Book Reviews
The Social Origins of Health and Well-Being
Richard Eckersley, Jane Dixon and Bob Douglas (eds)
ISBN: 0-761983-4-2 2002 347 pages Cambridge University Press, Cambridge
Marwan Khawaja
Centre for Research on Population and Health, American University of Beirut, Lebanon
A significant body of work in recent years has addressed the social determinants of health, as evidenced by numerous editorials in leading scholarly journals, books and special journal issues on the subject. Yet as the editors point out, this research has been mainly confined to the American and European contexts and focuses on determinants of the socio-economic disparities on health outcomes. The Social Origins of Health and Well-Being is a welcome correction. Although this collection is primarily about Australia and New Zealand, it includes contributions that range widely in topic and analytical approach as well as theoretical sophistication. The strength of this volume is its emphasis on the historical and cultural dimensions of the social origins of health and living conditions, and in the inclusion of various disciplinary perspectives.
The chapters in the volume, most of which were originally presented as papers in a scientific conference on the social determinants of health held in Canberra in 2000, share an emphasis on the 'production' and distribution of health by economic and political institutions as well as by socio-cultural processes. The book is divided into five main sections. Part One is largely theoretical in orientation and devoted to the structural determinants of health inequality, with a focus on the global dimension. The four chapters of this section contain a variety of models and some detailed discussions of specific cases such as from Australia and Russia. The first chapter offers an essentially evolutionary / institutional perspective regarding differential adjustments of populations to economic development, giving primacy not only to the evolution of the economy but also to institutions and knowledge. The subject of the second chapter is the power of ideas such as neo-liberalism and 'claim making' to disguise widening health inequalities. The third chapter deals with largely neglected dimensions of global environmental change in the health inequality literature, and the final one by Richard Eckersley focuses on the equally important theme of culture, arguing forcefully that new cultural trends and emerging values in the west impact on health and well being independently of structural forces. Overall, the discussion in this section is likely to stimulate much needed research on values, cultural practices and health outcomes.
From our perspective, the second and third parts of the book on social explanations of health inequality are the most interesting of all, and deserve close reading. Part B includes six chapters devoted to socio-economic status and population health, offering general models and case studies on inequalities in health status, mortality, and access to health care. Although a socio-economic gradient in health status is evident almost everywhere, the causal links between inequality and health remain elusive. The chapters by Gavin Turrell and Richard Taylor provide a succinct overview of the main explanations of health inequalities, including neo-materialist, psychosocial, and behavioural risk factors. Turrell argues for a neo-materialist explanation while Taylor expresses reservations concerning the generality of the gradient in health, save psychosocial stress. The authors point to a number of measurement difficulties. Furthermore, the lack of clear evidence concerning the biological links between socio-economic status and many diseases is emphasised. Part C addresses issues largely similar to those tackled in part B, but with particular focus on the social context of health, including social organisation, social capital and place (broadly defined). The three chapters in this section tackle respectively the physical environment, workplace, and community, cautioning against a uni-directional or otherwise deterministic relationship between context and health. They offer important insight and preliminary evidence from community studies into the production of context and place through social network and engagement 'practices'.
The next section addresses population health inequalities from a developmental perspective, following a life-course, cumulative or generational impact on health and well-being. Although the discussion is largely informed by biological (genetics) and behavioral influences on patterning of health, some attention is given to the broader social and cultural 'endowments' of individuals and groups. It is unclear how interventions can be undertaken in these domains, but advances in this growing area of interdisciplinary research deserve greater attention from social epidemiologists.
The last part on policy issue and prevention is perhaps the most important of all from a practical perspective, despite the seemingly large overlap in some of its four chapters with previous ones. The first two chapters are concerned with race and poverty, and caution against generalisation and uni-dimensional conceptualisation of these terms. The last two chapters concern policy interventions. Ross Homel and his associates describe a broad intervention program to restrict or prevent behavioral and health problems among children of an ethnically disadvantaged community in Brisbane. The final chapter is broader in scope and calls for greater attention to 'evidence-based' interventions and findings based on sound methodologies in tackling health inequalities in Australia and elsewhere. The authors of the chapters in this section offer fresh insights into assessing and evaluating the consequences of 'ascribed' disadvantage on people's health and well being.
This is a well-written and useful collection. The blend of perspectives from policy and research is most welcome. The volume also includes a comprehensive list of references on social determinants of health and well being. I recommend it highly to students of medical sociology and the growing field of social epidemiology as well as to public health practitioners and policy makers.
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