Khloe Frank Uw Final Product Essay

The Truth About Socioeconomic Inequality And Khloe Frank 1
Societal Well-Being: A Case Study of Bolivia

Introduction

What do you feel when you see a beggar huddled on the sidewalk, desperately holding
out his hands for anything passersby might spare? Most of us are struck with a momentary
sense of discomfort, which we often try to dismiss by ignoring the situation or justifying it in
our minds. Why do we feel so uneasy in this circumstance? It is not simply because we are
different from beggars, for only in a utopian society would all people have equal status and
wealth. Rather, it is the severe nature of these differences that causes apprehension. Relative
to a beggar who is poor, homeless, hungry, raggedly clad, unhealthy, and sure to have a rough
future ahead, many of us lead luxurious lives. It is this drastic degree of social and economic
inequalities within our society that causes us discomfort.
Yet rather than smothering the resulting feeling of unease, I argue that we should be
thoroughly examining it. This spontaneous emotional response is the key to understanding a
concept that we intuitively recognize: social and economic inequalities are detrimental to
society as a whole, and to the health and well-being of all who live within it.
In this essay, I will review the concept that socioeconomic inequalities lead to poor
health and quality of life for all of society. Using the book The Spirit Level as a framework, I
will then reflect on my 10-week experience studying global health in Bolivia and elucidate
how my real-life observations abroad support this academic theory. I will also provide
background data on Bolivia (established previously in various academic studies and reports)
to support this assertion. Finally, I will present some ideas on how to improve global health
based on the premise that social and economic inequalities are a major factor causing poor
health and quality of life in societies worldwide.

The Theory

The Spirit Level (2009) is the product of "over 50 person-years" of research by
Professor Richard Wilkinson of the University of Nottingham Medical School and Professor
Kate Pickett of the University of York (Epidemiology) and the National Institute for Health
Research. In this book, the authors explicitly express the theory that social and economic
inequalities are detrimental to societies. They provide ample evidence to support this claim,
showing that the prevalence of society-wide social and health problems is positively
correlated with levels of socioeconomic inequality within both developed countries and the 50
United States. The data provided in this book come from credible sources and show that this
relationship holds true for the problems of:
Physical well-being: low life expectancy, health problems, and obesity
Poor educational achievement
Lack of upward social mobility and opportunities
High Teenage birth rates
Inefficient imprisonment and legal punishment
Mental health problems: poor emotional well-being and drug abuse
Community dynamics and social cohesion: issues with trust, fear, and violence

As a control, the authors provide data demonstrating that there is no relationship
between average national income and these societal problems for developed countries. Thus it
is the relative income differences within societies, rather than differences between societies,
that best predict the prevalence and depth of societal problems. The use of data from two
separate groups (developed countries and the 50 United States) to demonstrate this
phenomenon and show the correlations mentioned throughout this paper adds further
credibility to the point that the relationships illustrated by the data do not occur by chance.
The concepts and data included from The Spirit Level all result from either the authors own
research projects or credible organizations including the United Nations, the U.S. Census
Bureau, the World Bank, the World Health Organization, and UNICEF.
Two parameters are largely responsible for the correlation between socioeconomic
inequality and the prevalence of health and social problems within a society. Firstly, the slope
of the linear regression line for problem prevalence across the spectrum of socioeconomic
classes within a society is steeper in less equal societies. This is significant because it means
that societal inequality causes drastic increases in health and social problems for all below
those with the very highest standing. It also means that in less equal societies, a higher
percentage of the total population suffers from these problems because they plague a greater
proportion of each class.
Secondly, the values along the linear regression line are greater (i.e. the line has a
greater y-intercept) in less equal societies, indicating that health and social problems are
worse for everyone in less equal societies, even those with the highest socioeconomic
standing. These patterns occur because the majority of health and social problems are class-

dependent, and thus influenced greatly by the relative socioeconomic differences between
classes. These problems, which stem from relative deprivation, are interdependent.
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In
unequal countries, these problems afflict many individuals and burden all of society as a
result, often leading to a vicious cycle in which the results of previous problems stemming
from inequality promote further inequality and societal problems.
55

Although The Spirit Level focuses on developed countries, the authors emphasize that
there are some differences between developed and developing countries considering the way
that socioeconomic inequalities weigh on society. In developing countries, besides dealing
with the social and psychological aspects of low status, people at the lower end of the
socioeconomic gradient struggle to obtain access to basic necessities such as food, clean water
and sanitation, and adequate shelter. Therefore, while the benefits of economic growth have
reached their maximum capacity to deliver health, happiness, and a sense of well-being in
rich, developed countries, these same benefits continue to increase with increases in national
income per person in poor, developing countries (see graph below).
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This contrast is most important when considering how to improve population health
and well-being in different societies (see Future Outlook and Solutions). Throughout this
paper, the data quoted from The Spirit Level is exclusively from developed countries (using
income inequality as the indicator of socioeconomic inequality levels); I draw on academic
papers and my personal experiences abroad to comment on specific differences in the way
each societal problem listed manifests in poor, developing countries and how these
differences affect the approach that should be taken to improve societal health and well-being
as a result.

Background on Bolivia

The Plurinational State of Bolivia is a landlocked country in South America with a
population of around 10 million people. Its 1,098,580 square kilometers of territory are
composed of three different types of landscape and climate based on elevation mountains
and arid altiplano (high plain) in the west, semi-tropical valleys in the center, and tropical
lowlands in the east. The countrys natural resources include minerals, natural gas, petroleum,
and timber. The Bolivian economy is based on agriculture, forestry, and fishing; mining and
minerals; industry and manufacturing; and energy oil and natural gas.
22
Bolivia gained independence from Spain in 1825. During the next 109 years, Bolivia
lost land to neighboring Chile and Paraguay in several territory wars, thus becoming
landlocked. After a nationalist revolution followed by decades of military rule, Bolivia
established a democratic government in 1982. In 2005, Evo Morales was elected as the first
indigenous president.
22
The population of Bolivia is young and ethnically diverse. Around 35% of Bolivians
are under 15 years old, almost 60% are between the ages of 15 and 64, and less than 5% are
65 or over. Approximately 30% of Bolivian citizens are multiracial, 28% are Quechua (an
indigenous ethnicity), 19% are Aymara (an indigenous ethnicity), 12% are European, and the
rest are from various ethnic backgrounds.
22
The majority of the population speaks Spanish
(87%) and is Catholic (95%).
22
The healthcare system of Bolivia consists of public hospitals and private clinics. State
health insurance programs provide coverage for mothers and young children (SUMI), the
elderly (above 65 years old, SSPAM), and most government workers (CNSS). The public
education system is free, and there are many private schools in the country as well.
Bolivia is one of the poorest countries in South America, with some of the worst
health indicators: a life expectancy of 64.9 years, gross domestic product per capita of $4800,
maternal mortality rate of 180/100,000 live births, under-5 mortality rate of 51/1000 live
births, and tuberculosis prevalence of 216/100,000 people.
6, 22, 57
Bolivia also has a tremendous amount of socioeconomic inequality. According to data
from 2003, the [average] income of the wealthiest 20% of the population is 13 times higher
than that of the poorest 20%.
58
The degree of inequality in Bolivia is even greater than that
of both the United States and Singapore, the two developed countries with the greatest income
gaps between the rich and the poor, with the richest 20% earning around 8.5 and 9.5 times
more income than the poorest 20%, respectively.
55
Thus Bolivia can serve as a suitable model
country for the analysis of how the theory presented in The Spirit Level compares with data
and observations from a developing country that has high levels of socioeconomic inequality.

La Paz

La Paz, the executive capital of Bolivia, is located in the western region of the country
at an altitude of about 3500 meters. It has a population of about 855,000 people. Nestled in
the heart of a valley, the city consists of the main downtown area and a region called Zona
Sur (or South Zone). Surrounding the valley, roads and houses sprawl across steep cliffs,
ascending to an elevation of around 4000 meters. At this altitude, the terrain becomes

altiplano (high plain), upon which lies the city of El Alto with a population of 882,000.
During my global health internship abroad through Child Family Health International
(CFHI), I lived in La Paz with an elderly widow named Martha Gumucio for five weeks. I
worked in Hospital del Nino (Pediatric, Public), Hospital Los Andes (Maternal and Infantile,
Public), and Hospital Nuestra Senora de La Paz (General, Private) weekday mornings, and I
learned Spanish language from a tutor at the Centro Boliviano Americano (CBA) in the
afternoons.

