Radical
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BOOK REVIEW
The Widening Gap: Health Inequalities and Policy in Britain
Shaw, M., Dorling, D., Gordon, D. and Davey Smith, G. (1999), Bristol: The Policy Press. Price: £16.99 ISBN: 1 86134 142 3
Review by Rowland Atkinson
This book is something of a landmark geographically and statistically updating the data and policy prescriptions of the 1980 Black Report which aimed to profile health inequalities. The study locates the best and worst health million, based on mortality figures for those under 65, in parliamentary constituencies across England, Wales and Scotland. In each of these "extreme areas" we are given a wealth of data characterising the increasing disparity of life chances and health outcomes, marking out two very polar images of British Society. Familiar images of deprivation, educational under-achievement, poor diet, unemployment and child poverty are all examined in relation to the worst health million and contrasted against the aspirational and wealthy life of the best.
The book opens with a quote from a speech by Frank Dobson where he argued that "there is no more serious inequality than knowing that you'll die sooner because you're badly off" and, in the words of the authors, widening gaps in health inequalities continue in the Blair administration and have a 'real, lethal meaning for large groups of people living in Britain today'; (p.107). For the learned audience perhaps the clustering of social deprivation in these areas will be less of a surprise than the data which indicates that disparities have increased over the period studied (1991-1995) and beyond.
This has already been an influential study, not least north of the border and, speaking from the city with eight of the fifteen worst health constituencies, has provoked soul searching and some attempt to accord blame. Whether intended or not, the focus on parliamentary constituencies will inevitably give the book a deeper resonance for the representatives of residents of those areas. However, while blame may be more easily laid by politicians and the media, the book itself portrays a deeper tangle of social and individual pathologies and the complex causal relationships which bind poverty, ill-health and life-cycles together notably using graphical portrayals of the data.
The mass of new evidence given here points to the primary explanation of a health gap in terms of social and economic disadvantage and that these have a cumulative impact through the life-course. Some stark facts stand out in the memory: 62% of deaths were avoidable for the worst million compared to the best; infant mortality is twice as likely in the worst areas; and there are more than three times as many people not working in the worst areas. Those in the worst health areas were nearly three times as likely to have long-term illnesses.
Having covered the health gap and its continued growth the book turns to policy recommendations that will effectively tackle the problem. The authors propose realistic and redistributive measures, which will alleviate ill-health by dealing with poverty. In this respect, the writers pull no punches in assessing the present government's attempt to deal with this problem, characterising the approach as essentially one of warm words backed up with low funding for worthy proposals and a deep Blairite fear of redistribution.
I particularly liked the introductory glossary, which marks the book out as a technically proficient yet accessible text using intelligent commentary to bring to life a potentially lengthy mass of empirical data. The book also deals intelligently with different explanatory modes and understandings of health inequalities (artefacts, selection, cultural and materialist) stemming from the Black Report and also covers in more depth the stronger critiques of underclass explanations of health behaviours.
The authors are right to criticise the continuing erosion of entitlement that has continued under Labour and the lack of weight behind initiatives like Health Action Zones and the re-prioritising of policies away from redistribution to those which deal with symptoms, such as pollution, and not causes i.e. poverty. The portrayal of government explaining away the need for redistributive policies, committed as they are, to achieving economic growth without income equality inevitably leaves it depicted as a tinkerer rather than structural engineer of a healthier and less disparate society. The conclusions of the book are markedly similar to the warnings given by the Black Report and we can only hope that this study will not fall on similarly deaf ears. Some optimism may be found in the fact that such documents entering the public realm may have a cumulative impact on the direction of policy especially when they are as well written and researched as this.
Rowland Atkinson
Urban Studies
25-28 Bute Gardens
University of Glasgow
Glasgow G12 8RS
Tel: 0141 330 5048 ext. 2522
E-mail:
r.atkinson@socsci.gla.ac.uk
