Unequal

Commentary: Understanding it all—health, meta-theories, and mortality trends

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7072.1584 (Published 21 December 1996) Cite this as: BMJ 1996;313:1584
  1. George Davey Smith, professor of clinical epidemiologya,
  2. Matthias Egger, senior research fellowb
  1. a Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  2. b Department of Social and Preventive Medicine, University of Berne, Berne, Switzerland

    Investigations into the determinants of health within and between countries contribute to a generally slow, but incremental process. Leaping forward to the big picture of how it all fits together represents an attractive alternative to merely continuing with this laborious spadework. Bunker and colleagues advance the idea of bounded freedom as being the key to health and well-being, a viewpoint which shares some characteristics with others who consider embeddeness within strong social networks as being the important determinant of population health.1 The positive benefits of strong social ties seem self evident, but “the plausible role of biological pathways leading from social disconnection to disease” that Bunker and colleagues evoke has not been satisfactorily elucidated. Indeed, degree of social support may be influenced by health rather than the reverse. The supposedly protective influence of social support has been shown among the majority populations of the United States, United Kingdom, and Scandinavia, but in groups that have different connotations for such networks social ties can appear detrimental, rather than beneficial, to health.2

    One theory of population health that has received considerable attention is the income inequality perspective of Richard Wilkinson, recently elegantly summarised in his book Unhealthy Societies.3 This view, which incorporates explanations relating to social networks, considers that the psychological consequences of living in an unequal society are the primary determinants of overall state of health. Several alternative models of the important determinants of population health to these essentially psychosocial accounts exist. The high …

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