AJPH BOOK & MEDIA The Case for Politics and Public Health: 2017
Health Divides: Where You Live Can Kill You By Clare Bambra Bristol, UK: Policy Press; 2016 320 pp, $22.00 ISBN-13: 9781447330363
Socioeconomic factors affect the public’s health,1 but so do policy and politics when they converge in governance.2,3 Assessing the causal relationships between these broad concepts remains highly challenging. There is a history of mixed success in determining what should be done in public health practice to help these relationships to improve public health. Evidence of what works to effect change remains limited. Clare Bambra’s short, insightful book Health Divides: Where You Live Can Kill You addresses this complexity in a manner that is very helpful to any public health researcher or practitioner for understanding the state of the art. The book nicely complements much of the published research with the theoretical concepts that underlie this complexity.
SOCIOECONOMIC FACTORS How the role of socioeconomic factors has been handled in public health has varied through history. Most importantly, these factors were expressed politically by Bismarck1 and underpinned the mid-19th-century approaches taken by Virchow in Germany. Virchow remarked, “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human
June 2017, Vol 107, No. 6
AJPH
beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution”4(p42),5 The Dutch social epidemiologist Johan Mackenbach has explored this notion in terms of present-day public health and notes that there is considerable controversy among epidemiologists and public health professionals about how far one should go in influencing political processes (http://bit.ly/1U7Yji7). The challenge of determining the role of public health in the broader political process is a fundamental issue, particularly in today’s political atmosphere. However, seeing the importance of this challenge is not a recent phenomenon in modern public health. A century after the insights of Virchow, public health epidemiologists, practitioners, and researchers in the United States and Western Europe were exploring these broad concepts under the rubric of “factors” in health and illness. These factors originated as risk-related behavioral, socioeconomic, sociopsychological,
or sociocultural; more recently, they have originated as contextual or deterministic. In all these cases, there is an underlying belief in poor population health being a powerful result of these types of factors. This historical thread is found in the publication of the 2008 World Health Organization (WHO) report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (Geneva, Switzerland: WHO Press). Much of this history is well covered and summarized in Bambra’s book with special attention to the British history of the Black Report of 19886 and the Acheson Inquiry of 1999.7 These reports, which preceded the more epidemiologically based WHO report, carefully laid out the role of social factors and their contribution to the inequities in the health of the British population. More importantly, the reports led thinking in this general field of public health inquiry to the critical nature of inequality in relation to poor population health. From there, it was a short step to considerations of governance, policy, and politics as playing key roles in revising health outcomes. Bambra lays out this development in a very clear and persuasive fashion (pp. 184–206).
ABOUT THE AUTHOR David V. McQueen is with the Institute of Social and Preventive Medicine, Universitat ¨ Bern, Bern, Switzerland, and the Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA. Correspondence should be sent to David V. McQueen, 2418 Midvale Ct., Tucker, GA 30084 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This book review was accepted March 3, 2017. doi: 10.2105/AJPH.2017.303777
McQueen
Book & Media
825
AJPH BOOK & MEDIA
SHORTER LIVES, POORER HEALTH With regard to the US situation, Bambra brings into her discussion the seminal work of the National Academy of Sciences (NAS) document US Health in International Perspective: Shorter Lives, Poorer Health. This publication laid out many aspects that strongly support the work carried out in Britain and at the WHO. For example, the 2013 NAS report documented nine major areas of health disadvantage in the United States, ranging from adverse health outcomes to disabilities, but, more importantly, it pointed out their policy implications and the evidence-based policies that could address them at the national, state, and local levels (p. 235). This important, and unfortunately often overlooked, NAS publication benefited from presentations by Bambra to the NAS committee that wrote the report. It is clear from the content of Shorter Lives and its careful comparison of the United States with other advanced economies that the story of the Black Report and other British research on health inequalities resonates with the US situation with regard to health status. It is simply unfortunate that the overwhelming scientific documentation of the relationship between social factors and health is apparently not much appreciated in the US political arena. Of course, the argument could be made that it is understood but that politicians have little or no interest in contending with these socioeconomic factors. Alternatively, it could be asserted that US politicians are simply not interested in comparing and contrasting our health care system with those of other advanced economies. Perhaps
826
Book & Media
McQueen
the reasoning is that the United States is so unique that such comparisons are irrelevant. Still it could be argued that there is something to learn from other advanced industrial countries that have managed to provide universal health care at considerably less cost than the US limitedcoverage high-cost health care system and have produced better health outcomes in their populations.
