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Michael Marmot and Richard Wilkinson Oxford University Press, 1999 There is a renewed interest within public health circles in the contribution made by social and economic factors to health, reflecting the strength of the evidence base which now exists in this area. As part of a recent campaign to encourage wider recognition and action on these factors, the Centre for Urban Health, WHO Regional Office for Europe, requested the International Centre for Health and Society, based at University College, London, to summarize the growing evidence on the social determinants of health as 10 key messages for policy makers and the public. The resulting booklet, Social Determinants of Health—The Solid Facts, outlined the contribution of a range of social, material and psychosocial factors to population health: work, unemployment, early life, addiction, food, transport, stress, social exclusion, social support and the social gradient. The Solid Facts (as the booklet is more popularly known) made a strong but easily understood case for the various ways in which material disadvantage combines with the effects of insecurity, anxiety and lack of social integration to affect the health of those at progressively lower levels of socio-economic status. The evidence and policy implications contained in the booklet are given a much expanded and more technical treatment in the new Oxford University Press publication Social Determinants of Health. Edited by Michael Marmot and Richard Wilkinson, who were also co-authors of the WHO report, the book focuses in turn on each of the social determinants named above, with the 10 ‘messages' forming the topics for Chapters 2–11. Each chapter provides a clear and informative overview of the most recent research in the area, and the evidence underlying the message. Most chapters are written by leading researchers in the field, and all of the authors have an affiliation with the International Centre for Health and Society. The book begins and ends with ‘framing’ chapters by the two editors. Michael Marmot introduces the collection by rehearsing questions regularly asked of health inequalities researchers: What is the practical value of the research? How can the knowledge be applied? What is the role of medical care in health inequalities? What about the genetic basis of disease and individual risk? Are we dealing with natural selection or social causation and health status? How exactly does the social environment affect health? Using international comparative data from the World Development Report, the WHO Global Burden of Disease Study, and his own collaborative research in Europe (including the Whitehall studies of British civil servants), Marmot suggests that there is now sufficient evidence to argue the following. Differences in health between population groups are due to characteristics of society, not to differences in health care. When people change social and cultural environments, their disease risks change; people's disease rates are responsive to the environment in which they reside. The health gradient is not a function of poverty alone. Health inequality is not a question of poor health for the poor, and good health for the rest. It is a problem across the socioeconomic spectrum—as one moves down the social hierarchy, life expectancy gets shorter and mortality rates are higher. The health gradient can change, and change quickly, as events in central and eastern Europe illustrate. The health gradient is not a matter of selection. Ill health can be a barrier to success in life, but the effect is relatively small. By and large, health does not determine social position; social position determines health. In Chapter 2, Marmot joins with Eric Brunner to write about the ‘variety of biological pathways that can plausibly change the risk of developing major disease’. Marmot and Brunner examine the ways in which social organization can influence biology, and provide models for hypothesizing the links between the psycho-biological stress response, the social environment and disease states. This chapter provides a figure that attempts to illustrate a comprehensive model of the social determinants of health. The model links social structure to health and disease via material, psychosocial, behavioural and bio-physiological pathways. Genetic, early life and cultural factors are represented as permeating the entire series of pathways. The importance of the early years for shaping biological status into adulthood continues in Michael Wadsworth's Chapter 3, and in David Blane's contribution in Chapter 4. Together the material in these chapters supports the proposition that the optimal stress response in relation to long-term health is associated with the early life, and living and working conditions of the ‘materially advantaged’. These chapters emphasize how ‘the long reach of childhood’ has implications for physical health across the life course. Much of the material points to the cumulative effects of both social and biological events across the life course. This is a point that is emphasized in Chapter 5, ‘Living in a high-employment economy: understanding the health consequences’. Bartley, Ferrie and Montgomery highlight the importance of long-term studies which chart the process of accumulation of advantage or disadvantage. They argue that in the area of employment and unemployment it may be wise to consider a continuum of experience because the stresses of chronic insecurity of tenure in work can be as significant as the stresses of unemployment. The theme of work and employment status continues in Chapter 6. In this chapter, Marmot joins with leading work and health researchers to examine the relationship between health and the psychosocial environment at work. The authors note that the so-called ‘classical’ risk factors of high blood pressure, raised plasma cholesterol and smoking account for no more than one-third of the social gradient in cardiovascular disease—hence they argue it is necessary to look for explanations in the wider social and economic organization of societies. The nature of working life is a particular feature of social organization, and significant as a source of a number of psychosocial influences on health. The authors draw on a wide range of studies to show that the extent of perceived and actual control over one's working situation is a significant predictor of adverse health outcomes associated with the work environment. However, the authors also suggest that it is not sufficient to concentrate on conditions in any one setting, e.g. the workplace, without exploring the interrelationships between family and working lives and community structures. Chapters 9–11 include ‘Poverty, social exclusion, and minorities' by Shaw, Dorling and Davey Smith; ‘Social patterning of individual health behaviours: the case of cigarette smoking' by Jarvis and Wardle; and ‘Food is a political issue' by Robertson, Brunner and Sheiham. The authors remind us that it is premature to overlook poverty as a critical dimension to health outcomes even in the so-called First World. They all, however, elaborate some form of interrelationship between material circumstances, social structures and psychosocial mediators and responses. In the case of the unemployed, financial problems and risk of depression and loneliness go hand in hand in the first 18 months after losing a job. For minority groups there are multiple dimensions of social exclusion, but in general economic disadvantage is accompanied by threats to meaning and identity creation. The matter of why poor people smoke has been explained partly as a result of lower levels of self-esteem, and downward social mobility. In relation to food, access issues are vital but so is, it seems, community control over what is available. One theme that runs through the chapters is how important longitudinal cohort studies have been to the epidemiological insights in this complex field. The insight is particularly pertinent for countries, e.g. Australia, that have underinvested in this form of research. The challenge of ‘putting the picture together’ is taken up by Richard Wilkinson in Chapter 12. Wilkinson, author of Unhealthy Societies: The Afflictions of Inequalities, synthesizes one of the major arguments of his earlier book: that relative deprivation is as important as absolute deprivation. He provides data for OECD countries that show only a weak association between long-term economic growth and changes in life expectancy. So while the USA has twice the gross domestic product per capita of Greece, life expectancy is higher in Greece. Within nations or areas, the argument is that over a certain level of income where one is placed in the social hierarchy is as important as one's income. National social gradients of health reflect psychosocial factors as much as material hazards and circumstances. Wilkinson claims that a meta review of studies looking at the relationship between income distribution and health within a nation shows that greater income equality has a beneficial effect on the health of the whole population. He cites US research by Kaplan, and Kennedy and Kawachi —including the latters' findings of a relationship between homicide and income inequality—and urges further research on the role of shame, fear of incompetence, and inferiority on health endpoints. In Wilkinson's opinion, the psychosocial effects of social relations render a more plausible explanation for health outcomes than do materiality and risky behaviours. One of the few references to the role of cultural factors is made in this chapter, when Wilkinson addresses the generalized and institutionalized acceptance of the ‘shame–rage spiral’, and the impacts of racial discrimination. Each of the chapters contains a section, of varying depth and thoughtfulness, about the policy implications of the evidence that they cover. The chapter on food, and Chapter 7 ‘Transport and health’ by McCarthy, contain recommendations that apply from the global to the local level. Other chapters emphasize social policy recommendations—e.g. ‘psychosocial support’ policies, and ‘springboard’ arrangements rather than safety nets, which can help repair the damage of past disadvantage and move individuals and families to a more socially advantaged life trajectory. The enormous challenges in developing policy recommendations are obvious throughout the book, and are manifest in Stansfeld's comments in Chapter 8 in relation to the need for serious consideration of the influence of macro-level policy decisions on social support and social cohesion. But how many governments are willing to audit their economic and fiscal polices for their impact on social cohesion? A brief epilogue is provided by Tsouros and Farrington of the European Office of WHO. They argue that since the WHO strategy of Health for All, health policy making has been beset by change. First, the policy environment is characterized by the inclusion of more actors, intersectoral action, local action and the mobilization of networks, which combine to make the policy process a far more demanding activity. Second, the accumulating evidence described in books, e.g. Social Determinants of Health, reinforces the urgency of working upstream on the factors that influence lifestyles. An overview of the WHO Healthy Cities Project follows, with an explanation that the Project has become WHO Europe's principle vehicle for pursuing an understanding of, and policy action on, the social determinants of health. The epilogue returns us to the opening question asked by Michael Marmot about the practical value of doing research on social inequalities in health. Tsouros and Farrington argue that it is vital that policy makers have access to the type of research represented in Social Determinants of Health. They also stress the importance of such research being communicated clearly if it is to influence the policy agenda. The Social Determinants of Health provides a relevant and readable synthesis of current health inequalities research. It has all the right ingredients to make a major contribution to policy debates and decision making, and should achieve its aim of promoting a discourse among policy makers, practitioners and the public—in Europe at least—about research findings relevant to improving the health of us all. For readers of Health Promotion International, the Social Determinants of Health must be considered essential reading.
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