Tarija

Tarija, a city in the far south of Bolivia, near the border with Argentina, lies in a valley
at an elevation of 1840 meters and has 194,000 inhabitants. It is surrounded by many smaller
towns and rural villages. Due to its vast reserves of petroleum and natural gas, the department
of Tarija is one of the wealthiest in Bolivia. Thus, universal healthcare coverage is provided
for all residents of the department.
During my internship, I lived in Tarija with the local CFHI program director and her
family for five weeks. I worked in the Plataforma de Chagas (Specialized, Public) and
Hospital Obrero (General, Public) weekday mornings, and I learned Spanish language from a
tutor in the afternoons. I also had the opportunity to attend evening Semiology lectures at the
public Universidad Autonoma Juan Misael Saracho.

The Evidence

Physical Well-Being: Life Expectancy and Health

The authors of The Spirit Level support their claim that societal wealth distribution
affects physical health by showing correlations between socioeconomic inequality and three
indicators of physical health: infant mortality, childhood well-being, overall life expectancy.
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The relationship between socioeconomic inequality and poor physical health affects everyone
in society; health disparities are not simply a contrast between the ill-health of the poor and
the better health of everybody else. Instead, they run right across society so that even the
reasonably well-off have shorter lives than the very rich.
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In The Spirit Level, the effects of socioeconomic inequalities on physical health are
attributed to three psychosocial factors social status (i.e. sense of control over ones life),
[integration in] social networks, and stress in early childhood.
55
By creating a feeling of
powerlessness, a lack of community support, and an adverse environment for physical and
mental development, inequality promotes long-term stress via these three psychosocial
factors. In turn, prolonged stress suppresses the immune system; inhibits proper growth,
development, and bodily function; and increases the risk of developing non-communicable,
lifestyle-related diseases.
55
The higher prevalence of chronic stress within less equal societies
thus causes worse physical health at all class levels (even the richest) compared to more equal
societies.
In addition, studies of both wild and captive monkeys have shown that low social
status and the associated stresses cause animals to recover more slowly from wounds, have

higher susceptibility to diseases, have changes in gene expression, and have faster rates of fat
accumulation in their arteries.
2, 45, 55
This shows that social status can have a direct effect on
physiology, and lower status seems to cause worse health.
Obesity, a societal health problem strongly correlated with inequality, exemplifies how
non-communicable, lifestyle-related diseases derive from the psychosocial consequences of
socioeconomic inequality.
55
There are two main reasons for this pattern stress and status.
Stress induces both unhealthy lifestyle habits and physiological strain on the body, changing
the way it processes food.
55
Status matters because the higher levels of status satisfaction and
emotional health that accompany increases in socioeconomic equality enable people to
control their lifestyle choices and make behavioral changes to overcome unhealthy habits.
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An additional reason that societal inequality promotes obesity is that low economic
status relative to societal norms can prevent people from being able to afford more expensive,
nutritious food and to procure the time, energy, motivation, and facilities necessary for
exercise. In less equal societies, greater relative deprivation causes the consequences of low
socioeconomic status and low income, such as the risk of obesity, to affect a greater
percentage of the population.
55
This effect is particularly strong in developing countries like
Bolivia, where much of the middle and lower classes are below the poverty line. From my
observations of Bolivian supermarkets and street vendors, bread, potatoes, and fried
empanadas are by far the cheapest foods. Fruits and vegetables are more expensive, and meat
and nuts are the most expensive. Thus, the poorer people of the lower classes are forced to
dominate their diets with carbohydrates and fats. This not only increases their risk of obesity
and the related health problems, but also leaves them deficient of the variety of vitamins and
nutrients necessary to maintain good general health and immunity.
In developing countries, the people in the proportions of the population with lower
socioeconomic standing who live below the poverty line are unable to afford the necessary
food, sanitation, shelter, and services to maintain robust physical health. Because the gradient
of how much worse these problems are for the lower classes compared to higher classes is
much steeper in less equal countries, more people in all classes face these highly unhealthy
living and working conditions in less equal developing countries.
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According to the census of Bolivia, in 2001 64% of the population did not bring in
enough income to meet its basic needs and 35% of this group [was] living in extreme
poverty.
58
The poorest 20% of the population suffer from dramatically lower rates of access
to skilled birth attendants, antenatal care, vaccinations, clean water, adequate sanitation, and
health care services; they show rates of infant mortality, child mortality, and malnutrition that
are two to six times higher than those for the richest 20%.
57, 58
In Bolivia, these trends also
follow when comparing urban and rural populations, which is logical because there is a higher
percentage of poverty in the rural areas.
58, 60
In this developing country, the extreme poverty
of those on the lower end of the socioeconomic spectrum contributes to reductions in physical
health; the drastic degree of societal inequality in Bolivia causes these reductions to affect a
greater proportion of people in almost every class.
Many of the patients that I interviewed in the hospitals of La Paz exemplified how
socioeconomic inequalities cause poor physical health and are problematic for all of society.
In most of these cases, the patients were in very grave condition due to lack of preventative
measures, delays in accessing treatment, poor general health causing immunodeficiency and

increased susceptibility to prolonged disease with complications, and/or high levels of contact
with sick people in their families or communities.
For example, I saw two patients in Hospital del Nino with serious problems that may
have been prevented with vaccination. The first was a 15-month-old girl who had a developed
a complication from a Varicella (Chicken-Pox) infection. Her left eye was infected, inflamed,
and secreting pus. For the week in which she was interned in the hospital, the girl occupied a
bed and required some of the limited hospital resources. In addition, her mother could not
work during this time. The Varicella vaccine is one of two in Bolivia that are not administered
for free in public hospitals. Although this girls family did not suffer from extreme poverty,
they faced enough relative deprivation that they could not afford to go to a private clinic and
get the vaccine. This problem could have been prevented if the girl had received the Varicella
vaccine; thus health inequalities and the many negative consequences exacerbate other
inequalities and burden society as a whole.
The second case was a 12-year-old boy who had developed tuberculosis meningitis
that caused severe brain damage. In Bolivia, it is recommended that the free tuberculosis
vaccine be administered to all children due to the high incidence of the disease. This boy,
however, never received the vaccine, most likely because he was from the poorer, more
marginalized city of El Alto and/or because his parents had not understood that childhood
vaccination is a health priority for disease prevention. Not only did this boy spend months in
the hospital, occupying a bed, requiring time and resources, and causing his parents to miss
work in order to come visit him, but he also sustained irreversible brain damage; thus, he will
require costly physical therapy and palliative care for the rest of his life. Socioeconomic
inequality deprived this boy of the chance to receive a vaccine that could have prevented him
from becoming a burden on his family and society, and allowed him to live a productive,
fulfilling life.
In Hospital del Nino, I also saw many children who arrived in grave condition due to
delays of weeks, months, or even years in accessing treatment. Many of these people were
poor and from rural areas, making it difficult for their families to accumulate the funds
necessary to travel to La Paz and stay in the city in order for them to receive treatment at a
specialized pediatric hospital. For example, a 9-year-old girl admitted to the hospital with a
tentative diagnosis of blastomycosis had been brought in by her parents after enduring six
months with inflamed axillary and cervical nodes and one month with a swollen abdomen
both of which are severe symptoms that should be addressed promptly. The girl was also
highly malnourished, and appeared to be on the verge of death. She was from Yungas, a rural
region north of La Paz. Due to the relative financial deprivation, poor education, and
geographical isolation of this girls family, her parents did not realize that they should bring
her to the hospital and also did not have the means to do so until her illness had progressed to
an advanced stage. In addition, the girls poor general state of health and nutrition, also
attributable to the relative deprivation of a highly unequal society, left her with nothing [with
which] to fight off this infection.
40
This young girl died during my last week in La Paz, a
helpless casualty exemplifying the harsh consequences of socioeconomic inequality.
In the Emergency Room of Hospital del Nino, I saw a 14-year-old boy who had
osteomyelitis in his left tibia. It had been left untreated for four years, during which time the
infection had progressed greatly. The boy was from a rural area, and his parents had minimal

