Book Review

Unhealthy Societies: The afflictions of inequality

N Engl J Med 1997; 336:1616-1617May 29, 1997

Article

Unhealthy Societies: The afflictions of inequality
By Richard G. Wilkinson. 255 pp. New York, Routledge, 1996. $18.95. ISBN: 0-415-09235-3

Around 1980, the results of three studies with important implications for public health were published. The discovery that myocardial infarction was caused by a clot almost instantly led to a new clinical-services industry. The positive relation between maternal literacy and child survival in developing countries led to the current vogue in literacy programs for women in these regions. A third study found a strong negative relation between inequality of income and health among 64 countries. The responses to these disparate findings were as varied as the findings themselves. The finding of the first study led to costly therapy for infarctions, but the worldwide effect was limited. The finding of the second study, which did not seriously threaten the status quo, resulted in numerous policy declarations but little action. Implementation of the ideas suggested by the third study and the numerous confirmatory studies that followed, however, would have required changing international economic and political power bases. Not surprisingly, the prospects for such a project were swept under the rug. In Unhealthy Societies: The Afflictions of Inequality, Wilkinson lifts up the rug for another look at an idea that has been ignored for nearly two decades.

Wilkinson's main message is that income distribution, both within a country and among countries, is closely associated with the mortality rate, an indicator of health. He posits that the effect of the usual environmental and behavioral risk factors on health are small in comparison with the overwhelming effect of income distribution and that among rich countries, economic growth has little to do with health. These arguments, laid out like a mathematical proof, are compelling. I hope that this book will be read carefully, and the ideas cited correctly.

Wilkinson develops the concept that the health of a population is not merely an aggregate of the health of its individual members. He ponders the rapid rise in life expectancy almost everywhere during this century and casts doubt on the importance of improved nutrition, control of environmental factors, and medical care in bringing about the change. Wilkinson admits that medical services in poor countries reduce mortality, but in the United States, for example, only 5 of the 30 years gained in life expectancy during this century can be attributed to clinical and preventive health services. (One could argue that if deaths due to malpractice are factored into the analysis, even those five years may be lost.)

Wilkinson explores the nature of health inequalities, defined as the stratification of mortality rates according to socioeconomic position within countries. He examines studies showing that “every death rate and measure of health [is] more sensitive to variations in socioeconomic conditions than to medical care” and observes that the “role of medicine is to pick up the pieces.” Skin and breast cancers are the only exceptions to the expected pattern of increased mortality in the lower social classes. Among countries, however, the relation between income and health is different. Wealthier countries are not necessarily healthier. A notable example is the richest country, the United States, which ranks less than 20th among nations in life expectancy.

The important discussion in chapter 5 analyzes studies published since 1979 that show the pervasive influence of inequality of income on health. This relation is not only static and cross-sectional but also dynamic. Countries that change their income distribution through taxation and other fiscal means have concurrent changes in health indicators. This robust observation is true for states within the United States as well, even after adjustment for the effects of race, smoking, income, and absolute poverty level. The association does not appear to be strongly influenced by government expenditures for social programs, as illustrated by Japan and Sweden, which rank one and two in life expectancy, respectively, but are at opposite ends of the spectrum of social expenditures as a proportion of gross domestic product, with Japan spending only 15 percent, as compared with Sweden's 40 percent. Wilkinson acknowledges that it is unclear how low relative incomes have to be to affect health, as is the extent to which a reduction in relative poverty would affect the health of the well-to-do.

Wilkinson looks at national and regional examples of income distribution as a proxy for what he calls “social cohesion,” which is roughly the same as what Putnam and others term “social capital.” From studies of Eastern Europe and the former Soviet Union during the 1970s and 1980s, Wilkinson points out “how closely health is related to the political environment.” Today, health is declining in many of these countries, a reflection of the loss of social cohesion associated with political collapse.

The last third of the book looks at possible biologic and sociological mechanisms for the effect of income distribution on health. “Modern societies are still feeling their way towards a satisfactory social organisation of the highly integrated productive system which economic development has so recently produced.” Wilkinson notes that the monetary economy is a very recent phenomenon. Among hunter-gatherers, herders, and slash-and-burn agriculturalists, food sharing and gift exchange limited social inequities, and “most societies showed a strong taboo on any open expressions of material self-interest.” In contrast, the market and wage-labor economy institutionalizes individualism and the pursuit of individual gains. “We come to believe that human beings are by nature what their culture suggests they are,” Wilkinson states.

Wilkinson is a leading advocate of research on health inequalities and is on firm epidemiologic ground in making his public health arguments. The book is best read by those who have some familiarity with epidemiology. The sociological arguments are plausible, even believable. However, the presentation is at times difficult to follow; the chapters could have been improved by consistent use of subheadings.

Wilkinson's career began with an open letter to the secretary of state for health and social security in the United Kingdom, which indirectly led to the Black Report, a pioneering look at health inequalities in that country. After the suppression of the report's findings, there was some debate, but knowledge has not led to action. In Unhealthy Societies, Wilkinson suggests that attention to the concepts he presents will bring about changes in public policy. Putting treatments such as percutaneous transluminal coronary angioplasty and thrombolytic therapy into practice, or even teaching women to read, is worlds apart from implementing the egalitarian ideal of social justice or equality of income. But the need for action is clear.

Stephen Bezruchka, M.D., M.P.H.
University of Washington School of Public Health and Community Medicine, Seattle, WA 98195