from 8% in 1981 to 25% in 1991 while in the best healthareas the increase was from 4 to 10%.

In Chapter 5: Narrowing the gap } the policy debate,the authors conclude that the key means of reducinginequalities in health is reducing inequalities in income

and wealth. ‘‘Poverty can be reduced by raising thestandards of living of poor people through increasingtheir incomes ‘in cash’ or ‘in kind’. The costs would beborne by the rich and would reduce inequalities overall

} simultaneously reducing inequalities in health’’ (p.169). They call for changes in tax structure, strengthen-ing of services, improved equity in service delivery and

increasing payments through pensions, disability andsocial assistance. There appears to be widespreadsupport for this among the British public, yet analysis

of New Labour policies indicates that the political willfor such action appears lacking.The Widening Gap } with its emphasis upon

materialist explanation of health inequalities } providesan important balance to the relative income hypothesisadvanced in the recently published The society andpopulation health reader: vol. I, Income inequality and

health (Kawachi, Kennedy & Wilkinson, 1999). In thatvolume, psychosocial and social cohesion explanationsfor health inequalities were stressed with less attention to

material deprivation issues and the role social policydecisions play in supporting health. To illustrate thecontrasting emphases of these volumes, one argument

advanced in favor of the relative income hypothesis isthat socioeconomic differences in health are seen acrossthe entire range of socioeconomic status. This gradient ishypothesized to reflect psychological reactions to

differences in social position. The authors of theWidening gap however, explain the socioeconomic

gradient in health gradient in terms of how ‘‘. . .thesocial structure is characterized by a finely graded scale

of advantage and disadvantage, with individuals differ-ing in terms of the length and level of their exposure to aparticular factor and in terms of the number of factors

to which they are exposed’’ (p. 102). Another importantcontribution of the present volume is its emphasis upon13 key critical periods of the life course during whichpeople are especially vulnerable to social disadvantage.

These include fetal development, nutritional growth andhealth in childhood, entering the labour market, job lossor insecurity and episodes of illness, among others.

The Widening gap is rigorously researched and itsarguments cogently presented. It should be of keeninterest to all those concerned with the health of

populations. Its materialist arguments should be con-sidered in conjunction with the psychosocial and socialcohesion emphases contained in the society and popula-

tion health reader.

References

Kawachi, I. Kennedy, B. P. & Wilkinson, R. G. The society and

population health reader: vol. I, Income inequality and health.

New York: New Press.

Dennis RaphaelDepartment of Public Health Sciences,

Graduate Department of Community Health,University of Toronto,

McMurrich Building, Room 308, Toronto, Ontario,M5S 1A8, Canada

E-mail address: d.raphael@utoronto.ca

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The National Study of Health and Growth

by Roberto J. Rona and Susan Chinn. Oxford University

Press, Oxford, 1999, 133 pp

There are two narratives set within the cramped and

crowded pages of this book. One is about the mechanicsof survey work } a uniquely informative insight into thenuts and bolts of running a longitudinal study. The

other is about observing and interpreting change overtime, in this case the nutrition, the growth and the healthof children as their lives unfold in a changing social

environment.The National Study of Health and Growth was set up

as a response to radical changes in welfare policyannounced by the British government in the 1970 White

paper ‘New Policies for Public Spending’. This heralded

the phasing out of government subsidy for school mealsand an end to the provision of free school milk to all

school children over the age of seven. Concern that thesechanges would effect nutritional status and thus thegrowth of children, led to an undertaking on the part ofthe Department of Social Security that these aspects

of child health should be carefully monitored, so thatany adverse effects could be detected whilst theywere still reversible. The National Study began in

1972 and remarkably, continued for 23 years until1994. At the heart of the study lies routine measure-ment of height, weight and obesity, complemented

by detailed questionnaire items that elicit socio-economic and demographic characteristics and uptakeof meals and milk at school. As the years went on,more routine measurements were included to monitor

cardiovascular and respiratory health and more detailed

Book reviews / Social Science and Medicine 52 (2001) 323–327 325

‘food frequency’ measures were included in thequestionnaire.

