Book Review

Society and Health

N Engl J Med 1996; 335:756September 5, 1996

Article

Society and Health
Edited by Benjamin C. Amick III, Sol Levine, Alvin R. Tarlov, and Diana Chapman Walsh. 374 pp. New York, Oxford University Press, 1995. $49.95. ISBN: 0-19-508506-X

Today's headlines — welfare reform; community activism against an asphalt plant in a minority neighborhood; the growing number of uninsured people in the presence of managed care, capitation, mergers, and the consolidation of health care institutions; Congressional wrangling over an increase in the minimum wage; the Supreme Court's decisions on affirmative action in Texas and Maryland — represent a range of issues that ultimately affect health. The general public and health care providers and experts do not always acknowledge the connections between this broad range of social issues and health. Society and Health is an excellent work that makes a compelling argument for paying more attention to the relation between social factors and health.

This book, a collaborative effort of academicians from several different disciplines, grew out of papers presented during a 1992 conference convened by several of the book's editors. The chapters are organized around these papers, and thus the book is not an overview of the literature on health and social circumstances but more a series of case studies that help to bring into focus research and policy related to this topic. Each chapter raises complex and important questions about the topic at hand. The book also presents a helpful paradigm for understanding the importance of social circumstances of populations, communities, and individuals.

The chapter on race and health by Gary King and David R. Williams uses the health of blacks to explore race as a factor that determines health. The frank discussion of the meaning of race provides a useful perspective on the understanding of biologic as compared with sociopolitical determinants of race. The authors present a convincing argument against using race as a proxy for social class. Equating race and socioeconomic class is misleading and does not take into account that indicators of socioeconomic status do not have the same meanings for different racial groups (e.g., a given level of income may not have the same buying power for blacks as it does for whites). They challenge researchers and policy makers to “reject obsolete and simplistic intellectual paradigms and empirical methods involving race and health” and offer an alternative framework for examining the importance of race in health care. The chapter “Gender, Health, and Cigarette Smoking” presents a similar overview of the complexity of sex as a social determinant of health. The authors conclude that if antismoking campaigns do not address the limited choices of girls growing up in disadvantaged social circumstances, they will be less than successful and will continue to preferentially affect the better-off. The chapter on political economy and health is very pertinent to the debate over an increase in the minimum wage. The primary message is that economic policy does have an impact on health but that its effect is not felt through market forces alone.

The book does not leave unaddressed the effect of medical care on health status. However, the chapter on the topic is very condensed in its focus on prevention and life expectancy. I did not find that it added much to the book.

All in all, this book convincingly identifies race, sex, work, family, community, culture, and the national economy as social factors that influence health. The main conclusion of most chapters is that economic inequality is bad for health. Rather than leave readers feeling overwhelmed by the challenge to change the policies that have resulted in such economic inequities, the book ends with a chapter by S.M. Miller that presents an approach to policy that could create an overall vision for improving the health of the society. This vision is based on reducing inequalities in the allocation of resources, improving social roles and connections among those who are not respected in society, and improving the relative positions of those who have been traditionally marginalized. The discussion does not, however, address the realities of the current state of discourse in America, where debates over affirmative action, multiculturalism, the growing disparity between the wealthy and the poor, and other issues have been reduced to sound bites and dismissed by other tactics that impede frank and honest discussion. How to address these issues in medical institutions, which in every way reflect the greater society, is also not discussed.

Anyone interested in public health and medicine at the educational, policy, and practical levels will find in this book a useful discussion of the complicated social factors that determine health. The book is less clear about how to act on its important insights.

JudyAnn Bigby, M.D.
Brigham and Women's Hospital, Boston, MA 02115