STATISTICS IN MEDICINE, VOL. 9,855-859 (1990)

BOOK REVIEWS Editor: Douglas G. Altman

HEALTH INEQUALITIES IN EUROPEAN COUNTRIES. J. Fox (ed.), Gower, Aldershot, 1989. No. of pages: xix + 414.

One feature of the 1980s has been the abolition of health inequalities - at least as far as the prevailing political ideology has been concerned. They have been seen as an unfortunate aberration that would disappear as people pulled their socks up and liberal economic policies led us all into a brave new prosperous world. As we enter the 1990s the pendulum is starting to swing back as even the most avowed free marketeers recognize the limita- tions of their philosophy. It is therefore an oppor- tune time for a clear scientifically based statement on the state of health inequalities in Europe. This book meets just such a need.

Based on series of European Science Founda- tion workshops held during 1984-86, it brings together a multidisciplinary group with con- siderable expertise in the area. The authors, from nine European countries, were asked to consider: between-country comparisons of mortality differ- entials; between-country comparisons of differen- ces in health, illness and health care; and explana- tions of differentials. Some excellent coordination and editing successfully divide the book into four sections. First there is a background to concepts of inequalities in health and policy issues. There follow reviews of differences in mortality and of differences in morbidity. Finally there is a section on explanations. The highly readable text is well supported by plenty of quantitative data. Despite two or three reservations, I would recommend this book to anyone who wants to gain an overview of the subject and to understand the key debates about explanations.

The first reservation concerns the widespread acceptance by the authors of the validity of mor- tality data. There seems to be too much faith in data based on death certification and too little concern about the variations in clinical judgement that occur between individual doctors, between groups of doctors (relevant to international com-

parisons) and over time. This is something that has led to doubtful comparisons being made in the search for causes of coronary heart disease and is in danger of being repeated in the health inequal- ities debate.

The second reservation concerns the positioning of the chapter by Aaron Antonovsky at the end of the book. For those unfamiliar with his work (which this reviewer was), Antonovsky believes that the probability of disease and death is in- creased when our needs (physical, social, psycho- logical) remain unsatisfied. This is a simple idea but one that has profound implications for our approach to understanding ill-health. For instead of searching for pathogenic risk factors (as epi- demiology has traditionally done) we should be identifying salutogenic or health promoting and protecting factors. Such factors are characterized by a person having a sense of coherence with his or her work, relatives, friends, physical environment and so on. Coming at the end of a book that largely adopts an approach in which the world is implicitly viewed as being potentially pathogenic, Antonovsky’s view is marginalized. Whilst this was probably unintentional, it leaves the reader wondering whether or not to take it seriously or, as the book has done, shove it to the back of the mind. At the very least, a short commentary from the editor would help the reader in assessing how to react. Having said that, I for one am glad I got to the last chapter to discover Antonovsky.

Along the way there is a chapter by Roderick Floud, a historian who has made extensive studies of the changing height of the British over the past three centuries. Taking the mean height of military recruits as an indication of average net nutritional status during childhood and adolescence, he pro- poses that height can be used to compare the effects of multiple influences on the human body. Height could therefore be used to assess interna- tional and secular changes in inequalities between social groups. The beauty of such an approach, apart from the ease of obtaining the key measure, is that adult height attained can be taken to result

0 1990 by John Wiley & Sons, Ltd.

856 BOOK REVIEWS

from the sum total of many factors (food, shelter, emotional environment, work, struggle against dis- ease and so on), all of which may display sys- tematic inequalities in society. In addition, study of height has recently been given an added impetus by increasingly strong evidence of its association with the probability of developing coronary heart disease. It is somewhat ironic that after decades of increasingly sophisticated biological measurement

we may find that one of the simplest and oldest measures best serves our purposes.

NICK BLACK Health Services Research Unit

Department of Public Health and Policy London School of Hygiene and Tropical Medicine

London WClE 7HT. U .K .

CLINICAL EPIDEMIOLOGY AND BIOSTATISTICS. A PRIMER FOR CLINICAL INVESTIGATORS AND DECISION-MAKERS. Michael s. Kramer, Springer- Verlag, Berlin, 1988. No. of pages: xii + 286. Price: 76DM

A distinguishing feature of this textbook on epi- demiology and biostatistics is its sheer breadth, encompassing a rather traditional treatment of elementary statistics with separate chapters on observational cohort studies, clinical trials, case- control studies and cross-sectional studies. There are also several chapters devoted to special topics, including diagnostic tests, decision analysis and causality.

The discussion of the strengths and weaknesses associated with various research designs is done concisely but clearly, making good use of examples to illustrate complicated points. The style of writ- ing is entertaining and informal, easily holding the reader’s attention, with the chapter on case-control studies being particularly well written. However, the treatment of the various designs is highly selective, touching upon only the major conceptual issues. Thus, for example, the chapter on clinical trials is unable to deal with such important topics as data collection, patient compliance and interim analyses. The discussion of ‘efficiency versus effect- iveness’ is all too brief, leaving the impression that ‘intent-to-treat’ and ‘explanatory’ analysis are sim- ply two different equally viable approaches to the

interpretation of trial results. No mention is made of the major controversy involved in this issue, or that most authors now regard intent-to-treat as the analytic approach of choice, at least for the pri- mary analyses. However, this shortcoming is an inevitable result of attempting to cover such a broad range of topics in one text.

The only pedestrian part of the book is Part 11, which deals exclusively with statistics. There are a great many textbooks which adequately cover this material, and is difficult to see why the very traditional treatment offered here should be preferred. There are also some mistakes. Perhaps the most serious is that the sample size formula given for comparing two means on page 157 is simply wrong. I would also disagree with the assertion on page 84 that a pretrial study period can be used to decide whether a design random- izing groups can be safely accompanied by an analysis by individual.

As an introduction to the various research de- signs in epidemiologic research, this text is inter- esting and informative. However, other textbooks are more suitable for clinicians interested in a more in-depth treatment of particular topics.

ALLAN DONNER Department of Epidemiology and Biostatistics

University of Western Ontario London, Ontario

Canada N6A 5CI

CLINICAL CANCER MONOGRAPHS. VOL. 1: CANCER OF THE OESOPHAGUS. Matthews, H. R., Water- house, J. A. H., Powell, J., Robertson, J. E. and McConkey, C. (eds.), Macmillan Press, London, 1987. No. of pages: 184.

This book is edited by a thoracic surgeon and summarizes the facts obtained from the West Mid-

lands Cancer Registry over a 25 year period from 1957-1981. Cancer of the oesophagus ICD 150 is divided into upper, middle and lower oesophagus but the duplicate concurrent coding in 150 is not used. Cancer of the hypopharynx at the top end and cancer of the stomach or cardia at the lower end are excluded. This registry is one of our biggest and best and achieves a 95 per cent efficiency for recording cases gleaned from all possible sources.