education. Dr. Velasco, one of the mentoring doctors at Hospital del Nino, explained to me
that many of the marginalized, rural inhabitants of Bolivia have very little formal education
and instead give more credence to their cultural traditions; they often rely on naturopathic
treatments and only bring their sick family members to an urban hospital after all other
options have been exhausted. In fact, it is estimated that over half of the [Bolivian]
population practices traditional medicine.
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Due to the delay in proper medical attention, this
boy will have to endure debridement surgery; he may end up losing his leg and not being able
to walk ever again. This burdens the boy, his family, the hospital, and the community, for a
problem that could have been much less severe and had a far better prognosis if
socioeconomic inequality had not impeded the possibility of early treatment.
Another patient exemplifying the disastrous consequences of delayed treatment was an
8-year-old boy from Yungas who had endocarditis with vegetation in the tricuspid valve and
the base of the pulmonary artery. A severe congenital stenosis of the pulmonary artery and a
mouth full of teeth plagued with dental carries greatly increased this boys risk of acquiring a
serious heart infection. In effect, the boys poor dental hygiene provided bacteria an
opportunity to enter his bloodstream, while his congenital stenosis made it easier for the
bacteria to colonize the tricuspid valve. These factors could have been avoided with better
early childhood care, general child health and hygiene, and parental education.
This boy was born in a hospital, where doctors examined him and heard a heart
murmur. Because heart murmurs are commonly heard in normal infants, the doctors most
likely advised his parents to have their son checked again when he was older; this, however,
never transpired. Neither of the boys parents, who currently work as a farmer and a
homemaker, finished primary school. Their lack of education and the resulting ignorance
prevented their son from receiving earlier diagnosis and treatment for his severe stenosis. This
has affected his general health and education because throughout his life, the boy has suffered
from difficulty breathing, fatigue, and inability to gain weight. He was kicked out of school
because he did not have enough energy to stay awake in class. The familys isolated location
also played a major role. The boy only brushed his teeth once a day at most, and with no
dentists in the region, he developed many cavities. Also, his parents did not bring him to the
city to see a doctor until he had endured a fever for 3 months! This time delay, fueled by both
lack of education and physical isolation, allowed the infection to progress, greatly lowering
the boys chances of recovery. This boy has a high chance of dying from his heart infection.
Even if he survives, he will continue to have lifelong problems and be at a disadvantage due
to his lack of education. This case clearly demonstrates how the effects of socioeconomic
inequality cause poor health outcomes that contribute to other social problems and burden
society as a whole.
Finally, the harsh living conditions and relative deprivation of the lower classes
produce poor general health that puts children at a higher risk of acquiring disease and
developing serious problems. In La Paz, this seems to manifest most commonly as respiratory
infections in children. I saw many patients who had cases of pneumonia acquired in the
community. One in particular was a 4-year-old boy from El Alto. He lived in a house with
basic services, supported by his 33-year-old father who had completed only up to the first
year of secondary school and worked as a sewer. Because El Alto is a poorer community in
which respiratory infections are more prevalent and herd immunity is lower, this boys living

environment put him at high risk. He also had moderate anemia and grave malnutrition, which
made him more susceptible to acquiring an infection and also slowed his recovery process.
Thus, harsh living conditions and relative deprivation caused this boy to have poor health.
I saw a similar case involving a 3-month-old boy who had been struck with a cough
and conjunctivitis after having recently recovered from community acquired pneumonia. His
mother was merely 17 years old, had studied only up to her first year of secondary school, and
lived in a poor neighborhood of El Alto. When I asked her why she thought her son had
gotten sick, she said, Because of the cold in the house. More deprived Bolivians have to
live in the higher, colder city of El Alto and often face social struggles such as teen pregnancy
and lack of education. These conditions contribute greatly to the health problems of their
children. Finally, the case of a one-and-a-half-month-old girl with pneumonia acquired in the
community further exemplified this phenomenon. The girl was from El Alto and lived in a
rented house in which five people shared one bedroom. Her mother and brother had both
gotten sick before her and failed to receive treatment; the girls mother told me that she
believed her own physical contact with her daughter had made the girl sick. This exemplifies
how family environment and relative deprivation contribute heavily to poor health outcomes
in highly unequal societies.
Chagas, a disease of poverty that is endemic to Tarija and the surrounding areas,
also strikes the relatively deprived of society and burdens the entire community as a result.
12

Chagas disease is caused by a parasite that is transmitted via insect vectors known in Bolivia
as Vinchucas (which scientifically are insect species of the Triatominae sub-family). The
majority of the people affected do not have any symptoms until at least 20 years after
infection, when they start to present cardiac and gastrointestinal problems. Severely deprived
people are at the highest risk for Chagas because their lifestyles and living conditions provide
ample opportunity for Vinchucas to infest their homes; in the rural areas around Tarija, many
people cannot afford quality housing material and also live in close proximity to their farm
animals. Vinchucas thus get into their homes and eventually infect them with Chagas. This is
bad for all of Tarija and the world because infected people can transmit Chagas through blood
donations and from mother to child during pregnancy.
When rural people who have Chagas migrate, the problem spreads throughout
societies. Chagas is also detrimental to society because it exacerbates inequality by inhibiting
social mobility. As a debilitating disease that stems from poverty and relative deprivation,
Chagas traps people in the cycle of poverty and thus continues in a vicious pattern. Because
the disease affects mostly poor people and there is not much opportunity for profit to be
gained by developing a new drug, the same medication has been used to treat Chagas for
decades.
12
This is a problem because the treatment has many side effects and frequently
causes a life-threatening allergic reaction. Patients whose allergies prevent them from being
able to take the medication do not have an alternative treatment option and eventually
succumb to death due to cardiac insufficiency; as Dr. Andrew Suarez of the Plataform de
Chagas summarized it, In these cases, there is nothing we can do but cry. The lack of early
diagnosis and high quality treatment due to socioeconomic inequalities causes many people to
develop serious health problems. The financial burden of treating the numerous people
affected by advanced progressions of Chagas disease is also costly to society, especially in
Tarija where all residents are insured by the government.

These cases demonstrate how severe socioeconomic inequalities in poor, developing
countries cause serious physical health problems. In very unequal societies such as Bolivia,
the middle and lower classes are drastically deprived relative to the highest classes recall
that 64% of Bolivians are too poor to meet their basic needs. Thus, the abundance of physical
health problems plaguing unequal populations puts a great socioeconomic burden on whole
societies. Poor general health increases peoples risk of developing serious health problems.
When the majority of a population has high levels of disease and low levels of vaccination,
everyone in the community is at a greater risk of acquiring communicable diseases because
the society as a whole has reduced herd immunity. Everyone is also affected because
government funds that could be used for other important purposes are consumed by the costs
of expensive treatments for health problems that have progressed due to lack of relatively
inexpensive prevention. Children who develop serious health problems can require life-long
care that tallies up a tremendous bill and makes it difficult for them to perform well in school,
thus affecting their social mobility and opportunities to become productive members of
society.

