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 focusing 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

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