Health Divides. Where you live can kill you

This book sets out to persuade its readers that where you live can kill you. It does this by examining health divides in the USA and the UK, especially between the north and south of England, and between Scotland and the rest of the UK. Epidemiologists will be pleased that the text contains a good deal of data attractively presented in graphs, maps and tables. The author is a geographer with an evident passion for highlighting the existence and cause of health inequities. I felt great relief on reading that the author’s parents were born in the 1950s (as was I). Thank goodness for a new generation of health equity researchers to whom we can pass the baton! It is very good to read the work of a younger colleague who is pointing to health inequities as evidence of a moral and policy shortfall in society, whereby society becomes richer but fails to spread the spoils of wealth fairly. Clare Bambra has produced a great read, which presents evidence of health inequities in the USA, the UK (the north–south health gap, and the ‘Scottish health effect’ which has seen the comparative health of the Scots decline since the 1970s) and Europe. She uses sporting metaphors and league tables and maps of life expectancies along railway lines to explain the extent of inequities, which I’m sure will appeal greatly to many epidemiologists. For example, Londoners living in Canning Town, at one end of the London Underground Jubilee line, live 7 years less than those living eight stops along in Westminster. The book contains many such tables and figures to display health gaps between and within countries, including ample evidence that Trump’s call to ‘make America great again’ is certainly needed in regard to health. Despite being the wealthiest country and spending much more on health care than any other OECD country, the USA scores poorly in life expectancy, coming in lowest of the 19 wealthiest countries, with a life expectancy of 78.7 years compared with Japan’s of 83.0 and my country’s (Australia) of 81.8. Having presented the epidemiology of health inequities, Bambra unravels the reasons inequities exist. Her thesis is that places can be health promoting (salutogenic) or health damaging (pathogenic), and the degree to which they are either is shaped by the broader political economy within which they sit. Chapter 4, ‘Placing Life and Death’, provides an excellent and engaging explanation and disentanglement of compositional and contextual factors in the impact of places on health, as first identified by Sally Macintyre’s team in Glasgow.1 Compositional theories hold that differences in health between places are a result of the people who live there, especially their behaviour and social class. Contextual theories maintain that it is the characteristics (economic, social and physical) of places themselves that make the health difference. Chapter 4 also offers an insightful discussion of de-industrialization and how it has been associated with regional economic, environmental and social decline since the 1970s. Its processes have resulted in communities being left behind, leaving residents with a collective feeling of loss. Bambra links this discussion to a Putnam view of social capital, which neglects the impact of power on such networks. I found myself wishing Bambra had used Bourdieu’s take on social capital,2 which sees it as inextricably linked with economic capital and the drive of reproduction of class privilege, helping to explain the persistence of inequities in capitalist societies. A fascinating section on the epidemiology of toxic brown-field land links these areas with elevated rates of disease, such as cancer and respiratory conditions. Bambra concludes that compositional and contextual factors interact to produce good or bad health outcomes, rather than either being a sole determinant. In Chapter 5, Bambra’s consideration of the politics of health takes us over ground I first encountered in the 1970s, in Lesley Doyal’s ground-breaking book The Political Economy of Health.3 How depressing that, a generation later, public health academics have to cover the same ground, with the recognition that health inequities have only gotten worse. Bambra provides statistics highlighting the ways in which politics impinge on health status. One gem is a study (see page 158) which found that, from 1960 to 1964, the African American infant death rate was 20% higher in the Jim Crow states (which retained discriminatory legislation) than in the non-Jim Crow states; whereas after abolition of the Jim Crow laws (and the increased political emancipation of African Americans), the gap disappeared. Bambra rightly sheets much of the blame for declining health back to the implementation of neo-liberal public policy, especially in the USA and the UK. Her use of the case of the reunification of Germany to show that health gaps can be closed is effective. This happened through deliberate state intervention, including a ‘Solidarity Surcharge’ that was used to improve social security, health and other social services in the former East Germany. The German approach contrasts strongly with the UK, where the south of the country was allowed to prosper in economic and health terms, at the expense of the north. Chapter 6, ‘Too little too late’, provides a useful case study of how public policy has affected the health divide in the UK since the 1980s. It includes an assessment of the major reports—the Black Report, the Acheson Report and the Marmot Review—and policy responses, which ranged from ignoring the Black Report (under Thatcher) to concerted action under the Blair government (including Health Action Zones) in response to the Acheson Report. Despite some successes under Blair, Bambra concludes that the overriding commitment to neo-liberalism meant that health inequities persisted. Health Divides ends with an examination of what can be done in the three main case studies. I found this the least satisfying part of the book, as it presents lists of measures for each setting. I would have preferred a more general manifesto of what approaches governments in rich countries need to adopt if they are to reduce economic and health inequities. Here, I would have suggested (and declare my bias as a former Commissioner on the CSDH) drawing more heavily on the report of the Commission on the Social Determinants of Health that presented a coherent story of what is required, including how to tackle the influence of ‘power, money and resources’. The work of the World Health Organization through the Healthy Cities programme and, with the European Union, through the Health in All Policies initiative, also offers valuable lessons. These initiatives, combined with the United Nations Sustainable Development Goals, provide a good blueprint for action. I would also have stressed the importance of civil society in forcing the hand of government to adopt fairer public policies. Historical case studies indicate that when trade unions and other civil society groups agitate, progressive gains are made. In summary, Health Divides is an important book that demonstrates the value of careful analysis of health inequities data and close examination of the factors that explain why the data show the patterns they do. It will be especially helpful to epidemiologists in understanding the ways in which population health patterns are about so much more than the sum of individuals’ social classes and behaviours. Rather, patterns reflect in largely invisible ways the impacts of the immediate place and, in turn, the broader social, cultural and economic milieu in which places are situated. Bambra is to be congratulated on doing this in a highly readable way. I write this review during the early days of the Trump presidency, in which data and facts seem to be rendered meaningless. Pleasingly, Health Divides demonstrates the value of epidemiological evidence and demonstrates that a thorough, thoughtful and rigorous appraisal of why some people live shorter lives than others, and how environments shape and predict the outcomes, is a vital beacon to a fairer and more just society in which health divides will diminish and equity once again becomes a political ambition.