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Section on Developmental and Behavioral Pediatrics |
Fall 1999Printable Version (pdf)Section Home
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 The New, New PediatricsKarl Hess, M.D. FAAP Cleveland, OHUnhealthy Societies: The Afflictions of Inequality by Richard Wilkinson (1997) Routledge. Abraham Jacobi, founder of the first pediatric clinic in the United States, wrote in 1893: "Questions of public hygiene and medicine are both professional and social. Thus, every physician is by destiny a ‘political being." This book by Richard Wilkinson is a clear, multifaceted description of research into the patterns of disease, violence, and death within and between societies. Wilkinson states that countries that have attained a modest degree of affluence have experienced an "epidemiological transition," in which the primary causes of death are no longer infections interacting with malnutrition. Degenerative diseases become the leading causes of death. In developed countries, it is the gradient between rich and poor, relative rather than absolute poverty, which correlates most directly with markers of health status such as mortality rates and life expectancy. Such correlations have been demonstrated among the states of the United States as well. In societies with a steep income gradient, the relationship between socioeconomic status and health is a relatively linear one. Health is always worse for those on the lower rung, no matter how high the lower rung is. Wilkinson cites data to show the relationship of income and death rates within societies. For example, British civil servants in the lowest income categories have 4 times the rate of death from heart disease as those in the highest income categories. He shows that this pattern applies to diverse outcomes such as homicides and reading failure, as well as a large number of medical conditions. The differential in health is due to psychosocial factors, particularly chronic stress. For example, the lower you go in society, the more fear you have of unemployment and destitution. Also you have less space to live in, less education, and are surrounded by more stressed people. Stressed people have lower self-esteem. They are much less likely to be able to give up smoking. Other short-term pleasures, such as comfort foods, become harder to refuse. Wilkinson shows that many of the programs we invest in focus on treatment of symptoms rather than dealing with the causes. "Rather than relying on providing more special needs classes in schools, more prisons and police, more social workers and health services, more counselors and therapists, we have to tackle at their root some of the main causes of the problems with which they attempt to cope. Even if we could afford vast armies of counselors and community development workers with a small team for every street, there is no reason to think that it is possible to separate the structural causes from their social symptoms." This is a brilliant book, pulling together much data which illuminates the causes of
the diseases we experience in our everyday lives. Pediatricians in particular see this and
when we are not moralizing, wonder why it is. Unhealthy Societies is highly
recommended for physicians, parents, policy makers, and all others interested in the well
being of children and families. |
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