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Once again, reposting Dennis Raphael's message from Friday that apparently
came in an attachment.
-----Original Message-----
From: Dennis Raphael [mailto:[log in to unmask]]
Sent: Friday, July 27, 2001 3:40 PM
To: [log in to unmask]
Subject: New books on inequality
BMJ 2001;323:239 ( 28 July )
Reviews
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
I recently 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
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