THE CLIMATE CHANGE ANALOGY The US perspective on climate change can be seen analogously to the relationship between political context and health. Although the scientific evidence for climate change is voluminous and the scientific research very compelling, the evidence base of causality is fraught with a complexity that makes powerful, direct causal factors difficult to prove. In addition, the evidence of what to do to alter the course of causality, assuming that it is understood, is very limited. The case of social factors contributing to health effects is similarly faced with an extraordinarily multicausal complexity, even though the scientific research, as illustrated so beautifully by Bambra, is very clear. We have little or no doubt, as public health scholars, that social inequity leads to health inequities. Furthermore, the connection of population inequalities is clearly tied to political decisions at every level of government. This being so, why is there such a reluctance to take action that addresses this inequity and to incorporate the pertinent knowledge into
the search for a reform of health care?
THE ROLE OF GOVERNANCE Part of the answer to this question is provided in Bambra’s work as she considers the actions that should be taken to address inequities in health. She reviews with care the suggestions of reports and commissions established to address the actions to be taken. In particular, the Black Report for Britain, the WHO Commission on Social Determinants of Health, and the NAS report for the United States have provided well–thought-out suggestions for action. One could say, this is where one “walks the talk.” However, to date, there has been little walking. This is because the solution to the problem of poor health related to social factors is essentially political. Bambra’s suggestions for action are very politically oriented. She suggests three main tasks for the United Kingdom: (1) income redistribution through changes in taxation and funding, (2) devolution of power by changing from corporate and political elites to local democratic institutions and communities, and (3) resourcing regions and promoting growth in all parts of the country (p. 224). These tasks, especially the second, lie almost entirely in the political realm, but they also reflect what might be recommended in the context of a country with a history of universal medical care and a well-established governmentrun health system. The relevance for the United States
is questionable considering our historical indifference to what other countries do to provide universal medical care. Nonetheless, the political reality that is revealed in Bambra’s work significantly challenges public health and health promotion and care at a critical period in US health care history. Considering the background and training in public health that most of us have, are we suitably equipped to deal with reputed causal factors and solutions that are largely outside our traditional domain of training and expertise? Bambra has made a useful case for us to consider. David V. McQueen, ScD REFERENCES 1. Rosen G. A History of Public Health. New York, NY: MD Publications; 1958. 2. McQueen DV, Wismar M, Lin V, Jones CM, Davies M, eds. Intersectoral Governance for Health in All Policies: Structures, Actions and Experiences. Copenhagen, Denmark: World Health Organization; 2012. 3. Virchow R. Disease, Life and Man: Selected Essays by Rudolf Virchow. Stanford, CA: Stanford University Press; 1958. 4. Neumann S. Die o¨ ffentliche Gesuntheitspflege und das Eigenthum: Krittsches und Positives mit Bezug auf die Preussische Medizinalverfassungs-Frage. Berlin, Germany: Adolph Riess; 1847. 5. Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. J Epidemiol Community Health. 2009;63(3): 181–184. 6. Black D, Morris JN, Smith C, Whitehead M. Inequalities in Health: Report of a Research Working Group. London, UK: Department of Health and Social Security; 1980. 7. Acheson D. Independent Inquiry Into Inequalities in Health: Report. London, UK: Stationary Office. 1999.
