Books & Electronic Media
Poverty, inequality and health. An International Perspective
Edited by David Leon & Gill Walt. Published in 2001 by Oxford University Press, Oxford, England. ISBN 0 19 263196 9, price: £29.50.
A quick poll of colleagues suggests that this book will head to the top of the lists in what is now a well-published field. Reasons include the range of topics and points of view (seventeen chapters with contributors from Bangladesh to Uruguay), and the high quality of the individual papers. Poverty, inequality and health began as a series of presentations to a meeting in London in 1999 and has been converted into a single, polished and coherent text. An early chapter by the editors sets the stage for the action to follow, the chapters are cross-referenced effectively, the figures and tables are plentiful and follow a common format, and there is a detailed index. The book will suit newcomers to the field as well as readers who want to find out what is happening at its growing edges.
What is included? There is a mix of relatively familiar topics (such as the relation of income to health outcomes within and between countries, political upheaval and mortality in Eastern Europe and the broader poverty-disease-development axis) and less well known aspects. For example, Stephen Kunitz explores the dark side of social capital. He links racial segregation in US cities in modern times with the historical development of strong civic cultures, and makes the point that social structures (such as tight urban planning) may promote health but work against it when circumstances change. The chapter by Cesar Victora and colleagues on the effect of health interventions on inequalities brought to mind the worm-like plastic springs that were once popular childrens toys. Set in motion, these devices would expand and move across the floor, compressing when the leading edge ran into a border. In a similar way, it would seem that health services tend initially to expand social differences in health status, and reduce inequalities only when the most advantaged have reached a point beyond which further improvements in health are difficult to achieve.
What is missing? Everyone will feel that at least one of their favourite topics has not been done justice that reflects the breadth of the subject. Ethnicity does not receive close attention, although questions about the extent to which poverty and other measurable aspects of social disadvantage explain ethnic differences engage many policy-makers and researchers. Several chapters touch on the ethics and origins of inequality but there is no focused discussion of questions such as: which inequalities are of greatest concern? How much inequality is acceptable? And if inequality reduction is to be traded off against improvements in health overall, what should the exchange rate be?
A criticism frequently made of research on socioeconomic inequalities in health is that whilst the field is well furnished with descriptions of the problem, it is thin on explanations and almost devoid of evidence regarding interventions to tackle these inequalities. How does the book fare in this regard? First, while it is true that there are many descriptive studies in industrialized countries, the chapter by Gwatkin shows that even these basic data are thin on the ground in developing countries. The data that do exist suggest that we cannot extrapolate findings from developed to developing countries. For example, inequalities in infectious disease and injury may be far greater in poor countries than in rich ones. There is some evidence of greater variation between developing countries in overall health inequalities than between developed ones. Second, the chapter by Victora et al., based on fieldwork in Brazil, and that of Chowdhury and Bhuiya, in Bangladesh, provide informative case studies from developing countries. Third, the chapter by Graham selectively summarizes the evidence produced by various interventions to reduce inequalities, drawing mainly on data from developed countries. She concludes that we must consider the way society structures the distribution of socioeconomic advantage and disadvantage over the life-course, as well as the individual-level association of socioeconomic factors and health. Interventions must be formulated at both levels.
If there is a common theme, it may be that we need to be careful not to assume too much when faced by complex problems. Simple explanations are almost irresistibly attractive but are often very misleading. Amartya Sen writes elegantly about the subtleties of economic development and health gains, and challenges preconceptions about what constitutes success. The Indian state of Kerala does extraordinarily well in health terms with limited resources, for example, but why has it not converted these gains into economic progress? Chris Murray and his colleagues dissect different approaches to the measurement of health inequalities and show how sensitive results can be to variation in the settings. Social capital is a fashionable concept, but Kunitz reminds us that although social ties may bind us together ... they may also imprison us. David Leon and George Davey Smith demonstrate the pitfalls of assuming a common pattern of health inequalities when substantial differences apply by specific cause and time period.
In summary the authors are leaders in the field, the individual components are substantial but easy to read, and the book comes together as a whole thanks to careful editing and a high standard of production. 
Alistair Woodward & Tony Blakely
Wellington School of Medicine and Health Sciences, New Zealand