di�culties with which domestic life has to cope and cannot be separated from a rangeof what are seen as family problems. It is not just that worries about money, jobs andhousing spill over into domestic con¯ict . . .It is also that lack of money, of choices, playspace, the need for enough indoor space to accommodate incompatible familyactivitiesÐin short the lack of resources of all kinds (including time)Ðmeans thatpeople's needs and demands are brought into con¯ict with each other . . . (p. 163).

It's hard to see from this and several similar passages why there is any need to oppose`material' to `psychosocial' or `subjective'. We are biological entities, our experience isembodied, and our social environment is structured by power. Certainly, as the evidence cited byWilkinson shows, it is not lack of money per se which results in distress, illness and highermortality rates, but the powerlessness which relative inequality of income creates. But power isthrough-and-throughmaterial: it matters not to your `sense of' security, but to your security fullstop.Absolutely rightly, Wilkinson makes much of the importance for health and happiness of

social cohesion, but here again one must be careful not to cast this as an immaterial `sense of'cohesion. The public world constitutes a kind of exoskeleton of power which, near enoughliterally, we need to hold ourselves together as individuals (I tried to elaborate this notion inmy book, The Origins of UnhappinessÐSmail, 1993). The unbridled market economy attacksand erodes the social institutions which provide us with the possibility of social solidarity(virtually the only form of power available to the economically deprived). This again is athoroughly material matter, its remedies to be sought in equally material measures.Those material measures are not going to be achieved easily, and there is an implicit

optimism about Wilkinson's book which one fears may prove displaced. I have my doubts thatany government imaginable at the present time will set the public policies in place which theunderstanding of income inequality would seem to any rational and well-intentioned mind toindicate. Indeed, I am reminded yet again of the sobering words of Fernand Braudel thathowever much we may dream `of a society from which inequality would have disappeared,where one man would not exploit another':

. . . no society in the world has yet given up tradition and the use of privilege. If this isever to be achieved, all the social hierarchies will have to be overthrown, not merelythose of money or state power, not only social privilege but the uneven weight of the pastand of culture (Braudel, 1985, p. 628).

Those who seek greater equality have a battle on their hands. Richard Wilkinson hasprovided us with a valuable weapon. Community clinical psychologists, among others, shouldmake the best use of it they can.

REFERENCES

Braudel, F. (1985) Civilization and Capitalism 15th±18th Century. Vol. 3. The Perspective of theWorld, Fontana, London.

Smail, D. (1993) The Origins of Unhappiness, HarperCollins, London.

DAVID SMAIL

Nottingham Community Health NHS Trust, 261 Beechdale Road,Nottingham NG8 3EY, UK

A MEDICAL SOCIOLOGY PERSPECTIVE

There is little doubt that Unhealthy Societies will become established very quickly as a classiccontribution within the health inequalities research ®eld. Its strengths lie in its elegantmarshalling of the empirical evidence, including (most importantly) the ®ndings from seminalstudies conducted by Richard Wilkinson himself; and the richness of theorizing about the

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psychosocial pathways linking income inequality and societal health. Nevertheless, the bookalso raises a number of questions which merit more detailed consideration.At the very start (p. 3) Wilkinson states the central proposition of the book: namely, that the

`relationship [between income distribution and life expectancy] is now ®rmly established'. Non-specialists reading this book may therefore be somewhat surprised to hear that the evidence ismore problematic and contested than they may have been led to believe. It is somewhatregrettable that Wilkinson fails to cite a major critique of his work by Ken Judge (published inthe 11 November 1995 issue of the British Medical Journal). Wilkinson in fact produced arejoinder to Judge (published in the same issue of the BritishMedical Journal) and it is clear thathis discussion (pp. 78±80) of the other evidence is sensitive to critical points made by Judge.However, I would have expected Judge's critical appraisal to be openly addressed in the book.

How, then, should we evaluate the current standing of Wilkinson's proposition? In a morerecent conference paper (to be published in revised form in a peer-reviewed journal) Judgeundertakes a systematic review of evidence about the relationship between di�erent measuresof income distribution and indicators of population health and ®nds only modest support forthe view that income inequality is associated with variations in national health. Rather, heclaims that other equity-related features of the welfare state (especially the generosity of thesocial security system) may be at least as important as income inequality in explaining thesevariations. Judge's review will hopefully encourage a wider debate about this issue. In themeantime it would be prudent to treat Wilkinson's proposition as provisional rather than toregard it uncritically as an accepted fact.According to Wilkinson, the explanation for the relationship between income inequality and

lower premature mortality lies in the relative strength or weakness of the psychosocial fabric, inparticular features of everyday life which engender and promote social cohesion. This iscertainly a plausible hypothesis, in support of which Wilkinson cites evidence from Britain inwartime, Eastern Europe during the 1970s, modern Japan, variations between regions of Italyand Roseto (a small town in Eastern Pennsylvania, USA). In each example an associationbetween egalitarianism, social cohesion and better health can be demonstrated. What is missingis any attempt to undertake a direct empirical test of the hypothesis by specifying quantitativeindicators of social cohesion, gathering relevant data from a range of developed countries, andre-assessing the relationship between income inequality and mortality after `controlling for'indicators of social cohesion. This would be di�cult, however, sinceWilkinson does not providenominal or operational de®nitions of the concept, tending to refer instead to a range ofapparently related or analogous concepts, such as social capital, sense of coherence, civilisation,social a�litations and social support. Further elaboration of the existing bivariate data analysiswould be worth pursuing, if only because it would underline the need for greater clarity andprecision in the conceptualization of social cohesion.Another extension of Wilkinson's work that would be welcomed, in particular by medical/