The first chapters of this book (Chaps. 1–3) outlinethe methods, sampling frame and analysis adoptedby the NSHG team. They chronicle the procedures

involved in designing a longitudinal study, but morecrucially, they discuss the many problems that arefundamental to survey design and yet are so oftenomitted from conventional textbooks. A case in point

is sample selection and the often conflicting demandsof policy driven research and scientific rigour. Theauthors make it clear that for this study sample

selection was guided by the necessity to over select‘poor’ children, as they would be more vulnerableto any adverse social and environmental change.

This meant that their scientific instincts to constructa nationally representative sample were sacrificedand with this went any possibility of using the study

to establish national standards for height and growth.The sample was based on a non-random selection ofprimary schools that were predominantly located indeprived areas and the authors illustrate how they used

this schools-based sample design to develop close andproductive relationships with local professionals and thefamilies involved with the study. Such was the success of

their methods that they achieved an exceptionally highresponse rate that rarely fell below 90% across all theyears of the study. The meticulous attention devoted to

study design and management makes these chapterscompulsory reading for anyone contemplating large-scale survey work.What a shame then that the muted tones of the

remaining chapters obscure rather than proclaimthe significant findings of the study. These chaptersinclude research reports on height, on obesity, on

chronic heart disease risk factors and on respiratoryillness and lung function. There is a special contributionon trends in asthma (with P.J.G. Burney) and overviews

of the study from the public health perspective(W.W. Holland) and the auxological perspective

(J.M. Tanner). Interesting results can, with persistence,be unearthed from the research reports, but fulldiscussion of their meaning and social significance is

often missing. A notable example is that, contrary toexpectation, increasing obesity, rather than undernutrition characterised children’s growth patterns inthe 1970s and 80 s, irrespective of whether they came

from disadvantaged or advantaged families (Chap. 5).This was not discussed either in relation to the originalaims of the study (to monitor under nutrition) or to

social trends such as rising standards of living andchanging patterns of food consumption. Factors asso-ciated with trends in obesity were country of residence,

ethnic origin and gender. Children living in Scotlandshowed a greater trend in weight for height than childrenliving in England. Children of the Indian sub-continent

showed greater increases in weight-for-height than eitherwhite or Afro-Caribbean children living in inner cityareas. Girls of Indian sub-continent origin had greaterincreases than boys in triceps skinfold thickness. Once

again, the reader was left to ponder about thesignificance of these findings.On the whole I felt that this book was worth reading. I

would have enjoyed it more if the authors had cast awaytheir dry, scientific reportage of results in favour of astyle that would excite and involve the reader in what is,

after all, an important contribution to the study of childdevelopment and health.

Deborah BakerNational Primary Care Research

and Development Centre,University of Manchester, 5th Floor,Williamson Building, Oxford Road

Manchester, M13 9PL, UK

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Health, Civilization and the State: A History of Public

Health from Ancient to Modern Times

by Dorothy Porter. Routledge, London, 1999, 376 pp.,$25.99 (paper)

Graduate students studying for comprehensive examsin the history of medicine or public health will find thisencyclopedic synthesis of scholarship on public health

history and social policy to be an invaluable resource.Porter focuses on works which best illustrate the pivotalrole of health in political organization, paying specialattention to ‘‘the implications of health citizenship as a

‘right of man’ within democratic states from the late

eighteenth century’’ (p. 5). The book is organizedaround the concept of ‘‘population health’’, encompass-

ing collective social action by classes, institutions andnations to promote both the physical health ofindividuals and the civic health of the state.

The style of the first section on pre-EnlightenmentEurope is somewhat episodic, with chapters ending inabrupt summaries, but Porter does aptly demonstrate

that the same conditions facilitated both the spread ofdisease and the development of a diversifying social,economic and political structure. She establishes thecentrality of the sick poor as a political problem through

the centuries, and the continuing tendency of collective

Book reviews / Social Science and Medicine 52 (2001) 323–327326