.
Context Minimization Error
“Practitioners “should pay more attention to the community contexts of human behavior. Conditions in neighborhoods and community settings are associated with residents' mental and physical health, opportunities, satisfactions, and commitments.” (Shinn and Toohey, 2003, Annual Review of Psychology).
Synergy of Justice and Well-being
How Justice Influences Well-Being
Well-Being Justice
Well-Being is enhanced by
Justice is enhanced, and contributes to well-being, by the power, capacity, and opportunity to
Self-determination Experience voice and choice, participate in decision making
Caring and compassion Experience nurturing relationships free of abuse
Equality and freedom Benefit from fair and equitable distribution of resources and burdens
Ecological Model of Well-Being
Sites of Well-Being
Individual Relational Organizational Communal Environmental
Objective signs health networks resources social capital
low emissions
SubjectiveSigns
efficacy voice support belonging safety
Values as source and strategy
autonomy caring participation diversity protection of resources
Justice as source and strategy
My due/Our due
Your due/Our due
Its due/Our due
Their due/Our due
Nature’s due/Our due
When Is Inequality in Well-Being Inequitable? (question posed by Daniels, Kennedy, and Kawachi, 2000)
When inequalities in well-being are avoidable, unnecessary, and unfair (Dahlgren and Whitehead, 1991)
Do inequalities in well-being exist?
If so, are they Avoidable Unnecessary Unfair
Let’s examine the evidence…….
Colombia: Happy but Dead
Highest rate of murders per capita in the world Highest number of kidnappings in the world
Colombia 5181 in 7 years Mexico 1269 Brazil 515 Venezuela 109 Severe under reporting
Colombians report highest level of satisfaction 8.31 (out of 10) in the world in the 90s
USA
List of Best Nations (Newsweek, Aug 2010)
1. Finland
2. Switzerland
3. Sweden
4. Australia
5. Luxembourg
6. Norway
7. Canada
8. Netherlands
9. Japan
10. Denmark
11. United States
Colombia # 62
Metrics for Best Countries Survey
Education (TIMMS and or PISA) Health (Healthy life expectancy) Quality of Life (Gini coefficient, gender gap, extreme
poverty, homicide rates, pollution, unemployment) Economic dynamism (GDP, innovation,
diversification, business friendly laws, bankruptcy) Political environment (freedom house rating, global
peace index, political risk)
From Gallup Poll http://www.gallup.com/poll/103795/WellBeing-Report-Card-
President-Sarkozy.aspx
Life satisfaction and per capita GDP around the worldFrom: J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:J Econ Perspect. 2008 April 1; 22(2): 53–72. doi: 10.1257/jep.22.2.53.
Each doubling of GDP is associated with a constant increase in life satisfactionFrom: J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:J Econ Perspect. 2008 April 1; 22(2): 53–72. doi: 10.1257/jep.22.2.53.
Contradictions between objective and subjective criteria of well-being "neither life satisfaction nor health satisfaction
can be taken as reliable indicators of population well-being, if only because neither adequately reflects objective conditions of health.” (Deaton, 2008, p. 70)
J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as:
J Econ Perspect. 2008 April 1; 22(2): 53–72. doi: 10.1257/jep.22.2.53.
“life-satisfaction is higher in countries with higher GDP per head.
“it is not true that there is some critical level of GDP per capita above which income has no further effect on life-satisfaction.”
Data reject the Easterlin paradox, according to which happiness does not go up after certain income level.
(Deaton, 2008, J Econ Perspect. Author manuscript; available in PMC 2009 May 11. Published in final edited form as: J Econ Perspect. 2008 April 1; 22(2): 53–72)
Do inequalities in well-being exist?YES!!!!! If so, are they
Avoidable – YES, because social arrangements such as a good public education and equitable distribution of resources can avoid inequitable outcomes
Unnecessary – YES, because social arrangements in certain countries show that equity in well-being does not come at expense of human and social development, on the contrary. A NO answer is usually based on personal interests of doctors, insurance companies, or other interested parties claiming that the capitalist system and high levels of quality are based on competition
Unfair – YES, because people with limited opportunities in life, due to circumstances outside their control, have to suffer due to no fault of their own. This is especially true in the case of poor children, whose poor level of education is associated with many negative health and well-being outcomes.