AJPH
June 2017, Vol 107, No. 6
Health Divides: Where You Live Can Kill You By Clare Bambra Bristol, UK: Policy Press; 2016 320 pp, $22.00 ISBN-13: 9781447330363
Socioeconomic factors affect the public’s health,1 but so do policy and politics when they converge in governance.2,3 Assessing the causal relationships between these broad concepts remains highly challenging. There is a history of mixed success in determining what should be done in public health practice to help these relationships to improve public health. Evidence of what works to effect change remains limited. Clare Bambra’s short, insightful book Health Divides: Where You Live Can Kill You addresses this complexity in a manner that is very helpful to any public health researcher or practitioner for understanding the state of the art. The book nicely complements much of the published research with the theoretical concepts that underlie this complexity.
SOCIOECONOMIC FACTORS How the role of socioeconomic factors has been handled in public health has varied through history. Most importantly, these factors were expressed politically by Bismarck1 and underpinned the mid-19th-century approaches taken by Virchow in Germany. Virchow remarked, “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human
June 2017, Vol 107, No. 6
AJPH
beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution”4(p42),5 The Dutch social epidemiologist Johan Mackenbach has explored this notion in terms of present-day public health and notes that there is considerable controversy among epidemiologists and public health professionals about how far one should go in influencing political processes (http://bit.ly/1U7Yji7). The challenge of determining the role of public health in the broader political process is a fundamental issue, particularly in today’s political atmosphere. However, seeing the importance of this challenge is not a recent phenomenon in modern public health. A century after the insights of Virchow, public health epidemiologists, practitioners, and researchers in the United States and Western Europe were exploring these broad concepts under the rubric of “factors” in health and illness. These factors originated as risk-related behavioral, socioeconomic, sociopsychological,
or sociocultural; more recently, they have originated as contextual or deterministic. In all these cases, there is an underlying belief in poor population health being a powerful result of these types of factors. This historical thread is found in the publication of the 2008 World Health Organization (WHO) report Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (Geneva, Switzerland: WHO Press). Much of this history is well covered and summarized in Bambra’s book with special attention to the British history of the Black Report of 19886 and the Acheson Inquiry of 1999.7 These reports, which preceded the more epidemiologically based WHO report, carefully laid out the role of social factors and their contribution to the inequities in the health of the British population. More importantly, the reports led thinking in this general field of public health inquiry to the critical nature of inequality in relation to poor population health. From there, it was a short step to considerations of governance, policy, and politics as playing key roles in revising health outcomes. Bambra lays out this development in a very clear and persuasive fashion (pp. 184–206).
ABOUT THE AUTHOR David V. McQueen is with the Institute of Social and Preventive Medicine, Universitat ¨ Bern, Bern, Switzerland, and the Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA. Correspondence should be sent to David V. McQueen, 2418 Midvale Ct., Tucker, GA 30084 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This book review was accepted March 3, 2017. doi: 10.2105/AJPH.2017.303777
McQueen
Book & Media
825
AJPH BOOK & MEDIA
SHORTER LIVES, POORER HEALTH With regard to the US situation, Bambra brings into her discussion the seminal work of the National Academy of Sciences (NAS) document US Health in International Perspective: Shorter Lives, Poorer Health. This publication laid out many aspects that strongly support the work carried out in Britain and at the WHO. For example, the 2013 NAS report documented nine major areas of health disadvantage in the United States, ranging from adverse health outcomes to disabilities, but, more importantly, it pointed out their policy implications and the evidence-based policies that could address them at the national, state, and local levels (p. 235). This important, and unfortunately often overlooked, NAS publication benefited from presentations by Bambra to the NAS committee that wrote the report. It is clear from the content of Shorter Lives and its careful comparison of the United States with other advanced economies that the story of the Black Report and other British research on health inequalities resonates with the US situation with regard to health status. It is simply unfortunate that the overwhelming scientific documentation of the relationship between social factors and health is apparently not much appreciated in the US political arena. Of course, the argument could be made that it is understood but that politicians have little or no interest in contending with these socioeconomic factors. Alternatively, it could be asserted that US politicians are simply not interested in comparing and contrasting our health care system with those of other advanced economies. Perhaps
826
Book & Media
McQueen
the reasoning is that the United States is so unique that such comparisons are irrelevant. Still it could be argued that there is something to learn from other advanced industrial countries that have managed to provide universal health care at considerably less cost than the US limitedcoverage high-cost health care system and have produced better health outcomes in their populations.
