The title ‘What works in tackling health inequalities?’ is actually too narrow to do justice to the wealth of information that can be found in this book. A more accurate description would have been: ‘What do we know about the scale of the problem of health inequalities, about pathways giving rise to these inequalities and about policy interventions to address those pathways?’ But admittedly, this would not have been an equally ‘catchy’ title.
The book is divided into three parts. The first part describes the research and policy context of health inequalities. It briefly introduces the growth of interest in health inequalities after the publication of the Black Report, and discusses three theoretical ‘landmarks’ in the research into health inequalities. The second part, which is divided into ten chapters, focuses on four periods in the life course: early life, childhood and youth, adulthood and old age. For each of these periods, companion chapters, respectively, summarize the research evidence on pathways to health inequalities in these periods, evidence from policies and practices and recommendations for future policies and interventions. The third part of the book draws conclusions about limitations that exist to the evidence base of policies related to health inequalities.
There is a lot to be learned from this book. Its greatest value lies with its effort to connect scientific evidence on the pathways linking social position to health with existing efforts to tackle inequalities. There appears to be an important discrepancy in the complexity and diversity of the pathways of social inequalities and the relatively narrow approach (targeting downstream factors predominantly; mostly in middle-aged adults…) of interventions and policy. To overcome this discrepancy the authors suggest that much more theory based approaches to policy should be developed.
Another lesson that is implicit in this book, although it has not been identified as such by the authors, is that there may be an important role for social care and health care workers in many of the efforts to reduce health inequalities. As the complexity of the pathways and outcomes described in this book demonstrate, ‘inequalities in health’ provides the ultimate example of a public health problem where progress should be made through integrated efforts of workers operating in different areas of care. Increased efforts of health care workers to reduce the burden of ill health in the lower social groups specifically will be indispensable, but will not have lasting effects if they are not backed up by efforts in the field of social care to help people in lower social groups deal with the unremitting social determinants of health. Probably the first hurdle to be taken here is to make both social and health care workers more systematically aware of their potential and responsibility to make a contribution to this persistent public health problem.
But there is also a difficulty with the approach of this book. Actually very rarely are the effects of interventions and policies across different socioeconomic groups discussed, even though the main focus of the book is on socioeconomic inequalities in health. Throughout the book insightful descriptions present the experiences of specific interventions aimed at problems that are arguably more pressing in lower socioeconomic groups (being part of the pathways leading to social differences in health). However, without evidence that interventions have adopted an equity approach or have targeted lower socioeconomic groups specifically we should expect that some of those interventions may be more effective in people from higher social groups—thereby perhaps leading to increases in inequalities rather than decreases if they are implemented in the general population!
Another limitation of the book might be that it is predominantly UK-focused, both in terms of the policies observed, and the research examined. Surely, the majority of the knowledge will be covered, as the UK is leading in this area of research and practice. But as an earlier book about reducing inequalities in health has shown: there is an enormous potential for countries to learn from each other's experiences with tackling health inequalities. The authors of the current book have not yet seized this potential, and many readers will find it helpful to search for additionalinformation on research and practice in other pioneering countries such as Sweden and The Netherlands.
The conclusion of this book could be summarized as follows: the evidence for success in tackling health inequalities is fragmentary, but existing knowledge on pathways of health inequalities provide ample entry points for new and improved attempts. This book will help us to rethink our strategies, and to go about it with renewed energy and with an open eye for devising policy based on theory.
Mackenbach JP, Bakker M, editors. Reducing Inequalities in Health: A European Perspective. London: Routledge, 2002.