Edited by Michael Marmot and Richard G Wilkinson, OUP, 292pp
Review for Health Matters 2000
This is a collection of articles by researchers associated with the International
Centre for Health and Society at UCL and the ESRC Health Variations programme
who produced the WHO booklet Social Determinants of Health - The Solid Facts.
It is dense, fascinating and very wide ranging in every way. The effects of
stress in baboons and civil servants, health records from every part of the
world are marshalled to show how much we know about the mechanisms which cause
poor people to be unhealthy. We have a pretty good understanding of how it happens
at the population level, in the individual psychology and on a biological level.
We also have a fair idea about what happens politically, and that dimension
is addressed in this collection more than in most of the public health literature.
But is easier to describe the way in which the development of the global agri-food
monopolies damage health than to devise methods whereby the strategies of powerful
corporations can be thwarted.
One of the stimulating aspects of this book is the international range of examples
and studies, which make it abundantly clear that many of these problems can
only be tackled globally if they are to be effective. It is also makes painfully
clear that global health strategies up to now are fighting a losing battle.
Wilkinson argues that income inequality affects health through perceptions
of place in the social hierarchy based on relative position according to income.
These perceptions produce negative emotions such as shame and distrust that
are translated "inside" the body into poorer health via psycho-neuro-endocrine
mechanisms and stress induced behaviours such as smoking. So policies need to
tackle the structural sources of inequality. Economic growth alone will make
little difference. Merely focussing on relief of the poorest will not be effective.
John W Lynch has argued (BMJ 2000;320:1200-1204) that this approach is erroneous
and that the structural causes of inequalities are at least as important as
subjective perception of this inequality. He argues that Wilkinson's approach
leads to a concentration on personal psychological functioning which is a poor
focus for public health policy.
These debates are critical for Government policy on health inequalities, a policy
which at present seems to promise more than it has delivered. This book is an
excellent primer for those who wish to engage in the debate about how this policy
can be taken forward to make a real difference to the lives of those people
whose deprivations are analysed in it's pages.
Martin Rathfelder
Socialist Health Association