THE CLIMATE CHANGE ANALOGY The US perspective on climate change can be seen analogously to the relationship between political context and health. Although the scientific evidence for climate change is voluminous and the scientific research very compelling, the evidence base of causality is fraught with a complexity that makes powerful, direct causal factors difficult to prove. In addition, the evidence of what to do to alter the course of causality, assuming that it is understood, is very limited. The case of social factors contributing to health effects is similarly faced with an extraordinarily multicausal complexity, even though the scientific research, as illustrated so beautifully by Bambra, is very clear. We have little or no doubt, as public health scholars, that social inequity leads to health inequities. Furthermore, the connection of population inequalities is clearly tied to political decisions at every level of government. This being so, why is there such a reluctance to take action that addresses this inequity and to incorporate the pertinent knowledge into
the search for a reform of health care?
THE ROLE OF GOVERNANCE Part of the answer to this question is provided in Bambra’s work as she considers the actions that should be taken to address inequities in health. She reviews with care the suggestions of reports and commissions established to address the actions to be taken. In particular, the Black Report for Britain, the WHO Commission on Social Determinants of Health, and the NAS report for the United States have provided well–thought-out suggestions for action. One could say, this is where one “walks the talk.” However, to date, there has been little walking. This is because the solution to the problem of poor health related to social factors is essentially political. Bambra’s suggestions for action are very politically oriented. She suggests three main tasks for the United Kingdom: (1) income redistribution through changes in taxation and funding, (2) devolution of power by changing from corporate and political elites to local democratic institutions and communities, and (3) resourcing regions and promoting growth in all parts of the country (p. 224). These tasks, especially the second, lie almost entirely in the political realm, but they also reflect what might be recommended in the context of a country with a history of universal medical care and a well-established governmentrun health system. The relevance for the United States
is questionable considering our historical indifference to what other countries do to provide universal medical care. Nonetheless, the political reality that is revealed in Bambra’s work significantly challenges public health and health promotion and care at a critical period in US health care history. Considering the background and training in public health that most of us have, are we suitably equipped to deal with reputed causal factors and solutions that are largely outside our traditional domain of training and expertise? Bambra has made a useful case for us to consider. David V. McQueen, ScD REFERENCES 1. Rosen G. A History of Public Health. New York, NY: MD Publications; 1958. 2. McQueen DV, Wismar M, Lin V, Jones CM, Davies M, eds. Intersectoral Governance for Health in All Policies: Structures, Actions and Experiences. Copenhagen, Denmark: World Health Organization; 2012. 3. Virchow R. Disease, Life and Man: Selected Essays by Rudolf Virchow. Stanford, CA: Stanford University Press; 1958. 4. Neumann S. Die o¨ ffentliche Gesuntheitspflege und das Eigenthum: Krittsches und Positives mit Bezug auf die Preussische Medizinalverfassungs-Frage. Berlin, Germany: Adolph Riess; 1847. 5. Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. J Epidemiol Community Health. 2009;63(3): 181–184. 6. Black D, Morris JN, Smith C, Whitehead M. Inequalities in Health: Report of a Research Working Group. London, UK: Department of Health and Social Security; 1980. 7. Acheson D. Independent Inquiry Into Inequalities in Health: Report. London, UK: Stationary Office. 1999.
AJPH
June 2017, Vol 107, No. 6
