Monica Townson reviews and re-affirms the importance of the varied, but not new literature on the social determinants of health, with a particular emphasis on socioeconomic factors. The title of the book belies its most important message: that the strength of the evidence demonstrating the link between social and economic inequalities and health--evidence that has been available in Canada and elsewhere since before the 1970s-- requires political will and government action that directly addresses the growing risk of health inequalities resulting from unfavourable economic and social trends.
The three chapters that make up this book introduce and assess varying promises and limitations of population health research. The issue of how social and economic factors affect the well-being of populations is the central focus of all three chapters, and each leads to the conclusion that existing evidence demands action outside the health care sector.
In Chapter 1 "The Health of the Population", Townson introduces the general concepts and strategies of health promotion, population health and the socioeconomic determinants of health. She discusses the interconnectedness of the determinants of health and their relationship to lifestyles and health care needs of individuals, and she highlights the important implications of population health research examining relative social inequality. She addresses the tension between the policy agendas of health promotion and population health, noting, however, that "both health promotion and population health acknowledge that socioeconomic factors are key influences in the health of populations" (p. 7). Finally, she briefly reviews the politics of population health, the critique of "healthy public policy", and the apparent reticence of policy makers to challenge entrenched structures and practices of power.
In Chapter 2, "Inequalities in Health", Townson reviews the research on the health effects of inequalities related to incomes and social status, education and literacy, early childhood development and child poverty, aboriginal health, and housing and unemployment, noting that these factors are interrelated. In her discussion of the health costs of relative income inequality, Townson introduces the concept of social cohesion as used by Wilkinson in the UK. While no clear definition of social cohesion is included, Townson suggests that the concept denotes a moral commitment to a caring community. Here, she reiterates the need for action by those elected and responsible for the public good. Her discussion of gaps in research -- notably, the failure of government to monitor recent social and economic trends and their impact on the health of Canadians -- is supported by recent data. Townson discusses the growing disparity of income between the highest and lowest earners -- seemingly related to poor labour market performance, increased reliance on self-employment, a declining average minimum wage, and high rates of underemployment and unemployment. She notes the increasing rates of poverty among some portions of the adult population, and among children, and increasing numbers of homeless Canadians.
In Chapter 3, "The Policy Challenge", Townson's focus is policy makers’ lack of commitment to social and economic equity, shown, for example, by the significant reduction in access to employment insurance and social assistance for those in need. Perhaps distracting the reader from the central argument of the need for action, a considerable proportion of this chapter is devoted to a critique of social indicators research. Townson notes correctly that social indicators research is not value free (and is often gender biased), and "there are real dangers in simplifying complex relationship between various socioeconomic developments and trying to express them in terms of one overall index number" (p. 75). The allocation of resources to social indicators research means that there is no concerted effort to monitor the specific impact of social and economic trends on the health of sub-populations. She does not make explicit what the may be the most obvious criticism of social indicators research: that policy makers may mistake the motion -- ongoing data collection -- for action. Yet, when is the information going to lead to real action to counter the effects of the prevailing and growing political acquiescence for market ideology and "the underlying momentum of the private sector"? Townson takes a strong position, charging that "the mantra of globalization...is the newest ideological tool to quell domestic demands for greater equity" (p. 95).
All chapters of the book reiterate the important findings of major international documents on the social determinants of health (such as the UK Black Report (1982) by Townsend and Davidson, the Whitehead document The Health Divide (1988); the Canadian Lalonde (1974) and Epp (1986) Reports and the more recent Canadian reports by the Advisory Council on Population Health (Strategies for Population Health: Investing in the Health of Canadians, 1994 and their Report on the Health of Canadians (1996), among others). The latter report, Townson asserts, answers unequivocally that the health of Canadians can be improved and the inequalities in health status be reduced (p. 10) if some specific "challenges" are met, including collaboration across governmental sectors, since most factors influencing health fall outside the purview of the Ministries of Health.
Peri J. Ballantyne
Department of Public Health Science
University of Toronto.
p.ballantyne@utoronto.ca
November 1999
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