Social Determinants of Health

North American epidemiology has been justly criticized for its emphasis on risk factors (mainly relating to behaviour, physical environment, and now genetics) and specific diseases, to the relative exclusion of broader determinants and outcomes. This excellent compilation  demonstrates both the possibilities and the importance of a broader focus.

The 10 sections of a 1998 booklet from the European Office of the World Health Organization (Social Determinants of Health-The Solid Facts) have been expanded into 10 chapters: social organization and stress, early life, life course and social gradient, unemployment, psychosocial environment at work, transport, social support and cohesion, food, poverty and social exclusion, and social patterning of health behaviours. The opening and closing chapters by the very distinguished editors comprise an excellent overview in themselves, while the intervening chapters fill in the details.

Nearly all of the authors are from the United Kingdom (the remainder are also European), most of them from University College, London, a decision that limits the choice of authors but enhances the unity of the message; on balance, the advantages probably outweigh the limitations. As expected in a British book, the writing is generally literate and clear, and it is refreshingly free of disciplinary jargon.

The book covers one of the key elements of a population health approach, and does it more accessibly than Amick et al. (Society and Health)¹ and more comprehensively than Evans et al. (Why are Some People Healthy and Others Not?).² Almost every chapter contains something of interest, for example, a very clear explanation of the role of the sympatho-adrenal and the hypothalamic-pituitary-adrenal pathways in acute and chronic stress, and lots of good material on social inequalities in health.

The idea of life course pervades many of the chapters, explaining the importance of early childhood, while that of social exclusion is brought out very clearly in the chapter on poverty. Unfortunately, housing is addressed only as part of the chapters on social cohesion and poverty, and is not given a chapter of its own.

Most of the chapters are analytical in nature, looking for explanations of empirical evidence, whereas those on transport and food are strongly interventionist, urging changes in policy (and confirming many of my prejudices, which is always nice: "it is car driving that is unsafe, while cycling is much safer-the cause of an accident should not be attributed to the victim").

It is sobering to think of how many of the social determinants of health have been allowed or caused to deteriorate in Canada during the last 15 years or so. This book effectively demonstrates their importance, and it should give social epidemiology a shot in the arm.

Overall rating:	Excellent
Strengths:	Wide-ranging review of empirical evidence and discussion of its implications
Weaknesses:	Almost total lack of North American evidence (but then, we don't study social determinants much, do we?) Too bad that medium-sized paperbacks now cost over $50
Audience:	Epidemiologists, social scientists interested in health, public health policy makers

References

1. Amick BC III, Levine S, Tarlov AR, Walsh DC. Society and health. New York: Oxford University Press, 1995.

2. Evans RG, Barer ML, Marmor TR. Why are some people healthy and others not? Determinants of health of populations. New York: Aldine de Gruyter, 1994.

Robert A Spasoff
Professor
Department of Epidemiology and Community Medicine
University of Ottawa
451 Smyth Road
Ottawa, Ontario  K1H 8M5