American Journal of Epidemiology Vol. 154, No. 6 : 588-589
Copyright © 2001 by The Johns Hopkins University School of Hygiene and Public Health
BOOK REVIEWS |
Poverty, Inequality, and Health: An International Perspective
Edited by D. A. Leon and G. Walt.0–19–263196–9 Oxford University Press, New York, New York (Telephone: 212–726–6000, Fax: 212–726–6443), 2001, 368 pp., paperback $55.00.
Division of Epidemiology, School of Public Health, University of California, Berkeley, CA 94720–7360
Geoffrey Rose, in his seminal paper on the causes of sickness in persons and populations (1
), contends that international comparisons are critical for the identification of factors that elevate the incidence of disease in populations. Indeed, without comparing disease patterns across populations, Rose argues that the higher the prevalence of causal factors among residents of a population, the more likely that those factors are rendered invisible. As he writes, "The hardest cause to identify is the one that is universally present" (1, p. 33). D. A. Leon and G. Walt, the editors of Poverty, Inequality, and Health: An International Perspective (2), would seemingly agree with Rose's observation, proposing that international comparisons between developed and developing countries enhance our understanding of poverty, inequality, and health, clearly one of the most important and, arguably, one of the most controversial topics in epidemiology and health policy.
Leon and Walt explain in their introductory chapter that global inequalities in health represent one example, although perhaps the most profound example, of enormous disparities between rich and poor nations. The chapters in this volume are based on presentations made at a public health forum, organized by the London School of Hygiene and Tropical Medicine. Each chapter provides a detailed examination of either a single country, e.g., changes in health status and life expectancy in the former Soviet Union, or a comparison across a range of diverse populations, e.g., causes of death in developed and developing countries. Together, these chapters are based on the proposition that health disparities are due to the nature of social and economic organization. As the editors write, "The way in which a society is organized, where resources are invested, and in whose interests they are deployed, has a profound impact on the health of individuals within it" (2, p. 3).
Although the chapters cover a range of topics, including maternal and child health, gender differences in health, and the assessment of social capital, Leon and Walt provide a useful summary in their introductory chapter of the book's major themes and issues. The editors identify four themes: health consequences of social and economic change; conceptual issues associated with health and wealth, including the role of health services; emerging and neglected priorities, e.g., the significance of mental illness and injuries; and evidence for policy and interventions. The role of the health care system is considered to be a central issue. The editors argue that access to health care is typically viewed as being more likely to affect health differences in developing than in developed nations, where, relatively speaking, access is more readily available. In contrast, in the developed world, health disparities, they argue, are more likely to be viewed as being due to differences in lifestyle and environmental exposures. Later, they acknowledge that health disparities, in fact, are due to the independent and joint effects of access to health care, as well as to other factors, including lifestyle and the effects of the physical environment. The editors contend that this is a clear example in which international comparisons are especially insightful: "Seeing the way in which the focus varies around the world provides a stimulus to review whether in any one place the balance is correct" (2, p.14). In fact, the United States, with its privatized health system, is presented as an example of a country in which a more "balanced" perspective is maintained. Other central issues include the relative attention given to the topics of the socioeconomic gradient, a topic they charge has been given more attention among researchers in developed nations, especially with reference to chronic conditions, than to the effects of poverty and access to care, a topic that is considered more salient in the developing world.
A number of methodological issues are considered. These topics include the interaction between socioeconomic factors and health status over the life course of persons and populations; the measurement of health and the growing interest in alternative health outcomes, such as mental illness and injuries; and differences in the availability of longitudinal data on socioeconomic factors and health across developed and developing nations.
The relation between ethics, policy, and science is given special attention. Several of the chapters focus on the distinctions and connections between inequality (social and economic disparity) and inequity (injustice and unequal access). Moreover, Leon and Walt write, "Our view is that health inequalities and inequities are ultimately ethical issues: a perspective that is implicit throughout this book: Working towards the elimination of absolute poverty and the adverse health consequences that accompany it, is essentially to be justified on moral grounds not in terms of economic return" (2, p. 2). It is not surprising, therefore, that strategies to reduce socioeconomic and health disparities are addressed in considerable detail. Evidence is provided, for example, that social and economic development does not ensure a reduction in health disparities; specific efforts to improve health status must be made.
Overall, this volume provides a challenging and thought-provoking treatment of poverty, inequality, and health. It represents a fascinating attempt to consider both the sociology of research in this area and the research itself. The consideration of ethics as a central rather than a separate or even peripheral issue is especially noteworthy. The value of international comparisons is clearly demonstrated. Together, the chapters provide evidence that such comparisons provide much more than simple collections of anthropologic curiosities. The themes addressed in this book and highlighted in the editors' introductory chapter are critical for a consideration of socioeconomic factors and health.
Despite these strengths, some important topics were not considered, a point readily acknowledged by the editors. In my opinion, the most unfortunate omission is the absence of any systematic consideration of race and ethnicity. This topic can no longer be thought of as one that affects only a limited number of nations or be dismissed as a "preoccupation" of US researchers. Increasing "globalization" should bring increased contact among people of different racial and ethnic groups. It is fair to say that one of the central issues is to understand and reduce health disparities associated with the independent and joint effects of socioeconomic, racial, and ethnic factors.
In conclusion, this volume provides an excellent discussion of poverty, inequality, and health. Although there are certain notable omissions, it represents an important addition to the growing collection of studies and commentaries in this area.
References
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Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32–8.
[Abstract/Free Full Text] - Leon DA, Walt G, eds. Poverty, inequality, and health: an international perspective. New York, NY: Oxford University Press, 2001.
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