BMJ 2001;323:239 ( 28 July )

Reviews

Book

Poverty, Inequality and Health: An International
Perspective

David Leon, Gill Walt

Oxford University Press,



£29.50, pp 368

ISBN 0 19 263196 9

Mind the Gap: Hierarchies, Health and Human Evolution

Richard Wilkinson

Weidenfeld and Nicolson, £7.99, pp 76

ISBN 0 297 64648 6



Rating: ;

Irecently found myself haranguing an audience of trainee epidemiologists in
Finland. Too many epidemiologists, it seems
to me, are happy to spend their careers rediscovering the risk factors for
cardiovascular diseases. "Find yourselves an
interesting and unsolved problem and leave cholesterol, smoking and blood
pressure alone," I snarled. "For instance"
. . . and the first thing that came to mind was social inequality and health.

It's a classic case. We have known for more than a century that diseases are
unequally distributed. It is now also clear
that this inequality cannot be simply explained by unequal distributions of risk
factors and unequal access to health care.
But what are the other components that fuel the inequalities, both between
societies and within societies? The problem is
to epidemiology what the search for dark matter is to cosmology. Worse, indeed,
because investigating it calls on skills
that many epidemiologists lack, coming as they often do from a background in
medicine, upon which their
epidemiological training was tacked as an afterthought. They lack, so to speak,
social sophistication.

                   Leon and Walt have edited an excellent reader, which I
commend
                   strongly to anyone not interested in poverty, inequality, and
health. By
                   this I mean that the topic is often dealt with in one
mind-numbing
                   undergraduate medical lecture which presents a tedious
conveyor belt
                   of statistics.

                   David Leon and George Davey Smith contribute excellent
chapters
                   highlighting the need for both a panoramic view and a grasp
of the
                   detail. There are also thought provoking contributions from
                   developing countries, making this a genuinely international
perspective.

But the chapters that caught my attention were, inevitably, those which
introduced theoretical and methodological
approaches which promise to increase our understanding of inequalities and, more
importantly, suggest avenues by which
medical researchers can stimulate and inform societal debate on tackling health
inequalities. In general, the greater the
equality of income within a society, the greater the life expectancy. In other
words, it is not the absolute prosperity of a
society alone that determines health but also the social structure of that
society, with egalitarian societies enjoying health
benefits, as Stephen Kunitz points out in his essay.

It is these associations which are not so much the subject as the idée fixe of
Richard Wilkinson's book, which owes
much to the fascinating research that Robert M Sapolsky of Stanford University
has done on social structure and stress in
baboons (see http://inequality.org/baboons2.html for Sapolsky's quite reasonable
introduction to his work). But
Wilkinson's style is that of the polemicist. Instead of presenting us with a
review of the evidence, he introduces his
favoured explanations using phrases such as "it turns out that this is probably
because," and has a habit of using the
expression "we have already seen that" to mean "I made this unsupported
assertion in an earlier chapter." This book is a
disappointment; by overenthusiastic advocacy, Wilkinson badly undersells a
fascinating topic.

Ronan Conroy, lecturer in biostatistics.

Royal College of Surgeons, Dublin [log in to unmask]

© BMJ 2001