Educational Achievement

Most people are aware that education is often essential for achieving adequate
socioeconomic status to secure a healthy and enjoyable lifestyle. What is less emphasized, but
much more important, is understanding that education benefits entire societies in addition to
individuals and that the conditions produced by high levels of socioeconomic inequality
within a society are a key factor contributing to poor educational performance.
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The lack of self-esteem that stems from socioeconomic inequalities greatly affects
how students perform in school; in fact, numerous psychological experiments show that
performance and behavior in an educational task can be profoundly affected by the way we
feel we are seen and judged by others rather than by our actual abilities.
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This concept was
reinforced by my conversations with the CFHI program director in Tarija, her daughter
(Natalia), and her daughters friends. Natalia was in her junior year of high school during the
time that I lived with the family. The issue most discussed with relatives and friends
concerning school was not the classes or academic material, but rather the social hierarchies
of the students which students were in which social groups, how they acted, and news of the
latest teenage trends. Natalia did not feel valued in the social hierarchy of her school and
wanted to transfer to the other private high school in Tarija. Thus, great status differences and
material inequalities are not only a major distraction for students, but also a detriment to the
self-esteem that is necessary for them to be successful in school.
Relative wealth is also an important factor in the Bolivian educational system, mainly
due to the drastic differences between public and private schools. While public schools are
essentially free in Bolivia (other than small fees and textbooks for university students), private
schools cost 800-2000 Bolivianos per month (about 116-290 U.S. dollars). Students who
attend private schools have better facilities and more opportunities. For example, if a Bolivian
speaks English well, it is highly likely that they attended a private school and/or are from a
family that is rich enough to afford English classes as an outside supplement to public school.
The three Bolivians I knew who spoke English the most fluently all studied in private schools

and had the opportunity to either live in English-speaking countries or enroll in English
courses at the CBA in Bolivia. Knowledge of the English language is a definite advantage for
social mobility, as it secures more career and travel opportunities. Another example is the
differences in the quality of facilities between public and private medical schools. Private
schools have more equipment and smaller class sizes. Because relative wealth greatly affects
quality of education in highly unequal societies, family socioeconomic status is important.
High levels of socioeconomic inequality generate less nurturing family and
community environments (see Social Cohesion section), particularly for early childhood
development and educational achievement. Family background has a greater effect on
educational performance for students in less equal countries; thus, in a less equal society, the
difference in educational performance between children whose parents have even a moderate
level of education and those whose parents have an advanced degree is much more drastic
than the difference between these same groups in a more equal society.
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This trend in how
socioeconomic inequality affects education contributes to the cycle of poverty and decreases
societal social mobility. In addition, scores are lower for students across the spectrum of
parents educational level in less equal societies compared with more equal ones. Thus, the
drastic degrees of relative deprivation that prevail in unequal societies create conditions that
lower society-wide educational achievement.
In Bolivia, I encountered a fair number of children and adolescents who did not attend
school. There were three main reasons for this work, health problems, and social problems.
Many Bolivian children are expected to contribute to the family income, and thus must work
instead of going to school. I saw a myriad of young girls and boys working as fare collectors
in the mini buses, baggers at the supermarket, or shoe shiners on the street. There were also
two young girls working as assistants at Dr. Uribes office in El Alto rather than attending
school. Health problems that cause fatigue, malnutrition, disability, and/or frequent illness
also prevent Bolivian children from getting an education by diminishing concentration
capacity and school attendance (see Physical Well-Being section). Social problems, such as
drug addiction, teenage pregnancy, and lack of interest in school are heavily influenced by
family and community dynamics. The majority of students that I met in both La Paz and
Tarija who had persevered through high school and continued on to university were from
families with a history of high educational achievement. These families emphasized the value
of education, supported their children in scholarly pursuits, and associated with other families
that valued education as well. Unfortunately, socioeconomic inequalities deny many Bolivian
children this caliber of support and encouragement for education.
Education benefits all individuals and society. Data shows that people who are better
educated tend to have superior incomes, job satisfaction, health, and levels of contentedness
with life. As a benefit to both themselves and society, they also generally have lower rates of
unemployment and criminal activity. They fulfill their civil duties to a greater extent by being
more likely to volunteer their time and vote in elections and by providing society with the
contributions and economic productivity not to mention the tax of a skilled workforce.
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Overall, education improves health and quality of life for individuals while also maintaining
the productivity and functionality of societies and governments. This is why the failures in
education that are provoked by socioeconomic inequality have such devastating effects on
societies. Educational performance is negatively affected by inequality and the resulting

health and social problems; in turn, the poor educational performance that results from
inequality exacerbates other inequality-related problems, especially social mobility.

Social Mobility

Social mobility is a fundamental factor capable of influencing societal health and well-
being. Lack of upward social mobility results from socioeconomic inequality and exacerbates
it, trapping societies in an inescapable cycle of continuous or worsening conditions of
inequality. The resulting persistence of socioeconomic inequalities over time intensifies all of
the societal problems linked with inequality, which again demonstrates the interconnected and
interdependent nature of these problems. Data show a correlation between higher
socioeconomic inequality and lower levels of social mobility both when comparing various
developed countries and when examining changes in the U.S. over a period of time.
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Various characteristics of unequal societies lead to diminished social mobility. Firstly,
less equal societies have less opportunities and support to enable people to better their
socioeconomic standing (see Educational Performance section); for example, there is a
correlation between societal equality and government spending on education, with more equal
countries funding nearly 100% of public education, while government expenditures cover as
little as 68.2% of public education costs in less equal countries.
55
This is important because
education is generally thought of as the main engine of social mobility in modern
democracies people with more education earn more and have higher social status.
55

Class distributions also affect social mobility. Data show that in general the richest
maintain their wealth, the poorest have the most difficulty improving their income, and the
middle classes are the most flexible.
55
When the differences between the classes are large, as
they are in more unequal societies, it is a greater leap to move from one class to another. The
classes also are more spread out on the spectrum of relative wealth, which can lead to a
shrinking middle class and thus further decrease social mobility.
55
This phenomenon appears
to have transpired in Bolivia, where, when divided into 3 groups based on labor category, the
group with the lowest average income is 64.1% of the total, the middle group is 10.1%, and
the group with the highest average income is 25.7%.
1
I met Bolivians across the spectrum of socioeconomic statuses who exemplified this
phenomenon. Among the poorer people that I knew were Martha Gumucios maid, Antonia;
the doormen of Marthas building; many of the parents of patients at Hospital del Nino in La
Paz; and most of the adult patients at the Plataforma de Chagas in Tarija. These people were
from poor families and had jobs that did not offer much opportunity for promotion. Their
main opportunity to break out of poverty is supporting their children in pursuing higher
education or technical skills. This feat, however, is very difficult to accomplish because these
families are plagued by the health and social problems that most afflict people of the lowest
socioeconomic statuses, and which are significantly exacerbated in unequal societies. The
middle class Bolivians that I met were mostly students and teachers. The medical students
attending public university were from families that could not easily afford private school, but
were able to live comfortably. These students had sufficient opportunity and support to pursue
careers as doctors, thus giving them and their families much greater upward social mobility.
The middle class tutors and administrators at the CBA also appeared to live comfortably and

maintain this standard for their children. The richest people that I met in Bolivia were Martha
(the widow of a geologist in the oil industry), Marthas friends, and various doctors. Martha
and her friends were from rich families and had raised children that maintained this
socioeconomic standing. The Bolivian doctors I knew were from a variety of backgrounds,
but all had a high quality lifestyle that appeared to be preserved by their children. These
observations support the academic theory about how socioeconomic status affects upward
social mobility.
In addition, physical class distributions have an impact on social mobility because
greater social distances become translated into greater geographical segregation between rich
and poor in more unequal societies.
55
Poverty concentration is the concentration of poor
people in poor areas . . . when poverty concentration is high, poor people are not only coping
with their own poverty, but also the consequences of the poverty of their neighbors . . . [this]
increases all kinds of stress, deprivation, and difficulty.
55
This was very noticeable in La Paz
due to the clear physical separation of different classes. In this region, there is a negative
correlation between elevation and wealth. The poorest people are concentrated in the highest
residential area, El Alto. About 500 meters lower, downtown La Paz is more middle class and
mixed. At the lowest elevation, Zona Sur is home to the wealthiest Bolivians in the
department. This trend is especially noticeable because more indigenous people, with their
distinct traditional appearances, are poor and living in El Alto; Zona Sur, on the other hand, is
dominated by expensive, fancy shops and wealthier people who dress in more Western
fashion. While the streets of El Alto and La Paz are dominated by public transportation (mini
and micro buses) and taxis, the traffic of Zona Sur consists mainly of privately-owned cars.
The grand houses of Zona Sur, in contrast to the crumbling buildings of El Alto and the
smaller apartments of La Paz, are another indicator of the geographical segregation by wealth
in and around La Paz. This separation affects social mobility because the problems of the
lower classes compound on each other, causing worse health outcomes and a less nurturing
environment for education and development. This decreases social mobility for a majority of
the lower classes.
This also affects social mobility because people of lower classes are likely to face
stigma and feel worse about their status when in close proximity to those of higher standing,
thus [encountering] more frequent prejudice and discrimination and [having] less support as
they try to move up the socioeconomic ladder.
55
This phenomenon is particularly noticeable
in Bolivia due to differences in poverty prevalence for each ethnicity; in this country, higher
percentages of the large indigenous population are poor than of any other ethnicity.
21
Many
Bolivians of indigenous ethnicity wear traditional clothes and accessories that blatantly
distinguish them from non-indigenous people. Because most indigenous people are of
relatively low class standing and their physical appearance is so distinct, they face more
prejudice and discrimination when trying to improve their status. Associations between
ethnicity and low rank in highly unequal societies greatly diminish social mobility.
Lack of upward social mobility is one of the most important aspects of unequal
societies because it plays a major role in the persistence and escalation of inequality within
societies. It is greatly affected by other societal problems that stem from equality, such as
teenage birth rates.


