Health Promotion International, Vol. 15, No. 2, 179-180,
June 2000
© Oxford University Press 2000
Resource Reviews |
The Sociology of Health Inequalities
National Centre for Epidemiology & Population Health, The Australian National University, Australia
A substantial body of research documents the socioeconomic ‘gradient’ in which worse health outcomes are associated with lower positions in the hierarchies of income, education and occupational status. The Black report (Black, 1980
) was not the first major work to address this issue, but it was a milestone, and since it appeared, publishing on the topic has increased considerably, beginning with a trickle during the 1980s and becoming a flood since the mid 1990s. In the circumstances of such heightened interest and output, edited collections become both inevitable and necessary. The volume under review joins (at least) two others, also high quality, published in the last two years [(Keating and Hertzman, 1999): see review this issue (Marmot and Wilkinson, 1999)].
The editors' thoughtful, clear introductory essay acknowledges the intellectual and political history of health inequalities research, and sketches the developments and debates within which the chapters are located. The Black report confirmed that economic barriers to medical services were not the cause of inequalities in health outcomes. Subsequent research—especially longitudinal—has shown that the gradient is not simply an artefact of data collection, that it is not narrowing over time, and that selection does not explain what are complex interactions.
The first substantive section of the book contains four papers on ‘understanding the social dynamics of health inequalities’. Most of the chapters in this section grapple with research showing how health inequalities prevail throughout the SES spectrum, not only among those suffering absolute material deprivation. Elstad's ‘Psycho-social perspective’ proposes a theoretical model to account for observed patterns of inequalities, linking the large literature on the health effects of stress with work on the quality of social relationships and concepts of self-efficacy. His perspective links directly with the paper by Wilkinson, Kawachi and Kennedy who are well-known contributors to this discourse. Here they use data on US state crime rates and social capital to examine the nature of the social relationships (of competition, disrespect and shame) that give rise to violent crime which are, they suggest, closely connected to the psychosocial sources of ill health.
The other two chapters in the first section mobilize a somewhat different (but not necessarily conflicting) approach. Popay and colleagues summarize the Whitehead/Dahlgren model of concentric rings of influences on health inequalities, working from biological factors at the centre through individual and social influences to broad socioeconomic, environmental and cultural dimensions. I particularly warmed to their critique of the ‘profoundly non-social' approaches which continue to add ever ‘more social variables to an increasingly long list of risk factors' (p. 69). Usefully, however, their critique does not set up antagonistic dichotomies, but calls for an integration of the individual and the social, agency and structure, micro and macro.
In the title of their chapter, Curtis and Jones ask whether there is ‘a place for geography in the analysis of health inequality’, and supply abundant rich evidence for an affirmative answer. They distinguish compositional and contextual effects, carefully disentangling the fact that similar people may live in the same neighbourhood (composition) from the possibility that the social and physical environment (context) contributes to the health of individuals within that environment.
That chapter lays the groundwork for the book's second section on ‘social and spatial inequalities in health’. In ‘Changing the map: health in Britain 1951–1991’, Shaw, Dorling and Brimblecombe show that the persistent and rising mortality gap cannot be explained by class alone. Nettleton and Burrows describe the psychological and health consequences of the onset of mortgage debt and resulting housing insecurity, thus elaborating in detail one potential process contributing to patterned inequalities in health.
Two chapters call welcome attention to the ‘complexity’ of social categories. Nazroo's research on race/ethnicity constitutes a challenge to surveys and routine statistical collections which adopt a ‘tick box’ approach to the classification of ethnicity. He calls for a focus on ethnic identity which produces a much more intelligible analysis of the link between ethnicity and health because it considers such factors as the experience of racism and ghettoization. Similarly, Cameron and Bernardes' study of prostate disease locates the multiplicity concealed within the falsely unitary categories of gender. Deficiencies in the conceptualization and measurement of the basic categories (class, ethnicity, gender) must be overcome if research is to advance and inform practical policy responses to health inequalities. After all, the notion of ‘difference’ lies at the heart of any discourse in this field, and if our thinking around these fundamental concepts is inadequate, the data will not make sense and resulting policy recommendations are likely to be off the mark.
In its incarnation as a journal issue, this book contained no thematic sections. If there is an intellectual weakness in the collection, it is that the sections—particularly the first—do not hang together entirely comfortably. The move from journal to book also resulted in deletion of the abstracts which can be helpful, particularly for such complex and subtle material. As far as I can discern, the book and journal issue are otherwise identical except for a short index, repagination and the unfortunate omission of Bernardes' name from the book's contents page.
A frustration for consumers of this literature is its comparative parochialism, both national and intellectual. Fortunately, this collection is somewhat more cosmopolitan than usual. While most contributors to the book are from English universities, there are also Dutch and Norwegian authors, although the only American names are co-authors with Wilkinson (who is from Sussex). That might not matter if more people read and thought carefully about work from other nations and intellectual traditions. Some participants in these debates advocate strongly held ideological positions which may undermine their capacity to consider the implications other perspectives might have for their own research and policy preferences. As I have threaded my way through the books, reports and journals, I have occasionally wondered whether contesting authors are sometimes addressing different issues rather than arriving at different answers to the same question. Fortunately, this book contains a minimum of ideological rhetoric and a maximum of open-mindedness and inter-disciplinary flexibility with no compromise on intellectual or empirical rigour or loss of commitment to constructive change.
Many observers believe that policy decisions of the 1990s have contributed to widening health as well as income gaps. The UK is now striving to formulate concrete policy responses (Acheson et al., 1998) to the evidence available now (Wilkinson and Marmot, 1998) while it continues to invest in further research. The US National Institutes of Health have also committed significant research funding to inequalities in health. Bartley, Blane and Davey Smith's collection is a timely and welcome contribution which will be valuable for researchers and graduate students in public health and sociology. Writing from Australia, it remains to be seen whether this country will also invest substantially in research of this kind, and, over the longer term, whether policy interventions can make a positive difference.
FOOTNOTES
M. Bartley, D. Blane and G.Davey Smith (eds), Blackwell Science, Oxford, 1998 (Also published as Volume 20, Number 5, Sociology of Health & Illness)
REFERENCES
Acheson, D., Barker, D., Chambers, J., Graham, H. and Marmot, M. (1998) Independent Inquiry into Inequalities in Health: Report. The Stationery Office, UK.
Black, D. (1980) Inequalities in Health: Report of a Research Working Group. DHSS, London.
Keating, D. P. and Hertzman, C. (eds) (1999) Developmental Health and the Wealth of Nations: Social, Biological, and Educational Dynamics. Guilford Press, New York.
Marmot, M. and Wilkinson, R. G. (eds) (1999) Social Determinants of Health. Oxford University Press, Oxford.
Wilkinson, R. and Marmot, M. (eds) (1998) Social Determinants of Health: The Solid Facts. World Health Organization, Geneva.
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