Part II: Promoting Well-Being Domestically and InternationallyFrom Deficits Reactive Arrogance Individual blame
To Strengths Prevention Empowerment Community Change
Quadrant IIIExamples:Crisis work, therapy, medications, symptom containment, case management
Quadrant IExamples:Community development, affordable housing policy, recreational opportunities, high quality schools and accessible health services
Quadrant IIExamples:Skill building, emotional literacy, fitness programs, personal improvement plans, resistance to peer pressure in drug and alcohol use
Quadrant IVExamples:Food banks, shelters for homeless people, charities, prison industrial complex
Collective
Proactive
Individual
Reactive
Time and place of interventions
THIS IS WHERE WE ARE
THIS IS WHERE WE NEED TO BE
Quadrant IExamples:Voice and choice in celebrating and building competencies, recognition of personal and collective resilience
Quadrant IIExamples:Voice and choice in deficit reduction approaches, participation in decisions how to treat affective disorders or physical disorders
Strength
Empowerment
Deficit
Detachment
Focus and engagement in interventions
Quadrant IIIExamples:Labeling and diagnosis, “patienthood” and clienthood,” citizens in passive role
Quadrant IVExamples:Just say no! You can do it! Cheerleading approaches, Make nice approaches
THIS IS WHERE WE ARE
THIS IS WHERE WE NEED TO BE
The
Grameen Bank
1960s
Strengths, Prevention, Empowerment, Community change
Lesson #1: Strengths
We all have strengthsWe all need to be treated with
respectWe all need to be given a chance
9/7/1854…Removing the Handle of London’s Broad Street Pump
Lesson #2: Prevention
“No mass disorder, afflicting humankind, has ever been eliminated, or brought under control, by treating the affected individual”
HIV/AIDS, poverty, child abuse, school drop out, addictions, powerlessness are never eliminated one person at a time
Must focus on prevention to reduce the incidence of psychological, behavioral, and social problems in children and youth
Determinants of Health (by percent contribution)
http://content.healthaffairs.org/cgi/content/full/21/2/78
40
30
15
10
5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Determinants of Health
Environmental Exposures
Medical Care
Social Circumstances
Genetic Predispositions
Behavioral Patterns
McGinnis et. al., 2002
US Spending on Health
Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis, and U.S. Bureau of the Census.
National Health Spending (2005)
$1,661.40
$143.00
$126.80$56.60
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
$1,987.80
Per Capita Total
Government Public HealthActivities
Investment (Research andEquipment)
GovernmentAdministration and NetCost of Private HealthInsurance
Personal Health(Hospital/ClinicalServices, Nursing Home,Home Health Care,Medical Products)
04/19/23 Prilleltensky 61
Too much reaction, not enough preventionInvestments in Reactive vs. Proactive Interventions in Health and Community Services (Nelson et al, 1996; OECD, 2005; de Bekker-Grob et al., 2007)
0
10
20
30
40
50
60
70
80
90
100
Reactive Preventive
Investments in Prevention:
Italy 0.6%
USA 3%
Netherlands 4.3%
Canada 8%
Ratio of Benefits to Costs (Lynch, 2007, page 19)
0
2
4
6
8
10
12
14
16
18
Abecedarian CPC Perry Age 27 Perry Age 40
Strengths, Prevention, Empowerment, Community change
Lesson #3: Empowerment Identifying the external source of
oppression in life can be empowering Empowerment is a means and an end in
itself Empowerment can be a tool for social
change and personal healing at the same time
Strengths, Prevention, Empowerment, Community change
Lesson #4: Community change
“The psychotherapist, social worker or social reformer, concerned only with his (her) own clients and their grievance against society, perhaps takes a view comparable to the private citizen of Venice who concerns himself only with the safety of his own dwelling and his own ability to get about the city. But if the entire republic is slowly being submerged, individual citizens cannot afford to ignore their collective fate, because, in the end, they all drown together if nothing is done.” (Badcock, 1982)