Teenage Birth Rates

Teenage motherhood negatively affects the young mothers, young fathers, their
children, and society. Teenagers who become parents often get locked in a cycle of poverty
deprived, physically and mentally less healthy, and unable to take advantage of opportunities
to improve their lives.
50, 55
Babies born to teenage mothers are more likely to have low birth-
weight, to be born prematurely, to [die] in infancy and, as they grow up, to be at greater risk
of educational failure, juvenile crime, and becoming teenage parents themselves.
55
Societies
pay the price both financially, by having to fund welfare and support programs, and socially,
by facing a greater burden of health problems, crime, dysfunctional childhood development
environments, poor education performance, etc.
The occurrence of teenage pregnancy is closely linked with poor social and economic
circumstances (such as absent fathers), creating an endless, inter-generational cycle of
deprivation.
55
In less equal societies, teenage birth rates are higher across the spectrum of
classes, and the degree of difference in the rates between the poorest and the richest is very
steep.
55
A higher prevalence of poor social and economic circumstances stems from higher
levels of societal inequalities, which accounts for the definitive correlation between income
inequality and teenage pregnancy and birth rates. Evidence shows that this relationship is not
distorted by factors such as religion, ethnicity, or overall societal fertility (i.e. the pregnancy
and birth rates of women of all ages).
55
Additionally, income equality correlates with the
marriage status of teenage mothers; higher percentages of teen mothers are married in more
equal countries.
55

With a fertility rate of 76 of every 1000 for women ages 15-19, teenage birth is a
serious issue in Bolivia.
56
A study of adolescent girls in La Paz suggests that parental
relationships, self-esteems, and friendships are main factors influencing the risk of teen
pregnancy in this region.
23
When I interned in the maternity ward of Hospital Los Andes in El
Alto, many of the new mothers I interviewed were teenagers or in their early twenties, and a
great deal of them were of indigenous ethnicity. Comparatively, in the more equal city of
Tarija, the majority of the new mothers I interviewed were in their mid-to-late twenties or
thirties.
Another example I observed in Bolivia involved the daughter of Antonia, Marthas
maid. According to Martha, the girl had a baby when she was only seventeen years old.
18

Although she was able to complete high school, her education ended there. Antonia also gave
birth to her first child at a young age, and as a maid living in El Alto, was not able to provide
the most nurturing environment for her daughter to grow up in. Because Antonias family is
in the lower echelons of a society that has great amounts of relative deprivation (due to high
levels of socioeconomic inequality), they have become trapped in a cycle of teenage births
and the resulting socioeconomic immobility.

Imprisonment & Legal Punishment

Although a societal criminal justice system is necessary in order to maintain security
and deter crime, imprisonment and legal punishment are more detrimental than beneficial to
society when executed ineffectively. There is a correlation between lower levels of societal
socioeconomic equality and less effective imprisonment and punishment.
55
Imprisonment

rates are higher in less equal societies, and data shows that this increase is due mostly to the
expansion of imprisonment as a punishment for lesser crimes and the use of longer prison
sentences. A very small percentage of the imprisonment rate increases can be attributed to
higher crime rates, and in some societies, the crime rates have actually decreased while rates
of imprisonment were increasing.
55
In addition, prison systems tend to be harsher in less equal
societies.
55

Why are the high rates of imprisonment and harsh nature of prison life found in less
equal societies problematic? Harsh punishment is not effective; in fact, it appears to be
counterproductive. Data show that rates of re-offending are higher for criminals in the harsher
systems of less equal countries than for those in the relatively lenient systems of more equal
countries.
55
This is best explained by James Gilligan, a prison psychiatrist who stated, the
criminal justice and penal systems have been operating under a huge mistake, namely, the
belief that punishment will deter, prevent, or inhibit violence, when in fact it is the most
powerful stimulant of violence that we have yet discovered.
55
Less punitive prison systems
are generally more humane, [emphasizing] treatment and rehabilitation; this allows
criminals to maintain some sense of humanity and reintegrate into society more easily after
they have served their sentences.
55
In harsher systems, prison conditions such as lack of
movement, stimulation, and social contact contribute to mental illness and inability to rejoin
society; the longer someone is incarcerated, the harder it is for them to adapt to life
outside.
55

Bolivia has a prison system consisting of 53 institutions holding 11,516 inmates; this
is 185.1% of the official capacity (4,700).
20
It is estimated that over 950 Bolivian children live
with their parents in the system.
7
This means that the government spends substantial funds to
support these overcrowded facilities, and children suffer the consequences of growing up in a
less than ideal environment. Although I did not have any personal experiences with the prison
system in Bolivia, my host organization (CFHI) is involved with a prison-related program,
which will be discussed further in the Future Outlook and Solutions section.
The problems in criminal justice are a burden on everyone within the less equal
societies in which they prevail. Overpopulated, harsh prison systems take a tremendous toll
on taxpayers, diverting money from important programs without providing worthwhile
results. In fact, these systems seem to fail at deterring crime and rehabilitating offenders. The
people processed through these systems emerge with a diminished ability to be productive,
contributing members of society and a high risk of regressing to violent behavior. The harsh
and lengthy nature of criminal punishment in less equal societies also affects other societal
problems by contributing to dysfunctional family relations, inability to take advantage of
educational opportunities, lack of social mobility, mental illness, and more. The societal
trends in criminal justice demonstrate yet another way in which inequality is bad for society
as a whole.

Mental Health: Emotional Well-Being and Drug Abuse

The authors of The Spirit Level define mental well-being as the ability of individuals
to look after themselves, see themselves as valuable people, and judge themselves by
reasonable, rather than unrealistic, standards.
55
They show that there is an undeniable

relationship between the degree of socioeconomic inequality in a society and the
pervasiveness of both mental illness and drug abuse within that population.
55

In developed countries, this correlation is particularly strong for anxiety disorders,
impulse-control disorders, and severe [mental] illness, which may help explain why higher
proportions of the population suffer from drug dependencies in more unequal societies.
55
The
authors describe the cause of this phenomenon as luxury fever a worldview in which very
high value is placed on acquiring money and possessions, looking good in the eyes of others,
and wanting to be famous.
55
Luxury fever triggers emotional distress and affects how people
feel about their social standing, which makes them more susceptible to depression, anxiety,
substance abuse, and personality disorder.
55

