[Book review] Elizabeth Dowler and Nick Spencer (eds),
Challenging Health Inequalities. From Acheson to
“Choosing Health”, 2007

François Briatte

► To cite this version:

François Briatte. [Book review] Elizabeth Dowler and Nick Spencer (eds), Challenging Health Inequalities. From Acheson to “Choosing Health”, 2007. Medical Sociology Online, 2008, 3 (2), pp.39-40. halshs-00287428

HAL Id: halshs-00287428

https://shs.hal.science/halshs-00287428

Submitted on 12 Jun 2008

**HAL** is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
Challenging Health Inequalities. From Acheson to ‘Choosing Health’

Elizabeth Dowler and Nick Spencer (eds)

Policy Press, 2007.

ISBN 9781861348999. 272 pp. £24.99 (pbk).

https://www.policypress.org.uk/catalog/product_info.php?products_id=1109

*Challenging Health Inequalities* contrasts the current scientific evidence on health inequalities to the efforts that New Labour governments have put into tackling them. It does so by referring to two key policy documents that reflect different political contexts as well as divergent policy orientations. The *Independent Inquiry into Inequalities in Health* chaired by Sir Donald Acheson in 1998 was conducted right after New Labour came into power in with its manifesto promise to tackle ill health. The subsequent *Saving Lives* White Paper (1999) then seemed to reconcile public health research and health policy over the social determinants of health and the need for public action, in opposition to the dismissal of the Black report under Conservative governments. The *Choosing Health* White Paper (2004), on the other hand, reflects a shift from New Labour health policy elites towards the primacy of individual choice in health care.

The core issue underlying discussions of health inequalities is the articulation of structural and individual imputation. While scientific and political views of a same issue rarely coincide, this is clearly the case here. Both views do not strike the same balance between structure and agency, between public services (such as education, housing and health services) and private individuals; as a consequence, they come to different conclusions and emphasize different solutions. The scientific view embodied in the book, collectively supported by its authors through extensive references to research in public health and social epidemiology, acknowledges the role of collective processes generative of inequalities and ultimately responsible in shaping individual health status. On the other hand, the political view extracted from the wording of policy documentation shows that governmental orientations towards health inequalities have fluctuated: whereas *Saving Lives* targeted social factors 'beyond the control of individuals' as the most effective catalyst for change
in health policy, *Choosing Health* privileges focuses on encouraging individualised health-enhancing behaviours and emphasises the benefits of informed choice.

The authors of *Challenging Health Inequalities* clearly collectively regret the latter individualistic turn taken by the *Choosing Health* White Paper. To the authors of Chapter 4, who capture the overall impression left by the book and restated in its Conclusion, the retreat of public health policy into the subgroup of social determinants of health formed by lifestyle factors “certainly represents a shift, albeit a regressive one, in the government’s approach of tackling health inequalities” (p. 58). This feeling of disenchantment persists throughout the book, as the hope embodied in the Acheson report is obliterated by the reductionist view of health promotion that seems to have recently become the paradigmatic backbone of governmental policy towards health inequalities. The common concern, expressed here in the words of the authors of Chapter 3, is that “the bold statements and unprecedented promises of New Labour’s first years in power… have been wholly overtaken by the individualistic rhetoric of behavioural prevention” (p. 48), which seems to forget that choice, like all other determinants affecting agency such as rationality and organization, is naturally bounded. As shown in the subsequent chapters on early life, ethnicity and housing conditions (Chapters 5-7), a wide array of social determinants of health fall outside the boundaries of personal choice. Even lifestyle factors such as nutrition or nicotine intake (Chapters 8-9) are heavily conditioned by structural characteristics that are clearly beyond individual control and personal preferences, such as food pricing and stress (p. 132 and p. 162 respectively).

One chapter of *Challenging Health Inequalities* claims that *Choosing Health* brings England back to Margaret Thatcher's view that 'there is no such thing as society,' which is slightly mistaken (Chapter 3, p. 43). The complete quote from Margaret Thatcher is: "There is no such thing as society, just individuals *and their families*" (*Women's Own*, 3 October 1987; my emphasis). If choice is to remain in the sole hands of the individual under the policy trend initiated by the *Choosing Health* White Paper, then the current ideological context of health policy should actually be considered as even more reductionist than past ones. However, the very recent publication of *Health Inequalities: Progress and Next Steps* (Department of Health, 9 June 2008) shows some ambivalence towards the exact path to follow: while the document states that "Health inequalities are a reflection of wider inequalities,
which in turn are linked to inequalities in opportunities and aspirations,” (p. 5) it
persists in its focus on lifestyle attributes, stating that “Many inequalities in health
are a preventable consequence of the lives people lead, the behaviours and
lifestyles that cause ill health, many of which show a stark relationship with social-
economic factors” (p. 7). It hence remains unclear whether health inequalities are
to be tackled through a typical act of government of self – an internalised sense of
discipline (helped by ‘health trainers’) resulting in ‘healthy choices’ – or through
public authorities addressing the wider social circumstances in which individual
choices are made.

The book shows, finally, that the science-policy relationship is very dynamic in the
English context, as illustrated by Chapter 2, which is authored by a civil servant of
the Health Inequalities Unit. Other countries, such as France, have very different
records on that matter, for a number of reasons that are out of the scope of this
review. The reader might then regret that *Challenging Health Inequalities*
concentrates entirely on the single case study of England. Comparative research
indicates that national differences exist in the perception and treatment of health
inequalities, partly because the internal politics of public health take various forms
in different states. The comparatively exceptional level of academic interest in the
United Kingdom for health inequalities is, in itself, an indicator that cross-country
variations exist at the science-policy level, and further research is hopefully needed
in this domain for a full understanding of health inequalities to develop.

Reviewer:

François Briatte
Institute of Political Studies
University of Grenoble
f.briatte@ed.ac.uk