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Health inequalities in European countries
Health Policy, 16 (1990)
26!5-269
Elsevier
HPE
265
00376
Book Reviews
Health Inequalities in European Countries By J. Fox (Ed.) Gower in Association with the European Science Foundation, Aldershot, 1989, 414 pp., ISBN 0566-05497-3, f42.00 Since the end of the 1970’s, and partly as the result of the World Health Organisation’s programme ‘Health for all by the year 2000’, questions related to inequalities in health have received wide attention in national and international meetings. In 1982 three European Science Foundation (ESF) workshops on ‘inequalities in health in European countries’ were planned in order to maximise the collaboration between people from different countries and to emphasize the comparative dimension. This book presents papers originally prepared for these workshops and revised in the light of discussions. Its purpose is to explore the following questions: what is the current situation in Europe in terms of inequalities in mortality? (part II), inequalities in morbidity? (part III) and how should they be explained? (part IV). The first part of the book describes the background to the comparison. Fox and Can-Hill give a general introduction and outline some common themes in the discussions at the three workshops. The purpose of the second chapter by Aiach and Can-Hill is to examine the variety of debates about inequalities in health over the last decade in the countries of the European Region. This information about the cultural, economic, political and social contexts is considered an essential backdrop to any empirical comparison. The third chapter by Scott-Samuel and Szalai about policy issues in health inequality is based on a survey among participants in ESF workshops and some other people involved in this field of study. Several of the papers document differences in mortality. L,e Grand compares variation in the ageat-death (chapter 4); Leclerc the pattern of mortality by cause of death (chapter 5); Hart compares sex differences (chapter 6); Valkonen differences by level of education (chapter 7); Lynge et al. occupational differences (chapter 8) and Jozan geographic differences (chapter 9). Most nations confess to a lack of information about social differences in morbidity, compared with statistics of mortality. However, according to Blaxter, it can be argued that in developed countries morbidity or general health status are increasingly more important indicators of inequality than mortality. All men must die, and though premature death is certainly a part of inequality in health, it may be that the lifelong experience of health and illness most clearly demonstrates the difference between social groups. In Blaxter’s opinion, there is little possibility of comparing morbidity data across Europe in detail. Yet some general trends can be discerned: economically poor groups and populations in poorer regions suffer worse health as well as die younger, and this is especially true for chronic rather than acute illnesses (chapter 10). Floud advocates the use of height as a measure of health status (chapter 11). In chapter 12, Arber digs deeper into the class-gender interaction. In chapter 13. Leon and Wilkinson demonstrate that lower status groups may not only have a higher risk of contracting certain diseases, but also poorer prognoses. Ramis-Juan and Sokou compare in chapter 14 levels of death and health across countries and over time, concluding that as Mediterranean countries ‘develop’ economically, the gap between rich and poor in those countries is likely to widen. The fourth and final section considers explanations for the differences which have been found. MacIntyre, in studying the role of health services in relation to inequalities in health in Europe, advocates the investigation of the circumstances in which particular components of health care can do harm or good to specific conditions or social groups rather than trying to address the global 0168-8510/90/$03.50 Q 1990 Blsevier Science Publishers B.V. (Biomedical Division)
266
question ‘do health services matter?’ (chapter 15). Fogelman et al. ask whether class and tenure mobility explain social inequalities in health among young adults (chapter 16). Papers by Siegrist (chapter 17), Hasan (chapter 18) and Antonovsky (chapter 19) all focus on the psychosocial level of explanation (whether in terms of coherence or stress). These processes can however only be understood against the background of structural social determinants. In general, in most of the papers in this volume, the impact of structural/materialist features is considered to be essential. Finally, and although the group recognised its limited qualifications for discussing policy issues, the discussion brought out three main priority areas. First, and of greatest importance, was the need to redistribute real disposable income to those groups who have the poorest health. It was argued that there would be several multiplier effects of such a policy and that whereas increments, or decrements, in wealth at the top end of the scale would have little health impact, those at the bottom end would be most important, particularly with regard to child health and