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Why Are Some People Healthy and Others Not? The Determinants of Health of Populations
edited by Robert G. Evans, Morris L. Barer, and Theodore R. Marmor (Hawthorne, N.Y.: Aldine de Gruyter, 1994), 378 pp., $52.95 (cloth), $23.95 (paper)
The evidence for the effect of social inequality on population health and mortality is compelling. In virtually every Western industrialized nation there is a gradient between social class position (usually measured by occupation, education, and/or income) and risk of death. In the United States this relationship was documented twenty years ago by Evelyn Kitagawa and Philip Hauser, and more recent work by Gregory Pappas shows that mortality has intensified with increased social inequality.(1) The strength of the relationship raises a host of questions: What are the physiological pathways by which class and status affect health? To what extent do these pathways differ for different diseases? What is the role played by culture, and particularly by social networks and patterns of social support, exchange, and caretaking, in mediating or moderating the effects of social position on health and disease? And, if the major forces that shape health and disease differentials are social and economic in origin, what role is there for public health and medical care, and will health care simply reflect or will it compensate for underlying social inequalities?
This line of research raises a vexing policy issue, particularly troubling in an era of retrenchment, anti-federal government sentiment, and the dismantling of the U.S. social welfare infrastructure. If inequality--whether measured by education, occupation, or wealth--is a major, if not the major, determinant of differences in health and mortality, what then are we to do? And if health care plays only a modest role, where should scarce resources be placed? For one hundred years or more public health has provided ready and often effective answers, but it appears that we may be at the margins, at least in the Western industrialized world, of what public health solutions can provide. What answers lie between income equity and public health, and what tools do we need to design useful policies?
These are the questions raised by a new book, a product of the Program in Population Health at the Canada Institute for Advanced Research (CIAR). Why Are Some People Healthy...