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Volume 12 - Issue 2

Book review – Health Divides: Where you live can kill you

Clare Bambra
Bristol: Policy Press, 2016, 320 pages, £12.99 (Pb)
ISBN 978 14 4733 035 6

Clare Bambra’s Health Divides: Where you live can kill you covers well-trodden ground on the topic of health inequalities. As a public health researcher working in the inequalities field, I felt a little over-familiar with the arguments and the evidence presented here. About half-way through, however, I figured I wasn’t really the intended audience for the book. And it is with that hat on – the one that identifies me as a curious outsider – that I will review the book.

The book starts with an enthusiastic Foreword by the esteemed academic and commentator Danny Dorling. It is then arranged into seven highly readable chapters on how health and socio-spatial inequalities have been inextricably linked over time and space. The overall approach is consistent with those concerned with the wider determinants of health. The analysis of politics in the latter chapters adds a vital component to Bambra’s argument about how long and how well we live our lives is a product of choices – though not necessarily ours as individuals – but of those who make them in our name.

Bambra prefaces her publication with a personal reflection on her travel through the place and places of health; good and bad. From her mother’s North East England birth to her own employment in northern universities, Bambra states she has examined ‘international, national, regional and local inequalities in health for well over a decade’ (p.xiv). She starts her analysis at the larger scale. Health divides between high-income countries are examined using a series of good-looking maps, tables and sports league and tournament metaphors. We discover that we would want to be pulling out Switzerland in the European Health Championship work sweepstake and would definitely want to avoid Hungary. From this grand scale, the book takes us through different levels of analysis with health divides described first between the countries of the UK, and then within and between its regions and localities. Using male life expectancy as a measure, a ten mile trip eastwards along the Jubilee train line between Westminster (central London) and Canning Town (East London) costs you seven years’ life expectancy.

A history of health divides in the UK is then presented with a quick canter through the dangerous environs of industrialising Britain and the conditions within which communicable disease thrived. It seems monstrous that the average age of death for labouring men in urban industrial Manchester was just 17 years in the 1840s. The development of the welfare state, better nutrition and advances in medical science brought relief to some of these injustices. Then we move swiftly through to the present day where non-communicable disease is the biggest killer; much of this is stratified by socio-economic background. The world we live in today is riven with inequalities in health. Cardiovascular disease, cancer, diabetes, obesity and mental health are all in the mix, with poorer outcomes the poorer you are. Bambra also notes that health divides are not just a matter of poor people but also of poor places. In truth, the two sit together.

The book provides a good chapter on the political economy of health inequalities, starting with a great quote from the pathologist Rudolf Virchow (1821-1902): ‘Medicine is a social science, and politics nothing but medicine at a larger scale’. Current wrangles over the NHS demonstrate this point. The chapter centres on ideologies and how these inform policy choices and their inevitable and inequitable outcomes. It is noteworthy that ideologically-informed choices across socio-political systems – transport, housing, education, you name it – almost always have health implications. Neo-liberal systems, Bambra identifies, have bolstered the growth of such inequalities between both people and places.

Amid the misery of how systems are failing us is a most encouraging section on how decisive state action can change things. Germany provides a case study of how policy was able to positively alter the living conditions of East Germans and significantly reduce health inequalities between West and East after reunification. It is evidence of what can be done using policy levers when the political will is there. Bambra also ends the book with a rallying note to her readers: we need income redistribution, devolution of power and a resourcing of the regions to make economic growth work for all. She sees a need to change the political economy to a more social democratic model as a route to this end.

And herein lies the challenge. Bambra notes multiple policy and state-of-the-art reviews that have taken place over the last three decades: Black, Acheson and Marmot are the star players. The reports are staggeringly consistent in their identification of problems and solutions. Yet challenges remain and indeed seem to worsen. This is clearly not an easy issue to solve; it is a classic ‘wicked problem’ that has deep and complex determinants and no quick-fix, catch-all solutions. So is Bambra seeking a different approach in this book? Is she addressing issues differently or merely repeating the observations of others? I think the book does contribute to an agenda-changing discourse that speaks to a growing public unease about inequalities. By making it accessible and good to look at, Bambra also might be reaching a broader audience (i.e., someone not working in the health inequalities field). But I think questions remain as to how we really mobilise the knowledge we have to effect change in the health inequalities sphere. Alongside current work exploring how to communicate and ‘frame’ messages about health inequalities to best effect, Health Divides might provide a handy reference point for the start of such a mobilisation.

Liz Such, Research Fellow Public Health and Inequalities, ScHARR, Regent Court, 30 Regent Street, University of Sheffield, S1 4DA. Email: