Poverty, Inequality and Health: An International Perspective; Mind the Gap: Hierarchies, Health and Human Evolution

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.