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Human Nature Review 2003 Volume 3: 373-375 ( 6 August )
URL of this document http://human-nature.com/nibbs/03/navarro.html
The Political Economy of Social Inequalities: Consequences For Health and Quality of Life
Edited by Vicente Navarro
New York: Baywood, 2002
Reviewed by David Paul, MB BS, Centre for Aboriginal Medical and Dental Health, Faculty of Medicine and Dentistry, University of Western Australia, Australia.
The Political Economy of Social Inequalities: Consequences For Health and Quality of Life edited by Vicente Navarro makes an impressive and welcome contribution to the literature. This collection of critiques analyse the increasingly recognised importance of social inequalities for health and well-being. Much of the collection represents updated articles or presentations, some of which previously appeared in the International Journal of Health Services. As Navarro points out in the introduction, this journal has been one of the few exceptions in the academic literature by showing its willingness to embrace detailed discussion on this topic since its inception some thirty years ago.
Structurally the book is divided into six parts: a review of the literature; a discussion of the causation of the growth of inequalities; critiques of the major international agencies; consideration of the effects of deregulation, maximisation of profit and privatisation on the welfare state; the Wilkinson-Muntaner and Lynch debate, and a final section detailing some possible solutions to the impacts of social inequalities on health. Apart from the opening literature review by Navarro, in itself justification enough to acquire this book, each section comprises between three and six chapters offering a detailed analysis of an area of relevance in this growing field.
The critiques presented in the book frequently challenge mainstream interpretations of the ways social inequalities are produced and reproduced and the ways they influence health and well being. They represent a shift from the all too common focus on the individual to a broader understanding of the social, political and economic factors that influence social inequality. Navarro’s thoughtful and informative overview of the research into the area over the past thirty years is the text of his address to the 1997 annual convention of the American Public Health Association. Not only does this chart Navarro’s journey into this field, so much earlier than many, it offers a much needed historical context to the research into social inequalities and the connections to health. Navarro clearly documents the, at times, hostile rejection by many in the mainstream academic arena to the growing analysis developing from the mid sixties, a rejection that continued well into the nineteen eighties.
The ideas and analyses that were both nurtured and sustained by Navarro and his colleagues owe much to the resistance and persistence of this group in the face of much hostility and rejection. Those who applaud the more recent growing acceptance of the importance of the social determinants of health, in particular the role of social inequality, as a new advance in understanding would do well to read this chapter so that they may better understand the origins of these understandings which date back many decades. As an example, Navarro points out that the important work of Wilkinson and others, in relation to social cohesion and health, represents a renaming of what some scholars used to call solidarity.
In the second part of the book Navarro sets the scene for the rest with in-depth commentary on some of the structural changes that have occurred post World War II to reinforce rather than diminish social inequalities. In particular, he discusses the rise of neoliberal policies and their social and economic consequences. He then moves on to a detailed argument showing how countries with a more regulated labour market and stronger welfare state are not disadvantaged compared to countries which have adopted a more free market economy. This section concludes with two chapters on globalisation and political economy and the welfare state in richer societies and the consequent erosion of social democratic policies.
The third part of the book focuses on international agencies with six chapters that look at the social costs of the policies and programs of, in particular, the International Monetary Fund, the World Bank, WHO and UNICEF. Understandably the policies and practices of the World Bank come under particularly close scrutiny in these chapters. A range of authors draw on examples from around the world of the negative impacts of the Bank’s approach to health policy. The realities of the Bank’s structural adjustment policies, underpinned by the notions of privatisation and marketisation which in effect commodify health and locate health as a private rather than social responsibility are clearly revealed. Laurell and Arello’s analysis of the World Bank’s 1993 World Development Report: Investing in Health is helpful here. Perhaps the most engaging for me was Bannerji’s chapter which argues that there is a certain ‘intellectual fascism’ in the ways the ‘new’ public health policies and understandings of WHO, the World Bank and UNICEF are implemented in some Asian countries. This may seem a harsh analysis but his argument is well made and deserves close consideration. Numerous examples are given of the multiple ways the Primary Health Care principles articulated in the Declaration of Alma Ata have been undermined by the rapid invention of Selective Primary Health Care, ‘as if from nowhere’ (p.250) and the imposition of technically focussed health programs in various settings. It is argued that the cost of the pursuit of such programs has been to the detriment of the health and lives of many of the poorest people in the world.
Part four of the book considers the linkages between health and social policy. Laurell draws on the social security entitlement reforms in Mexico since 1995 have in fact been a counter reform which have failed to improve access or income security for many. It represents a shift from income redistribution and social obligation of the state to a market economy with a focus on individuals capacity and profit incentives. Drawing on the proposal of Medicare vouchers and social insurance the chapters by Oberlander and Boff remind the reader of the potentially negative impacts of health policy and practice, in richer settings, that focus on notions of individual choice and competition.
The final two sections to this book offer compelling reading. Muntaner and Lynch challenge the limits of Wilkinson’s income inequality and social cohesion analysis of health inequalities. Their approach is not so much to dismiss it but to reveal its limits and shortcomings. They acknowledge the importance of Wilkinson’s contribution in shifting the focus from individual behaviour (smoking, alcohol, inactivity, diet, etc) as an explanation for health inequalities. As they put it: the increasing acceptance of income inequality as a major contributing factor to health inequalities shifts the focus from the individual to the relations between individuals. Further Wilkinson has concentrated his analysis on the health in richer settings which helps the argument of income distribution as a key factor rather than absolute income. Particular criticisms Muntaner and Lynch have of Wilkinsons’ analysis is the focus on within-country inequality rather than considering between-country inequality, not considering class and its connection to social cohesion, the notion of Western progress embodied in his assumption of ‘developed’ and ‘undeveloped’ countries, and the ignoring of politics as a determinant of health. Finally Muntaner and Lynch consider that this model of social cohesion can still be used to ‘blame the victim’ with the community rather than the individual being considered at fault. Wilkinsons’ responding chapter whilst usefully expanding on his analysis is somewhat unconvincing in addressing some of these criticisms.
The final section of the book consists of five chapters that offer some thoughts as to ways the connections between social inequalities and health and well being may be considered in a more useful context for future change. These contain the message of the continued importance of equity, long term planning and systems based rather than individual based approaches to addressing social inequalities. Further, Navarro warns that the constraints of globalisation and market economies should not be seen as justifications for further eroding the welfare state. Given the political will it is argued that it is possible to diminish social inequalities and hence reduce health and well being inequalities.
Readers who still cling to the notions of Selective Primary Health Care, with all its economic rationalist imperatives, as the solution to poor health outcomes may not warm to this book. Hopefully the arguments presented by Navarro and his colleagues will help to reveal the problematic nature of promoting technical solutions to the complexity behind poor health outcomes. Navarro hopes that the book ‘will broaden the much needed debate on the social, political, and economic determinants of populations’ quality of life’ (p. 9). It certainly achieves this goal with its diverse, detailed and inclusive critique. All who are interested in developing a deeper understanding of the complexities that influence social inequalities and their effects on health and well being should seek this book out.
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© David Paul.
Paul, D. (2003). Review of The Political Economy of Social Inequalities: Consequences For Health and Quality of Life edited by Vicente Navarro. Human Nature Review. 3: 373-375.