development. The second priority area concerned the use of knowledge about particular substances and the development of coherent well understood national programmes of prevention, for example to tackle cigarettes and alcohol. The third priority area was the design of preventive health programmes. It is considered important that providers of services draw on what is known about socioeconomic factors affecting take-up of services and treatment in the &sign of services for antenatal care, child health and development, in dental health as well as in adult conditions, such as breast and cervix cancer and heart disease. This is an interesting and useful volume for several reasons. First, although comparison across national boundaries present theoretical and methodological challenges, it also holds out the promise of new perspectives and insights. For example, Lynge et al. show how the overall similarities between the Nordic countries in fact conceal quite wide differences among them in terms of mortality. At the other end of the continent, Ramis-Juan and Sokou show how apparently large overall differences conceal basic similarities between Greece, Portugal and Spain. Second, the book draws attention to the lack or the inappropriate nature of the data in several European countries, especially the data related to morbidity and to health care systems. As Fox and Carr-Hill write in their opening chapter, the volume will hopefully persuade countries throughout Europe to continue to El1 the gap in their statistics on this important issue. Last but not least, this book shows that future comparative research will need to go more in depth and study particular problems or social groups. Dr. R. Schepers Department of Health Care Policy and Management Erasmus University Rotterdam Rotterdam. The Netherlands
*****
The Dutch Sentinel Practice Network: Relevance for Public Health Policy By A. Bartelds. J. Fracheboud and J. van der Zee (Bds.) Utrecht, Netherlands Institute of Primary Health Care (NIVEL). 1989, 357 pp.. ISBN 90-6905-109-5, B. 40.00 While hospital and mortality statistics provide a wealth of information about death and severe morbidity, by comparison, far less is known about the problems of primary care. The Netherlands was among the first countries to develop an organization to study common problems seen by general practitioners. This book describes the workings of this inexpensive network and presents summaries of 20 of the 66 topics that were studied between 1970 and 1988. The sentinel practice network was conceived to take advantage of the situation which places the general practitioner as the point of entry into the Dutch health care system. The target of the
26!5-269
Elsevier
HPE
265
00376
Book Reviews
Health Inequalities in European Countries By J. Fox (Ed.) Gower in Association with the European Science Foundation, Aldershot, 1989, 414 pp., ISBN 0566-05497-3, f42.00 Since the end of the 1970’s, and partly as the result of the World Health Organisation’s programme ‘Health for all by the year 2000’, questions related to inequalities in health have received wide attention in national and international meetings. In 1982 three European Science Foundation (ESF) workshops on ‘inequalities in health in European countries’ were planned in order to maximise the collaboration between people from different countries and to emphasize the comparative dimension. This book presents papers originally prepared for these workshops and revised in the light of discussions. Its purpose is to explore the following questions: what is the current situation in Europe in terms of inequalities in mortality? (part II), inequalities in morbidity? (part III) and how should they be explained? (part IV). The first part of the book describes the background to the comparison. Fox and Can-Hill give a general introduction and outline some common themes in the discussions at the three workshops. The purpose of the second chapter by Aiach and Can-Hill is to examine the variety of debates about inequalities in health over the last decade in the countries of the European Region. This information about the cultural, economic, political and social contexts is considered an essential backdrop to any empirical comparison. The third chapter by Scott-Samuel and Szalai about policy issues in health inequality is based on a survey among participants in ESF workshops and some other people involved in this field of study. Several of the papers document differences in mortality. L,e Grand compares variation in the ageat-death (chapter 4); Leclerc the pattern of mortality by cause of death (chapter 5); Hart compares sex differences (chapter 6); Valkonen differences by level of education (chapter 7); Lynge et al. occupational differences (chapter 8) and Jozan geographic differences (chapter 9). Most nations confess to a lack of information about social differences in morbidity, compared with statistics of mortality. However, according to Blaxter, it can be argued that in developed countries morbidity or general health status are increasingly more important indicators of inequality than mortality. All men must die, and though premature death is certainly a part of inequality in health, it may be that the lifelong experience of health and