Family Practice Vol. 20, No. 1, 95
© Oxford University Press 2003
Book Review |
Reducing inequalities in health: a European perspective.
John Mackenbach, Martijntje Bakker (eds). (378 pages, £18.99.) Routledge, 2002. ISBN 0-415-25984-3.
Clinical Research Fellow, Department of General Practice and Primary Care, University of Birmingham
Social inequalities in health—the fact that poorer people experience more sickness than richer people and live shorter lives—have been apparent as long as information allowing health to be related to social position has been available. In the UK, these gaps are becoming wider. The child of an unskilled labourer, born today, has a life expectancy 10 years shorter than that of the child of a doctor. Such stark social injustice recently has become a political issue. Governments of several European countries have suggested that reduction in health inequalities should be a key policy goal.
Reducing inequalities in health: a European perspective is published against this background. It contains a comprehensive description of inequalities in various measures of morbidity and mortality from several European countries, a brief critique of the different explanations for inequalities that have been advanced and a review of interventions derived from these explanations that may effectively reduce inequalities.
The editors have done an impressive job in bringing together opinion and evidence from many of the most prominent academics in the field and presenting it in a coherent form. Sophisticated accounts of the health inequalities debate accessible to those outside of academia are clearly needed. Popular conceptions of inequalities (including those of broad-sheet journalists, politicians and many doctors) still appear dominated by assumptions that the poor health of poor people is due mainly to either social selection or their unhealthy behaviour. Such assumptions lead to particular conclusions regarding policy priorities. In contrast, academic agreement on this issue is virtually unanimous. Behaviours and social selection make a minimal contribution to inequalities. The principal explanatory factor behind inequalities in health is inequalities in wealth. Any policy to reduce health inequalities that does not involve a reduction in wealth inequalities ultimately will fail.
These authors state that, "By addressing the fundamental causes of inequalities in health one also avoids the possibility that after one of the more immediate causes has been eliminated, other immediate causes take its place because the same fundamental causes are still in operation." This point is relevant to the case of smoking, the behavioural explanation most commonly advanced as the ‘cause’ of health inequalities. Leaving aside relatively technical statistical arguments, it should be intuitively apparent that smoking is an unlikely, fundamental cause of inequalities. At various times in numerous places, smoking was actually more common amongst the socially advantaged. However, its undoubted health-damaging effects were offset by other protective effects of affluence, and richer people were still healthier overall. Being poor, in contrast, has always been extremely bad for your health.
For politicians with a genuine desire to reduce health inequalities, this book provides guidance as to what is likely to work and what is not. I recommend that these politicians, and anyone else with an interest in inequalities, read this book in conjunction with The Widening Gap by Mary Shaw et al.,1 which gives a complementary focus on essentially the same areas.
References
1 Shaw M, Dorling D, Gordon D, Smith GD. The Widening Gap. The Policy Press, 1999.
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