348 Book reviews / Social Science & Medicine 55 (2002) 347–351
The power of the critical perspective lies not in the
ability to reject mainstream ideals; rather, it lies in the
broadening of perspective that forces us to question
before adhering, and alerts us to the fact that the
‘‘social’’ cannot be ignored in the consideration of
illnesses, diseases, and well-being.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 4 1 - 1
The Social Determinants of Health
Michael Marmot and Richard G. Wilkinson (Eds.);
Oxford University Press, Oxford, 1999, 306 pp., price
d26.50 (paper), ISBN 0-19-263063-5
This coherent collection is an expansion of an earlier
booklet, ‘‘Social Determinants of Health: The Solid
Facts’’ (Wilkinson & Marmot, 1998). Each paper is
dedicated to one of the ten determinants connecting
health and location within the social hierarchy, includ-
ing stress, early life, social gradient, unemployment,
work, transport, social support, food, social exclusion,
and cigarette smoking. This volume contributes to the
understanding of the many social pathways to health,
based on studies conducted worldwide.
Michael Marmot argues in the Introduction that the
environment shaped by social and economic organiza-
tion is partly responsible for the status of health.
Richard Wilkinson concludes the volume with a
discussion of the relative income hypothesis, maintain-
ing that societies with wider income differences display
lower levels of average health than societies with greater
income equality. However, the foundation of this
volume is the presentation of ten papers, each discussing
one pathway to health. Marmot and Wilkinson then
present evidence to justify their selection of ten socially
structured intervening factors. Each paper draws upon a
variety of studies to develop its theoretical framework.
Wadsworth argues for the genesis of adult health status
as traceable to biological processes beginning before
birth, snowballing into adulthood as children develop
personal social capital based upon numerous factors tied
to family socio-economic position, such as self-esteem
and peer-group pressures. Blane’s paper on the life
course thesis draws upon Wadsworth’s arguments to
explain adult health as an outcome of past social
position, and a precursor to future social advantage or
disadvantage. The concept of risk behavior, such as
cigarette smoking as socially constructed around stress-
ful situations and material circumstances, hence inti-
mately linked to the social gradient of health, will
resonate with readers who believe that such individual
behavior is attributable to more than simply personal
choice.
Paulin Tay Straughan
Department of Sociology, Faculty of Arts & Social
Sciences, National University of Singapore, 11 Arts Link,
Singapore 117 570, Singapore
E-mail address: socstrau@nus.edu.sg
It is evident that these ten pathways overlap, eliciting
similar health effects and feeding into one another so as
to create a circle of pathways with health as the epicenter
and the socio-economic climate as the circumference.
However, for those fond of categorizing causes and
effects, Brunner and Marmot do offer a conceptual
framework in their paper regarding the health effects of
social organization and stress that may be cautiously
applied to the ten links. In offering material, social, and
work factors as ‘‘upstream’’ pathways, and psychology
and biology as ‘‘downstream’’ factors mediating be-
tween upstream and health, these authors clearly
emphasize the social construction of biological processes
such as stress, and risk behavior such as smoking and
diet.
The editors’ second mission is to persuade the readers
that, while it may be next to impossible to structure the
sort of society that would guarantee good health for all,
it is possible to formulate and implement policies to
improve health. However, if this volume is an indication
of how far the field is towards contributing to workable
solutions to health problems, there appears to be a long
way to go. In the case of the Brunner and Marmot’s
paper on stress, no policy suggestions are provided. In
other papers, policy suggestions are general, and can
only be starting points for specific policy implementa-
tions.
With respect to the majority of the pathways,
particularly early life, the social gradient, unemploy-
ment, work, and social exclusion, government interven-
tion is given a large remedial role in improving health.
For example, Bartley et al., in their discussion concern-
ing the health policy implications of unemployment,
suggest a need for ‘‘spring boards’’ such as positive help
in the shape of social and emotional as well as improved
financial support. These are policies which have no
immediate payback for government investments. How-
ever, proposed policies which go beyond government’s
role via financial support, training, income redistribu-
tion, or education at the individual level, seem the most
forward-looking and central to the thesis of this volume.