illness most clearly demonstrates the difference between social groups. In Blaxter’s opinion, there is little possibility of comparing morbidity data across Europe in detail. Yet some general trends can be discerned: economically poor groups and populations in poorer regions suffer worse health as well as die younger, and this is especially true for chronic rather than acute illnesses (chapter 10). Floud advocates the use of height as a measure of health status (chapter 11). In chapter 12, Arber digs deeper into the class-gender interaction. In chapter 13. Leon and Wilkinson demonstrate that lower status groups may not only have a higher risk of contracting certain diseases, but also poorer prognoses. Ramis-Juan and Sokou compare in chapter 14 levels of death and health across countries and over time, concluding that as Mediterranean countries ‘develop’ economically, the gap between rich and poor in those countries is likely to widen. The fourth and final section considers explanations for the differences which have been found. MacIntyre, in studying the role of health services in relation to inequalities in health in Europe, advocates the investigation of the circumstances in which particular components of health care can do harm or good to specific conditions or social groups rather than trying to address the global 0168-8510/90/$03.50 Q 1990 Blsevier Science Publishers B.V. (Biomedical Division)
266
question ‘do health services matter?’ (chapter 15). Fogelman et al. ask whether class and tenure mobility explain social inequalities in health among young adults (chapter 16). Papers by Siegrist (chapter 17), Hasan (chapter 18) and Antonovsky (chapter 19) all focus on the psychosocial level of explanation (whether in terms of coherence or stress). These processes can however only be understood against the background of structural social determinants. In general, in most of the papers in this volume, the impact of structural/materialist features is considered to be essential. Finally, and although the group recognised its limited qualifications for discussing policy issues, the discussion brought out three main priority areas. First, and of greatest importance, was the need to redistribute real disposable income to those groups who have the poorest health. It was argued that there would be several multiplier effects of such a policy and that whereas increments, or decrements, in wealth at the top end of the scale would have little health impact, those at the bottom end would be most important, particularly with regard to child health and development. The second priority area concerned the use of knowledge about particular substances and the development of coherent well understood national programmes of prevention, for example to tackle cigarettes and alcohol. The third priority area was the design of preventive health programmes. It is considered important that providers of services draw on what is known about socioeconomic factors affecting take-up of services and treatment in the &sign of services for antenatal care, child health and development, in dental health as well as in adult conditions, such as breast and cervix cancer and heart disease. This is an interesting and useful volume for several reasons. First, although comparison across national boundaries present theoretical and methodological challenges, it also holds out the promise of new perspectives and insights. For example, Lynge et al. show how the overall similarities between the Nordic countries in fact conceal quite wide differences among them in terms of mortality. At the other end of the continent, Ramis-Juan and Sokou show how apparently large overall differences conceal basic similarities between Greece, Portugal and Spain. Second, the book draws attention to the lack or the inappropriate nature of the data in several European countries, especially the data related to morbidity and to health care systems. As Fox and Carr-Hill write in their opening chapter, the volume will hopefully persuade countries throughout Europe to continue to El1 the gap in their statistics on this important issue. Last but not least, this book shows that future comparative research will need to go more in depth and study particular problems or social groups. Dr. R. Schepers Department of Health Care Policy and Management Erasmus University Rotterdam Rotterdam. The Netherlands
*****
The Dutch Sentinel Practice Network: Relevance for Public Health Policy By A. Bartelds. J. Fracheboud and J. van der Zee (Bds.) Utrecht, Netherlands Institute of Primary Health Care (NIVEL). 1989, 357 pp.. ISBN 90-6905-109-5, B. 40.00 While hospital and mortality statistics provide a wealth of information about death and severe morbidity, by comparison, far less is known about the problems of primary care. The Netherlands was among the first countries to develop an organization to study common problems seen by general practitioners. This book describes the workings of this inexpensive network and presents summaries of 20 of the 66 topics that were studied between 1970 and 1988. The sentinel practice network was conceived to take advantage of the situation which places the general practitioner as the point of entry into the Dutch health care system. The target of the