Research and publications
| Pages | 53-56 |
| DOI | https://doi.org/10.1108/17465729200500032 |
| Published date | 01 December 2005 |
| Date | 01 December 2005 |
| Subject Matter | Health & social care |
UPDATE
53
journal of public mental health
vol 4 • issue 4
© Pavilion Publishing (Brighton) Ltd
Inequalities I
Social determinants of health
Michael Marmot, Richard G Wilkinson
Oxford University Press (2006)
The first edition of this collection of papers (Wilkinson
& Marmot, 1998) was published in 1998 by the World
Health Organisation and summarised the evidence
supporting ten policy recommendations for addressing
the social determinants of health: namely, the
circumstances in which people live and work. This
welcome new edition, with new chapters on ethnicity,
age, neighbourhoods and housing, demonstrates the
strength of the case for moving the psychosocial domain
to the heart of the public health agenda.
The social gradient in health is a remarkably
widespread phenomenon and its effects are evident at
every step down the social hierarchy, as the Whitehall
studies demonstrated. Subjective experience and
emotions are significant determinants of behavioural
and biological markers of disease and our response to
inequalities lies at the heart of understanding the
relationship between social organisation and health.
Brunner and Marmot’s chapter on stress epidemiology
provides a comprehensive and compelling account of
the biological pathways (endocrine, cardiovascular and
immunity) through which our feelings impact on
mental and physical health.
In a political climate in which lifestyle is the
predominant focus of interventions, it is worth noting
that the major risk factors for coronary heart disease,
high blood pressure, cholesterol and smoking account
for no more than a third of the variation in mortality. In
other words, as Marmot et al argue in their analysis of the
impact of work, we have to look beyond both material
factors per se and individual behaviour and lifestyle to
understand health inequalities. A social gradient
according to occupation is evident for all-cause
mortality, CHD morbidity and mortality and psychiatric
disorders (notably depression). High demand/low
control and effort/reward imbalance in employment are
associated with increased CHD and depression in a very
wide range of studies.
Two other chapters of special interest include
Stephen Stansfeld’s review of the literature on social
support and social networks and Stafford and
McCarthy’s compelling exposition of neighbourhood
influences on health. As Stansfeld shows, the design of
housing and public spaces has a significant influence on
neighbourhood relationships and levels of informal
social interaction, which in turn impact on health.
Nevertheless, it is difficult to isolate the effects of
neighbourhood characteristics and to disentangle effects
of area residence from individual risk factors. What is
clear is that rising inequalities are matched by rising
concentrations of affluence and deprivation at
neighbourhood level, leading to increasing spacial
segregation. We have only to look across the Channel,
to the recent riots in Paris, to be reminded of the
consequences.
Essential reading and perhaps the best available
summary of the evidence that we are how we feel, and
that how we feel is a direct consequence of how society
is organised.
Wilkinson RG and Marmot M (eds) (1998) Social determinants of
health: the solid facts. Copenhagen: World Health Organisation.
Inequalities II
The impact of inequality: how to make sick societies
healthier
Richard G Wilkinson
Routledge (2005)
The work of Richard Wilkinson has long been a source
of inspiration for colleagues in mental health
promotion. His first book, Unhealthy societies: the
afflictions of inequality (1996), inspired New Labour in
those heady days following the 1997 general election,
although it may be difficult to believe this now. This
new book is primarily a work of synthesis, bringing
together a wealth of material on the health effects of
social and economic inequalities and analysing this from
a human rights and social justice perspective.
Social and psychological factors loom large among
the determinants of health in developed countries,
because rising living standards have reduced the direct
effects of material deprivation. Most important are three
intensely social risk factors: low social status, poor social
affiliations and early childhood experience. Wilkinson’s
core argument is that we need to understand our
response to inequality and dominance hierarchies and
‘that means understanding the social life of monkeys at
least as much as it means understanding the writings of
Marx’ (p21). The chapter on violence, with its
argument that low social status assaults our sense of
dignity and self-worth, provides an empirical account of
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