For instance, Stansfeld’s report on social support and
social cohesion presents a convincing portrait of
improved mental health associated with improved
 Book reviews / Social Science & Medicine 55 (2002) 347–351
neighborhood services. Given the recent continuing
interest in the health effects of relative income and
income inequalities, as highlighted by Wilkinson’s paper
concerning prosperity and redistribution of wealth,
neighborhood intervention is one possible area of policy
implementation.
This volume should be relevant to anyone interested
in health determinants, given its clear organization and
concise writing. This book concerns issues pertinent to
policy-makers, population health and health promotion
analysts, public health specialists, and academics in the
PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 6 4 - 2
Producing patient-centerd health care: patient
perspectives about health and illness and the
physician-patient relationship
James Monroe Smith; Auburn House, Westport, CT,
1999, 232pp., price $65.00 cloth.
Modern medicine is frequently criticised for failing to
respond to the wider emotional and spiritual needs of
patients. The development of a ‘patient-centred’ health-
care system is increasingly regarded as important if
medicine is to meet these needs more effectively in
future. In this book, James Monroe Smith provides a
‘holistic view of the many factors that affect a patient’s
health’. Separate chapters deal with issues such as the
meaning of health, patients’ beliefs about treatments
(including the placebo effect), the role of emotions in
illness, and doctor–patient communication. Interviews
with patients, relatives and healthcare providers are used
throughout to illustrate particular issues and add depth
and meaning to the general discussion.
The book is very well referenced, though it is probably
fair to say that this is not a traditional ‘academic’ text.
Monroe Smith marshals an impressive array of studies
and facts to support his general thesis that a wide variety
of emotional and spiritual factors impact on peoples’
health, and that fundamental change is required in the
way healthcare is organised and provided to take full
account of this. The author is a lawyer and, to this
reader, the presentation reflects this professional back-
ground in that data and studies are used to build up a
persuasive ‘case’ for patient-centred healthcare rather
than provide an unbiased judgement as to its effective-
ness in practice. There is very little critical analysis of
cited studies, and the reader cannot be sure that all
relevant counter-arguments have been considered. In
one sense this style is appropriate, reflecting as it does
one of the key underlying theses of the book: the
importance of hope and belief for the alleviation of
patient suffering and promotion of well-being. As with a
placebo, Monroe Smith’s book seeks to build up an
349
areas of social inequality, medical sociology, and social
psychology. Specifically, this volume targets those
interested in providing the ‘‘testing and implementation
ground of the social determinants evidence provided in
this book’’. Marmot and Wilkinson have made a timely
addition to the maturing field of health and health policy
research.
Julie Kosteniuk
Department of Sociology, University of Saskatchewan,
Saskatoon, Saskatchewan S7N 5A5, Canada
expectancy that changing the nature of medical care will
reap enormous benefits for all concerned. A more
critical analysis might well be out of place in such an
endeavour.
What is the appropriate audience for this book? The
author’s ‘introductory note to medical students’ suggests
it might be intended to function as a medical school
introduction to lay perspectives on health and illness
The author also presents some ideas about the role of
the health professional as patient ‘advocate’, which may
be of additional interest to those entering the profession.
However, it should be noted that the book does not offer
specific advice for improving doctor–patient commu-
nication (although one chapter is devoted to the wider
issues). This is not a technical guide to ‘doing’ patient-
centred healthcare but an impassioned and unashamed
espousal of the benefits of ‘being’ patient-centred.
Medical students and educators, encouraged by this
book to seek a more detailed account of the skills that
underpin a patient-centred approach, should be aware
of the availability of a number of useful physician-
oriented texts (e.g. Neighbour, 1987; Stewart et al., 1995;
Lipkin, Putnam, & Lazare, 1995; Silverman, Kurtz, &
Draper, 1998).
Patients and their families who are living (as is the
author himself) with the realities of chronic or terminal
illness would also seem a major audience for this book.
The work provides what the author describes as a
somewhat ‘unorthodox’ perspective on illness and
suffering. Monroe Smith encourages patients to resist
conforming to societal expectations that sickness
is debilitating and instead consider the opportunities
their illness offers for personal growth and empower-
ment (including challenging the way they are dealt
with by health professionals). The book also
provides some useful practical discussion of legal issues
such as advance directives and physician-assisted
suicide.
In summary, this book is an effective introduction to
the broad issues concerning patient perspectives on