"Social inequalities in health rarely feature in general books for the lay public. But they are something that vitally affects us all, from cradle to grave. To its great credit, this collective book makes a valuable contribution to a debate that too seldom makes it onto the agenda. In fewer than 300 pages, the authors look at health inequalities in France from three angles. They show them at work throughout life from infancy to old age, painting a compelling picture of their pervasiveness from early deaths from cancer through cardiovascular disease to AIDS, not forgetting mental health. They single out the lack of systematic preventive activity, picking up on the importance of working and employment conditions, often the Cinderellas of public health policies seemingly uncertain of their own legitimacy to intervene in business management.
Looking at the part played by working and employment conditions, the authors refrain from putting the whole emphasis on psychosocial conditions, and instead stress how they interact with the physical factors of production, arguing that the key to a prevention policy lies in work organization. A look at the unequal distribution of domestic duties between men and women, and how they interact with paid work, would have been welcome here.
Three of the many points made by this book are worth picking up on.
Health inequalities are not on the way out in our societies. Access to care alone is not enough without a prevention policy on the collective determinants of health. Throughout the 20th century, the trade union movement rightly fought for social security systems that would provide access to health care. This remains a key aim, but it is not enough. As the introduction states, “social inequalities in health are found as much in the case of illnesses where the healthcare system is effective, as those where it is less so”. Progress in diagnosis or treatment is sometimes seen to do no more than shuffle the inequalities around. Middle-class women have benefited greatly from advances in the early diagnosis of breast cancer, for example, closing the gap with the comparatively lower mortality of working class women for this disease.
Social inequalities in health are not confined to there being a chronically deprived section of the population. Public policies too frequently focus on social exclusion and its health impact. This results in emergency measures to address what are described as exceptional situations. Every winter, emergency services for the homeless are brought into play, when the housing problem demands completely different answers. In reality, health inequalities are present in the population as a whole. Looking from top to bottom of each level in the social hierarchy, a gradual deterioration of most health indicators can be seen. As the authors say, “the health of poorest is only the tip of the iceberg”.
Tackling social inequalities in health is not just a public health concern. The authors emphasise the importance of a critical assessment of policies in a wide range of spheres, be it education, housing or agricultural policy.
The authors show how France has built up data on social inequalities in health across a wide range of areas over the past decade. The knowledge gap with other countries – Britain and the Scandinavian countries in particular, which had a longer tradition of data collection and analysis – has largely been narrowed. Sadly, increased knowledge is no guarantee of a more effective policy. In the final analysis, health inequality always comes down to inequality straight and simple, and the policy responses that are made to it. — Laurent Vogel"

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