Wilkinson RG. Unhealthy Societies: the afflictions of inequality. London: Routledge, 1996

This monograph by one of the leading researchers in this area is the best place to begin study of these ideas. It ranges over a variety of disciplines and provides references for the arguments made.

Table of Contents

Preface

1. Introduction : The social economy of health

• It is the social rather than the material factors that are the limiting component in the quality of life in developed societies and explains why some societies are healthier than others.

Part I The health of societies

2. Health becomes a social science

• Surely the determinants of health identified in studies of individuals add up to become the societal determinants of health? In practice, the answer is no and the difficulty in aggregating individual factors affecting health is explored. He argues for looking at societal rather than individual determinants of health for disease is not an autonomous individual affliction. There is a common misperception in social policy that services and interventions are more effective than they are. There are problems of deprivation that impose costs on society, because the costs deal with symptoms rather than the causes of social failure in society.

3. Rising life expectancy and the epidemiological transition

• There are two striking features of population health that are not properly understood, namely why is life expectancy continually rising in almost every country in the world this century, and why does health vary so dramatically with socioeconomic status within each country? The first question is considered here, with two hypotheses presented. One is that there are qualitative improvements in standards of living in societies that are not measured by the usual economic indicators that account for the rise. The other suggests that there are sharply diminishing returns to health from further economic growth.

Part II Health Inequalities within societies

4. The problem of health inequalities

• Health inequalities refers to the gradient between socioeconomic status and health that is almost universal in populations today. It is not a result of social mobility and health, and not explained by environmental or genetic factors, nor does medical care have much of a role. Behavioral factors don't account for the strong differences either.

5. Income distribution and health

• Whereas there is only a weak relation between income and health among countries, it is a strong relation within a developed country. Among countries, it is the income distribution that is associated with health, and this is true within relatively large divisions within countries. It is unlikely that there is another more important variable than income distribution to explain this. Different countries are analyzed to help understand this. Other social measures besides mortality are considered.

Part III Social cohesion and social conflict

6. A small town in the USA, wartime Britain, Eastern Europe and Japan

• The distinction between absolute and relative income and the concept of relative deprivation is explored by looking at regions that enjoyed remarkable and unexpected health for a time. Reasons for decline in health are explained in terms of social changes that occurred. He concludes that for a cohesive society a necessary condition is a narrow income distribution. As well, in more egalitarian societies the public sphere of life remains more social than it does elsewhere.

7. An anthropology of social cohesion

• Human societal origins are considered, showing that for most of human existence, there was a strong taboo on any open expression of material self-interest. Gift exchange, food sharing and the material egalitarian nature of early society was the result of people's needs to keep the peace themselves. The birth of consumer society resulted in growth of conspicuous consumption, the rise of fashion, and the development of shopping and commercial life. He suggests that we may not be psychologically well adapted to inequality and individualism

8. The symptoms of disintegration

• The diseases most strongly related to socioeconomic status vary from one country to another, and countries with unusually high disease fatality rates usually have a socioeconomic gradient. Wilkinson suggests that one can regard income distribution as a proxy for inequalities in both economic and educational capital. It is chronic stress in society through which income distribution affects health primarily.

Part IV How society kills

9. The psychosocial causes of illness

• This chapter ties together stress and health-related behavior. Most of the variation of disease with social class is not explained by the different health behaviors among the different classes. Diseases which don't have strong behavioral components still have the social gradient. Psychosocial factors may be the most important factors affecting health.

10. Baboons, civil servants and children's height

• What are biologic pathways through which income distribution, measuring relative deprivation can affect health? Primate data and from rats, as well as studies of British civil servants and the height of children as a marker for health shed light on how material factors influence health.

Part V Redistribution, economic growth and the quality of life

11. Social capital, putting Humpty together again

• Social capital is considered as the features of social life-network, norms, and trust - that enable participants to act together more effectively to pursue shared objectives. Measures to increase social capital are available, but proposed changes must be assessed in terms of their impact on social justice and social divisions within society.

Reviews of this book from many health disciplines that are worth reading include:

• Albee GW. A community psychology perspective:  Book review of Unhealthy Societies. J. Community Appl. Soc. Psychol. 1998;8:163-165.
• Bezruchka S. Review of Unhealthy Societies. N Engl J Med 1997;336(22):1616-7
• Catalano R. An epidemiological perspective:  Book review of Unhealthy Societies. J. Community Appl. Soc. Psychol. 1998;8:165-168.
• Smail D. An clinical psychology perspective:  Book review of Unhealthy Societies. J. Community Appl. Soc. Psychol. 1998;8:169-170.
• Webley P. An economic psychology perspective:  Book review of Unhealthy Societies. J. Community Appl. Soc. Psychol. 1998;8:173-173.
• Wilkinson R. Unhealthy Societies:  Richard Wilkinson replies to reviewers. J. Community Appl. Soc. Psychol. 1998;8:233-237.