The status anxiety that results from this outlook on life is particularly detrimental to
mental health and emotional well-being. The authors of The Spirit Level show how social
status can affect brain chemistry, which in turn affects mental health and vulnerability to drug
addiction. This was demonstrated in a study in which, when provided the opportunity to self-
administer cocaine, monkeys with lower social statuses self-medicated in significantly higher
doses. This kind of experimental evidence in monkeys adds plausibility to our inference that
inequality is causally related to mental illness.
55
In a study of the Bolivian village Tsimane,
Richard Godoy and his colleagues found that income inequality was associated with more
negative emotions, which they postulated can then cause detrimental effects on health and
well-being.
14
This increase in mental illness, negative emotions, and drug use that results from
greater social inequality negatively affects all of society. Firstly, the people who develop
mental illness and/or drug addiction due to their inability to cope with socioeconomic
inequalities suffer directly; they struggle to lead productive and worthwhile lives, maintain
good health, raise a stable family, improve their socioeconomic situation, take advantage of
opportunities, and function autonomously. The close friends and family members of these
people are affected too, and children in particular struggle physically and emotionally when
they live with a mentally ill and/or drug addicted parent during their crucial years of
development. Neighbors and community members in close physical proximity are also
affected, as the mentally ill can become violent, and desperate drug abusers encourage illegal
drug dealing activity. Finally, everyone within the same society as the mentally ill and drug-
addicted is affected by the tremendous social and financial burden these people exert on the
entire population. To combat the problems of mental illness and drug abuse, society must
dedicate resources and funding to mental institutions, drug rehabilitation facilities, and police
patrols. Insurance rates and government medical programs also can be affected as society
pays for the antidepressants and other medications related to mental illness that are prescribed
in abundance in less equal countries.
55
In addition, fear, violence, and social dysfunction are
more prevalent throughout these societies.
The consequences of the mental illness and drug addiction that derive from
socioeconomic inequalities were exemplified by a case I saw in Hospital del Nino. A 10-
month-old, HIV-positive girl was interned in the infectious disease unit with pneumonia.
Because their 25-year-old, HIV-positive mother was suffering from chronic alcoholism, the
girl and her older sister lived with their father, who cared for them as a single parent. The
mother did not know that she was HIV-positive until after her children were born, and thus

she did not take anti-retroviral drugs to potentially lower their risk of contracting HIV. She
does not physically care for her children or offer them financial support. Thus, due to their
mothers alcohol addiction, these young girls have worse physical health and a less nurturing
family environment, which affects other aspects of their lives.
Although The Spirit Level focuses mainly on how ones sense of ones own
socioeconomic status affects mental well-being, I argue that drastic inequalities in social
status within a population are also detrimental to mental health because they vicariously
degrade emotional well-being. Humans are generally empathetic by nature, and even if one
feels secure with ones own place in society, being aware of the suffering of other people can
be emotionally destructive and stressful. Thus, socioeconomic inequalities are detrimental to
the mental health and well-being of every member of society, even those with high social
status.
The negative impact of socioeconomic inequalities in La Paz on emotional well-being
due to empathetic suffering was revealed to me during a discussion I had with Sonia, my
Spanish language tutor. We were having a conversation about our favorite holidays, and
Sonia surprised me by stating that she does not like Christmas. When I asked her why, she
explained that Christmas makes her sad because people are not able to enjoy it equally
poorer families often cannot afford to buy gifts for their children, while richer families have
an abundance of presents, decorations, and special food. Even though Sonia herself has a high
enough socioeconomic standing to afford a good Christmas celebration, the holiday is not
enjoyable for her because of the deprivation she sees in those of lower socioeconomic
standing within her society. Thus, socioeconomic inequalities diminish her emotional well-
being. Sonia said her favorite holiday is the Bolivian equivalent of El Dia de Los Muertes
(The Day of the Dead) because people celebrate by collecting food, clothes, and other
necessities that the deceased might need in their afterlives, and following an honorary
ceremony, they give these provisions to the poor in their communities.
43
The fact that
community well-being can have such a profound effect on individual happiness relates to
societal interactions, another aspect of life that is affected by socioeconomic inequality.

Community Dynamics & Social Cohesion: Fear, Trust, and Violence

The authors of The Spirit Level contend that equality of conditions creates an
atmosphere of trust within a society, while inequality provokes violence and fear that disrupt
community dynamics and social cohesion.
55
This is because social and economic inequalities
incite a mentality of us-versus-them, which divides people by classes and propagates
prejudices. Alex de Tocqueville described when he said: [prejudice is] an imaginary
inequality [that follows the] real inequality produced by wealth and the law.
55
Thus
inequality generates distrust, and these two elements reinforce each other to foster a cycle of
societal division and suspicion. People generally have less empathy and more distrust for
those of drastically different social standing. As Eric Uslaner, a political science professor at
the University of Maryland, summarizes it, Trust cannot thrive in an unequal world.
55

Trust is important because it cultivates cooperation (rather than competition) and a
sense of security in society. Two examples of how greater equality and trust benefit society as
a whole are clear when one examines the data concerning both womens status and

international aid. There is a statistically significant correlation between income equality and
high womens status in both developing countries and the 50 U.S. states.
55
This is important
because evidence has shown that higher womens status is correlated with lower death rates
for both men and women, and that this benefit is observed for both the rich and poor.
55
Thus,
greater socioeconomic equality benefits everyone in society. Trends in spending on
international aid also demonstrate how equality fosters a sense of unity and generosity. Data
show that there is a positive correlation between the level of equality within countries and the
percentage of gross national income that is dedicated to foreign aid.
55
This illustrates how
equality within a society can create an atmosphere of trust and cooperation that promotes an
attitude of giving and sharing. Equality is the foundation of trust, and the two forces together
create a cohesive, cooperative community, to the benefit of all.
55

In contrast to the attitude of trust and cooperation evident in more equal societies,
violence and fear seem to dominate less equal ones. The authors of The Spirit Level explain
that while patterns in the profile of perpetrators of crime appear to be consistent in all of the
developed countries and through all periods of time, it is the nature and quantity of crimes
that differs between societies of different socioeconomic equality levels.
Less equal societies tend to have higher overall crime rates and greater incidences of
violent crime. For example, a study comparing homicide statistics for Chicago with those for
the United Kingdom (UK) revealed that while in both locations the majority of murders are
committed by men aged 15 to 29, the rate of murder is 30 times higher in Chicago than in the
UK for almost every age of perpetrator.
55
Homicide rates are higher in more unequal
countries, U.S. states, Canadian provinces, U.S. cities, and areas of U.S. cities.
55
In developed
countries, higher rates of homicides and assaults [are] . . . closely associated with income
inequality.
55

Rates of violence vary not only between societies with different levels of inequality,
but also within individual societies over periods of time during which changes in inequality
levels occur. In the U.S., for example, inequality increased in the 1980s, decreased after the
early 1990s, and then began to increase again from the year 2000 onward. National homicide
rate trends followed the same pattern over this period of time.
55
This evidence further
supports the theory that inequality within societies leads to increased levels of violence.
One might wonder, what is it about less equal societies that produces this rise in
overall crime rate and increased incidence of violent crime? According to the authors of The
Spirit Level, status competition and a harsh living environment are the two driving factors of
violence in unequal societies. The more hierarchical a society is (i.e. the greater the degree to
which it is divided into distinct classes by large differences in socioeconomic standing
between people), the more status matters. This leads to more competition for status, especially
among young men who are facing issues of pride and sexual competition. In less equal
societies, a greater percentage of the population lacks status protection or buffers to secure
their self-respect and sense of status in society. Thus, more people are likely to become
violent in less equal societies.
In addition to this intensive status competition, more people struggle with relative
deprivation in less equal societies, often growing up in harsh environments.
55
There are
higher rates of family conflict and disintegration in more unequal societies (shown by divorce
rates and other indicators), which is important because lack of family support and especially

the absence of fathers during childhood increase the likelihood of violent behavior in
adulthood. Because the increased family breakdown and family stress in unequal societies
leads to inter-generational cycles of violence, this problem, which stems from inequality, is
continuous.
55
School and neighborhood environments in less equal societies are also harsh on
children, as neighbors and peers seem to be less trusting and more likely to engage in
bullying, fights, and conflict.
55
The prevalence of conflict and caustic conditions may
encourage high risk behavior due to the implication of short life expectancy. In other words,
Life is short where life is brutal.
55

