Richard Wilkinson and Kate Pickett. Penguin, 2019, PB, 352pp, £9.99,978-0141975399
This book should be on every forward-thinking GP’s bookshelf; but unlike many of the other books it should be read and acted upon! Professors Wilkinson and Pickett are epidemiologists and founders of the Equality Trust, which ‘Seeks to promote public understanding of the effects of inequality’.1 Their original book, called The Spirit Level,2 has been widely celebrated for highlighting the obvious connection between income inequalities leading to, among other outcomes, health inequalities. The Spirit Level prompted an ‘Equality Pledge’ to be signed by 75 Members of Parliament before the 2010 UK general election, which promised to ‘actively support the case for policies designed to narrow the gap between rich and poor’. Sadly, as we all know, this hasn’t happened. Wilkinson and Pickett’s central message very much supports Marmot’s theory of the social gradient in health: the higher the social position, the better an individual’s health, and that’s not fair.
As GPs we see evidence of the social gradient every day, especially when working at the Deep End.3 Wilkinson and Pickett’s latest book, The Inner Level, is of even more relevance to us, and our patients. It explores the personal impact of us living in unequal societies. The Spirit Level explained why less equal societies don’t perform as well as more equal ones, whereas The Inner Level demonstrates how inequalities affect us as individuals. So many of the findings revealed in this fascinating book ring true to our day-to-day experience in general practice. For example, as income inequalities increase, rates of mental illness also increase: aren’t we seeing this every day in our surgeries at the moment? The authors show how anxiety also increases as income inequalities increase and we need a multitude of social props to carry on our daily lives. We require more drugs, drink, and greater consumerism to make us feel normal. As family doctors we deal with the impact of these traits in our surgeries every day; additionally we have to endure the impact of needing these toxic soothers in our own lives. In the book we are shown how there is a greater sense of community and friendship in more equal societies, both of which are key to not just mental, but also physical, health.
This is certainly no self-help book, but is a very readable resource for all GPs who want to look beyond their consulting rooms. It’s one for GPs who are interested in how politics can influence equity, and how in turn this impacts on a nation’s health. It will be of particular interest to Deep End GPs who require this evidence to be able to present the case for equality in funding of services for their patients; a theme we recently discussed at a Deep End conference in Glasgow.4 Like many, I’ve recently been inspired by Greta Thunberg, the Swedish student and climate change activist who has triggered a global climate change movement: ‘We can’t change the world by playing by the rules so the rules have to change’, she has said. Thunberg asserts that we have all the facts laid out for us here; now we just need to take action and do something about it — the same is true for health inequalities. Just look at the numerous reports (Black, Acheson, Marmot) we have had over the years reiterating the same thing, yet inequalities just get wider.5 Professor Philip Alston’s recent report eloquently yet shockingly describes poverty as it is in the UK.6 It is disturbing reading but sadly familiar to those of us working with vulnerable groups.
Often we read and echo the phrase ‘tackling inequalities’ in heartfelt pieces in journals such as the BJGP and in national reports. This is obviously written with good intentions, but I wonder if it puts an inappropriate emphasis on the oft-cited ‘undeserving poor’ to change their nasty habits of smoking, drinking, taking drugs, and gambling: shifting blame onto individuals. The essence of this fantastic book is that it shifts focus and blame towards the politicians, policymakers, and those who vote for them, as it is they who have created this unequal society. It is my belief that it is they who now need ‘tackling’, and then equity will surely follow.
- © British Journal of General Practice 2019