health sociologists, is an assistant of the impact of income inequalities on health. Despitereference throughout the book to `health inequalities', Wilkinson tends to rely on death rates,defending himself by claiming that `health [is] an amorphous concept', that `good measures ofhealth and illness do not exist', that `it is often hard to know exactly what [measures of `self-assessed health'] . . . mean', and that `death rates at least have the advantage of being a fairlyclear-cut, accurate and objective measure' (pp. 55±6). Death, however, is a highly sociallyconstructed event, with cause-speci®c death rates subject to considerable inaccuracy andunreliability. And there is no shortage of measures of self-reported health and symptomatol-ogy which exhibit exemplary psychometric properties and (in some cases) are highly predictiveof (premature) mortality. In view of the shift of emphasis in global health policy towardshealth promotion and illness prevention, Wilkinson is urged to refocus his future research inthis area away from pathogenesis towards salutogenesis.

The book ends on a somewhat unexpectedly upbeat note. Wilkinson ®nds three groundsfor optimism (pp. 232±2): ®rst, `the extraordinary increase in public awareness of healthinequalities which has taken place over the last twenty years'; second, the political response topublic concern about hypothermia; and, third, the pervasive e�ects of greater inequality,leading to negative consequences for `the quality of life of us all'. I ®nd it di�cult to acceptthe truth and/or relevance of these statements. Inequality remains a nearly invisible issue. ToThe Observer (23 March, 1997) it was `perhaps the single most salient fact in contemporary

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British society'. But the conservatives ignore it altogether, while the Labour party prefers toconcentrate on equality of opportunity (not of outcome) and on moving people from welfareto work. As long as the have-nots (who have fallen furthest behind during nearly two decadesof laissez-faire market-orientated economic policy) remain quiescent, the haves will doubtlesscollude to keep equality o� the agenda. No, one of the grounds for any optimism I may feel liesin the potential impact of this book (and other similar work) on the development of healthpublic policy. That is the highest tribute I can pay to Richard Wilkinson's endeavour.

STTEEPPHHEENN PLLAATTTT

Research Unit in Health and Behavioural Change,Department of Public Health Sciences,

University of Edinburgh,Teviot Place,

Edinburgh EH8 9AG, UK

AN ECONOMIC PSYCHOLOGY PERSPECTIVE

Unhealthy Societies is an unusual book. At one level it serves as a very readable textbook-styleintroduction to the methodological problems involved in carrying out research into medicalsociology. Wilkinson is a good guide to the di�cult measurement and analytical problemsinvolved. At another level it is a book with a message to us all: put bluntly, that inequalitiesmatter, and have a marked e�ect on health and the quality of life generally. The book succeedson both levels but the message is less powerful than it could and should be. First, Wilkinson'suse of evidence from outside medical sociology is highly selective: second, the characterizationof the approach of economists is a caricature: and third, evidence on happiness and the qualityof life is not mentioned, although it would have considerably strengthened the argument.After dealing with the evidence from medical sociology about the health of societies and the

nature and impact of health inequalities within societies, Wilkinson draws on a wide variety ofsources. This information, on changes in cohesion in an American small town, on the nature ofJapanese society and so on, is interesting but unpersuasive. For example, the idealized pictureof Japanese society is based on essentially three sources: two books published over 20 yearsago and an article in The Guardian. Japanese management, which Wilkinson commends for itspaternalism and concern for its workforce, may not be as kindly as he imagines: B. Wilkinson(no relation) and his colleagues (Sewell & Wilkinson, 1992; Delbridge et al., 1992) havecharacterized their approach as one that minimizes labour problems but leads to an intensi®-cation of work, and Garrahan and Stewart (1992) see Japanese management as involving apassive workforce disciplined through surveillance and peer pressure. In other areas,Wilkinson's use of evidence leaves something to be desired. In discussing changes in child-rearing, for example (p. 218), he cites DeMause's (1974) work, although this is now widely seenas inaccurate (for a corrective, see Pollock, 1983). On the very next page he comments that, theending of compulsory military service has presumably reduced people's familiarity with someforms of brutality'. Leaving aside the Anglo-centric nature of this statement, it also fails toacknowledge the role that military service may play in fostering the social cohesion on whichhe is so keen (Switzerland and Israel are good examples, see Cohen, 1995).Economists do not need me to spring to their defence (and usually I am found on the

opposite side of the barricades), but Wilkinson's comment (p. 211) that `it is easy to think ofeconomics as a mental illness' is typical of his approach to the discipline. Although he iscareful to acknowledge that economics is `far from exclusively asocial' (p. 109), in general he ishighly critical of it and feels that `the powerful e�ects of relative income . . . present a formid-able challenge to conventional economics'. But the concept of relative income has beenimportant in economics for at least 50 years: Duesenberry (1949) made it the cornerstone of hisapproach to saving (he argued that consumption will always depend on consumers' incomes asa proportion of the average income in their reference groups). Exactly the kind of disparitybetween longitudinal and cross-sectional data that Wilkinson reports has acted as a spur totheorizing in the economics of consumption.

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