For this reason, it is poor young men from disadvantaged neighborhoods who are
most likely to be both victims and perpetrators of violence.
55
This point is important to
understand because it epitomizes the fact that what happens at the very bottom . . . matters
most in unequal societies.
55
It is the relative position of those with the lowest
socioeconomic standing that correlates with the prevalence of violence, fear, mistrust, and
other societal problems.
55
Within unequal societies, these brutal living conditions tend to
ensnare greater proportions of the people who are in the lower socioeconomic classes. This
concept will be significant later when considering how best to address the problems of
unequal societies.
While violence is directly harmful to the victims, it is also detrimental to the quality of
life of entire populations. This is because, although the majority of people in a society are
never the targets of violent crime, many people fear it.
55
Inequality produces violence, which
in turn generates fear. Fear disproportionately affects the vulnerable the poor, women, and
minority groups . . . [this infringes] on basic human freedoms.
55
Thus, the violence and fear
that result from inequality within societies diminish personal safety, quality of life, levels of
trust, and overall community cohesion. This is detrimental to society as a whole.
The relationship between inequality, trust, violence, and fear, and the effect of this
relationship on societal interactions, is very apparent in the city of La Paz and the surrounding
area. Many Pacenas (people from La Paz) fear El Alto, the neighboring city on the cliff 500
meters above. El Alto has a greater indigenous population and a higher concentration of
poverty than La Paz; the streets and buildings are noticeably lower in quality, and the people
who live there are more homogenous, causing outsiders to stand out more distinctly. None of
the interns from the CFHI program are allowed to go to El Alto alone, especially at night.
During my internship, the other students and I were always accompanied by a mentoring
doctor who was familiar with the area when we had to work in Hospital Los Andes in El Alto.
We were driven directly to the hospital and later guided to a safe public transportation option
for the return commute. We were advised never to take a taxi to or from El Alto; to get from
the airport in El Alto to our host homes in La Paz (or vice versa), we were always driven by a
trusted driver associated with the CFHI program.
On one occasion, I went to a cultural event in El Alto with some of the other interns.
Martha, my host mother, was visibly concerned for my safety. Before I left, she bombarded
me with advice. Do not bring anything valuable . . . wear plain clothes . . . stay in a group
with the other interns and make sure that at least one or two of them are boys . . . try to come
back before dark, even if you have to leave early. Martha went so far as to offer me some
makeup that would darken [my] face so that [I would not] look so white. This reflects how
prejudices stem from inequality; because the people of El Alto struggle with great poverty and

a high percentage of them are of indigenous ethnicity, Pacenas fear the indigenous population.
Before I left, Martha concluded by saying, Its a terrible place, El Alto . . . dangerous.
19
The
vast socioeconomic inequalities between residents of La Paz and El Alto incite discernible
fear in this society.
A conspicuous indication of the lack of trust and the abundance of fear within the city
of La Paz is the omnipresence of doormen, security guards, and police officers in the city.
Every apartment building that I entered in the downtown area had an exterior gate, one or two
secure doors, a doorman, and sometimes elevator security. At night, most buildings have a
guard posted outside in addition to the doorman monitoring the main lobby. Furthermore, the
majority of the residents have at least two locks on the individual doors to their apartments. In
fact, three of my fellow interns in La Paz lived with a host family that would not give them
keys because the lock system on their door was too complex; instead, they had an adult son
stay home and let the students in when necessary. In La Paz, there are police officers with
rifles stationed at the entrance to every bank and military personnel outside all government
buildings. Groups of police and military officers assemble along the main streets of the city
with shields, gas masks, and batons to maintain order when there are public marches or
demonstrations for various strikes.
The many strikes, marches, and blockades that I observed during the five weeks in
which I lived in La Paz were another indicator of how inequality leads to societal conflict.
The main protest occurring during my time in the city was the doctors strike in response to a
recent government decree requiring public doctors to work eight hours a day rather than six
without an increase in salary. While strikes are common in Bolivia, this event was unique.
Bolivian teachers and public transportation workers strike every year during their contract
renewal period, but none of the citizens that I talked to could remember a time when the
doctors had gone on strike before. Also, the teacher and transportation worker strikes
typically last one or two days; the doctors strike began three days before I arrived and was
not only continuing, but escalating, at the time that I left the city. During the five weeks in
which I observed the strike, only the Emergency Rooms of public hospitals were open to
patients (all specialized consultations were closed), with minimal medical staff continuing to
work at these hospitals. Every day, hundreds of doctors and medical students marched down
one of the main streets in La Paz or created a blockade to stall traffic on one of the primary
highways through the city. Often they carried signs, hung effigies of the countrys president,
and lit off firecrackers to draw attention to their cause. These actions definitely caused
conflict, disrupted peoples lives, and disturbed the secure, peaceful cohesion of the city.
How can inequality be causally linked to these disruptive and sometimes violent
protests? What I discovered as I discussed the doctors strike with citizens, patients, medical
students, doctors, and other government workers is that the underlying issue is not actually the
amount of hours doctors should work for their salaries; that particular point of disagreement
just happened to be the means for the manifestation of a more fundamental matter how
Bolivian doctors feel about their status and respect. The six-or-eight-hour debate stemmed
from an agreement that doctors made with the government during the 1970s, stating that they
would practice medicine for six hours a day and do continuing education research for two
hours a day. The government recently claimed that the doctors have been using the two hours
as personal time, and thus wants to change the shift to eight hours of practicing medicine. It is

really a petty point reflecting a greater issue. As one Bolivian said to me, It is all about
entitlement. The doctors think they deserve all of these benefits, and the government is trying
to put them in their place and maintain control.
8
When I asked doctors and medical students why they were striking, their cardinal
complaint was that under Bolivian law and governance, they do not receive the status and
respect that they believe they deserve. First of all, public doctors all receive the same salary. It
does not matter if they work overtime, take night shifts, work on weekends, or are more
specialized with higher levels of education and training. They are all paid the same amount,
which is significantly less than that which private doctors can make. In addition, public
doctors are the only government employees not included in the provision of benefits under the
General Labor Law of Bolivia, although they are expected to obey government mandates like
all other public workers. Finally, the doctors feel that the government does not support them
enough or value their skills. From their perspective, the demand for them to work more hours
suggests that it is a lack of time, effort, and care on the part of the doctors that causes poor
outcomes for patients. This is a direct blow to their pride, as the doctors feel that they do their
very best work and are limited by a lack of supplies, equipment, facilities, and adequate
government funding. All of these underlying issues give the doctors the perception that they
have low status and a small degree of respect in a highly unequal, hierarchical society. This
incited them to strike, lead marches, set up blockades, and cause other disruptions. The city-
wide conflict resulting from the protests and the subsequent neglect for patients in public
hospitals due to a lack of working staff were detrimental to the entire population of La Paz.
Driving patterns were another visible indicator of differences in socioeconomic
inequality and social cohesion. While the taxis, buses, and cars of the low and middle classes
of El Alto and downtown La Paz almost never yield to pedestrians, the resident-owned cars of
the more exclusively affluent Zona Sur residents frequently stopped for people in the
community to cross the street.
As mentioned above (see Teenage Birth Rates section), La Paz and Tarija can also be
compared in terms of socioeconomic inequality and the societal consequences. Tarija is a
more socioeconomically equal city than La Paz for two main reasons. First, while the rich
neighborhoods of Zona Sur and the poor neighborhoods of El Alto are both so close to
downtown La Paz as to form what is essentially one continuous city, the poor areas
surrounding Tarija are farther from the city center indeed, the poor, rural inhabitants of the
department live in small towns and communities miles away from Tarija. Second, Tarijas
universal healthcare system promotes equality both by physically providing health services
for everyone and by contributing to the perception of social equality. As a result of their
different levels of socioeconomic equality, I observed differences between Tarija and La Paz
concerning societal cohesion. Because the city of Tarija is not divided into sections that are
clearly much poorer or richer, it feels like everyone is more equal. There is also more
homogeny in the physical appearance of the population of Tarija, since there is less
integration of people who dress in traditional indigenous clothing within the city limits. In
general, there is a greater sense of camaraderie and friendliness toward strangers in Tarija
compared to La Paz. This shows that improvements in socioeconomic equality have the
potential to foster more nurturing community dynamics and better social cohesion.


