To suggest that these relationships are causal does not involve a major departure from what we know already. Within countries we know that all the components of our Index of Health and Social Problems are strongly related to social status: the further down the social ladder the more common they become.  The new part of the picture is simply that if you stretch out the social status differences all the problems related to social status become more common. Rather than postulating entirely new causal processes we are therefore only providing a bit more information about the relationships that have always been recognised.

People who have studied the graphs on this web site and in The Spirit Level carefully will have noticed that there is a clear tendency for countries which do badly on one outcome to do badly on others. We show evidence that 10 or 12 different problems tend to move together. That implies that they share an underlying cause. The association between inequality and our Index of Health and Social Problems is very close and no one has yet suggested an alternative. 

Lastly, as the different chapters in our book show, many of the causal processes leading from inequality to the various health and social problems are already known. For example, the effects of social status on health have been demonstrated among monkeys in experiments which kept diet and material conditions the same while altering social status by moving animals into new groups and the effects of chronic stress on the immune and cardiovascular systems are increasingly well understood. Similarly, violence is more common in more unequal societies (where status competition is intensified) because it is so often triggered by people feeling looked down on, disrespected and humiliated.