Well-Being, Justice, and Inequality

Isaac Prilleltensky

isaac@miami.edu

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)