Future Outlook and Solutions

The commonality between the societies that do the best in the aforementioned issues is
that they all have high levels of socioeconomic equality regardless of how it is achieved.
This is significant because it implies that there is not a singular, all-encompassing solution
that must be applied to every society in order to improve global health and well-being. Each
country can develop a unique solution to combat socioeconomic inequality, based on the
specific values, systems, demographics, and problems of that society.
Greater societal equality can be achieved either with greater equality in gross
incomes before taxes and benefits or by using taxes and benefits to redistribute very
unequal incomes.
55
Because instigating the first method would require major changes in
fundamental government policy and organizational ideology, I will focus on solutions that are
more attainable, following the second option. I will outline solutions for Bolivia to exemplify
suitable possibilities for a developing country. I will then explain how the ideas presented can
potentially be expanded to developed countries with specific differences, using the U.S. as an
example.

Solutions for a Developing Country: Bolivia

As I have explained in the above sections, socioeconomic inequality and the societal
problems it causes occur in a cyclic pattern. The aspects and consequences of inequality are
interdependent and exacerbate each other greatly in highly unequal societies. Their
interconnected nature, however, can also act in the opposite direction. There seems to be a
threshold level of socioeconomic equality that much be achieved in order to facilitate a cycle
of improvement, with the benefits of societal equality compounding on each other to gain
further equality or at least maintain a fundamental level.
The best way to improve societal health and well-being by attaining this threshold
level of socioeconomic equality and the associated benefits is to enact efficient solutions that
make the greatest impact while using the least amount of money and resources. This can be
accomplished by focusing on the most devastating aspects of socioeconomic inequality and
targeting the groups that will reap the greatest benefit from intervention. Due to the highly
impressionable nature of their development, children arguably should be the target group in
almost every society.
The three central aspects of childhood that can help youths escape the cycle of
inequality by empowering them to lead healthy, productive, upwardly socially mobile lives
are education, health, and family life. According to Dr. Tejerina, a specialist in pediatrics at
Hospital del Nino, nutrition, vaccination, growth, and development are the most important
factors in promoting childhood health and well-being.
44
These vital elements can be cultivated
by the provision of quality education, health services, and family dynamics.
Access to free, high quality public education is essential. The Bolivian public
education system could be improved with advances in both quality and access. The
opportunity for all children and adolescents to achieve high levels of scholarship would make
tremendous progress toward reaching the threshold level of equality necessary to initiate a
positive cycle of societal improvement because education empowers youth to overcome the

barriers of social immobility, sidestep the social problems associated with hopeless
desperation (criminal activity, drug use, teenage pregnancy), and avoid the health problems
provoked by ignorance.
Preventative health measures also have an immense impact on children. Nutrition is
the foundation of health, and could be improved in the youth population of Bolivia through a
cooperative campaign with the education reforms mentioned above. Past programs have
attempted to utilize excess national income from Bolivias petroleum and natural gas revenues
to fund a nutritious meal program in public schools.
8
This would be particularly effective
when coupled with the expansion of access to free public education, as more children
throughout the country would benefit in terms of both education and nutrition.
The prevalence of childhood vaccination and access to basic primary care services has
been improving in Bolivia over the past decades, but the programs need to cover a higher
percentage of the population and encompass more of the isolated rural regions and overlooked
inner-city areas. This could be accomplished by adopting the Census-Based, Impact-
Oriented Approach developed by Henry Perry and colleagues, which works by providing
key, high impact [primary health care services targeted at those with the] highest risk of
death.
33, 34
Comparative experiments with this method have yielded promising results:
decreases in under-5 mortality, and increases in childhood vaccination and nutrition.
34
Also,
the low cost per impact of this program makes it feasible for implementation.
34
Designing a
census-based, impact-oriented approach based on infant mortality statistics of the greatest
causes of death and the highest-risk populations in Bolivia could have huge benefits.
10, 11, 28
Another aspect of efficient preventative health is ensuring access to those who can
most benefit from early treatment and preventative services by providing targeted insurance
programs. SUMI, the relatively new program covering mothers (through pregnancy and six
months afterward) and their children (for their first five years of life) is a step in the right
direction for Bolivia.
35, 42, 52
The SESO program covering youth from ages six to eighteen in
El Alto is another high-impact measure that has the potential to make great progress in
improving health.
52

Sanitation is the final major factor that should be addressed concerning preventative
health measures, as improving sanitation is one of the main correlates with [positive]
changes in life expectancy.
17
A study on the changing organization of the water management
systems in Bolivia shows that it may be possible to greatly improve sanitation for many
people without incurring a tremendous cost; instead, organizational changes can be made to
improve the efficiency of the system.
27
After education and health, the third central aspect of childhood that can help youths
escape the cycle of inequality is improvements in family dynamics. Although family
dynamics are highly personal and private in many respects, there are some societal
interventions that can facilitate improvements in family life and a more nurturing environment
for child development. This can best be accomplished with the provision of paid parental
leave and free early development programs for infants and children.
55
Another important
measure is to target support programs at the most vulnerable children. For example, CFHI
runs a program that provides medical aid, child psychological support, and social support
for over 80 Bolivian children living with their parents in jail.
7
The goal is to give these
children the opportunity to develop in a way that will allow them to easily integrate into

normal society when they are older, thus avoiding a life of deprivation and crime.
The key societal improvements I have listed above, though highly cost effective, do
have a substantial cost, especially for nation-wide application. In addition, developing
countries such as Bolivia have particularly low levels of available funding and resources from
the government. So how will these programs be funded? I recommend that the necessary
government money be acquired by eliminating or reforming less effective programs, as
designated by the revelations of the socioeconomic inequality data mentioned above. These
funds should be funneled instead into the more efficient programs outlined in this section.
For Bolivia specifically, funding could be attained by making changes to the prison
system and by reining in extra spending on aesthetic public showcases; for example, I
observed many excessively lavish parks and orphanages while in Bolivia. I also heard that a
new government palace is being planned for construction, which many Bolivians consider
unpractical and unnecessary.
18
Another option is to improve the taxation system, which
according to the CFHI program coordinator in La Paz, currently collects taxes from only a
small fraction of Bolivians. System reform to increase the taxpayer population would provide
more funding for programs to combat socioeconomic inequality, without increasing tax rates.
Finally, the national government should continue using its abundant petroleum and natural
gas revenues to fund programs that will improve societal socioeconomic equality.

Solutions for a Developed Country: The United States

The threshold level of equality could be achieved in a developed country like the U.S.
following the same basic principles with country-specific modifications. While all public
schools, including universities, are essentially free in Bolivia, public universities are relatively
expensive in the United States. Though it may be impossible to provide free attendance to
public U.S. universities in the near future, even working to substantially lower tuition would
improve upward social mobility and equality in the country. The U.S. also lacks universal
healthcare for mothers and infants as an equivalent to Bolivias SUMI program; although
universal healthcare for all is currently a much-discussed ideal, starting with a program
exclusively for mothers and young children is a better option. This smaller scale, higher
impact (i.e. greater life-long health benefits for the cost of service provision) program would
be both more efficient and easier to pass into law. In terms of family life, parental leave could
be improved, and early childhood development programs could be made more accessible for
people of all socioeconomic levels.
Compared to Bolivia, the United States could obtain substantially more funding for
effective programs in education, health, and family dynamics by improving the prison system,
yet probably would not benefit from making changes in taxation.

Conclusion

Despite the earlier statement that societal socioeconomic equality should be improved
by instigating resource redistribution rather than income equalization, it is not necessary for
all countries to become socialistic welfare states in order to achieve greater equality. In non-
communistic societies, welfare programs are arguably easier to instigate than income
equalization measures. Because the cycle of improvement in socioeconomic equality follows

from these changes, however, societal incomes should become more equalized as a result of
efficient welfare programs allowing the threshold level of equality to be reached and thus
generate further equality. Currently, the most equal countries all benefit from relatively good
health and social cohesion despite having a variety of government types and cultural values.
Thus, it seems possible for any society to achieve a high level of sustainable socioeconomic
equality that will greatly advance the health and quality of life of its people.


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