Intended for healthcare professionals

Book Book

Tackling Inequalities: Where are we now and what can be done?

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7285.560/a (Published 03 March 2001) Cite this as: BMJ 2001;322:560
  1. Catherine Law, epidemiologist
  1. MRC Environmental Epidemiology Unit, University of Southampton

    Eds C Pantazis, D Gordon

    Policy Press, £15.99, pp 250

    ISBN 1 86134 146 6

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    Hot on the heels of evidence based medicine comes evidence based health policy, with a proliferation of articles and journals and the birth of academic centres and review facilities. Advocates of this movement cite a sizeable body of research that might inform or even determine policy and press for randomised trials of health policy interventions. Others argue that the current evidence base is wholly insufficient and that a wider range of methodologies needs to be considered. Evidence based policy has become a Holy Grail.


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    But not all evidence is holy, pure, or perfect. It can be interpreted in different ways, depending not only on its content and method but also on the values and beliefs of the interpreter. The editors of Tackling Inequalities are refreshingly frank in setting out their political and scientific values. They see their role as campaigning rather than simply academic. Paraphrasing the old Marxist adage, they say that “the purpose of statistics … is not only to describe the world but also to change it.”

    The current government favours area based initiatives, like health and education action zones. Many of the book's authors note that basing policy on statistics collected at area level risks incurring the “ecological fallacy”—associations between variables at an aggregate level do not necessarily mean that the association exists at the level of an individual. A classic example is the (now discounted) link between hardness of drinking water and mortality from heart disease, which was based on area level analysis and not the exposures and deaths of individual people. Furthermore, area based approaches reach only a minority of poor people, most of whom do not live in poor areas, and benefit people who are not poor but who live in areas that are. On this evidence many of the authors advocate, in some form or another, policies based on income redistribution at the individual level.

    Although the focus of the book is inequality per se rather than inequalities in health, there is much to interest doctors, both personally and professionally. For example, the chapter on income inequality explores issues of wealth as well as poverty. In an examination of criminal and social harm we find that poor people are more fearful than rich people of being the victims of personal violence, but they are also more afraid of other adverse events such as job loss and debt. Topping all of these, the commonest fear is of illness.

    The authors take the government to task for doing too little to reduce inequalities. Whether you like this book will depend partly on whether you like this government. But it is difficult to remain unmoved by the stark contrasts between the haves and have-nots in our society.

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