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J Epidemiol Community Health. 2007 November; 61(11): 1014–1015.
PMCID: PMC2465612

Health inequalities and welfare resources: continuity and change in Sweden

Reviewed by Stephanie Burrows

Edited by Johan Fritzell, Olle Lundberg. Bristol: The Policy Press, 2006, ISBN 1-86134-757-X, £24.99 (paperback); ISBN 1-86134-758-8, £55.00 (hardback), 247pp.

The link between a person's position in the social structure and their health has been recognised throughout history, with those belonging to more advantaged groups tending to have better health than the other members of their societies. These inequalities have persisted despite major improvements in medical science, technological development, considerable demographic changes, and substantial efforts to create more equitable public‐health systems, governments and states.1 They are also found in every society, at least for some (if not most) diseases and demographic groupings, even wealthy societies such as Sweden.

This book presents new empirical evidence on the links between social and economic policies of the Swedish welfare state and several health outcomes for the Swedish population. Almost certainly to the envy of most other countries, Sweden is fortunate to have a rich dataset available longitudinally, which permits the examination of social determinants of health over time. The use of the Swedish Level of Living Surveys (LNU) as the primary source of data throughout the book confers a sense of continuity and consistency in measures and outcomes between chapters. Each chapter assumes a specific empirical focus while remaining located within the larger international debates regarding health inequalities. As elucidated by the editors, the aim is not so much to describe the theory but to understand and test it, thereby not only investigating whether theoretical constructs, such as sense of coherence, the psychosocial work environment, relative deprivation and social capital, are important for health status but also the extent to which they are important when trying to explain the gradient by class or gender.

The book manages to explore the issues on several levels simultaneously – an impressive achievement. It assesses longitudinal changes in health and inequalities against a background of changes in welfare state institutions; understands health inequalities from a life‐course perspective and includes groups not typically examined (the very old and the very young); and covers several health outcomes such as musculoskeletal pain, psychological distress, mobility limitations, self‐rated health, psychosomatic complaints, and anxiety. This approach not only highlights the complexity of the issues involved, but also offers a more detailed picture of health as a welfare problem.

The presence of health inequalities in a context such as Sweden may be surprising for some, given its reputation as a society based on equality, and as exemplified by several fairly distinct features of its social democratic welfare state: universalism, commitment to full employment, active labour‐market policies, relatively generous benefit policies, high‐quality public‐care services for children and the elderly, and low poverty rates. Yet, as demonstrated throughout this book, health inequalities have not only persisted from the late 1960s into this new millennium, but are of a substantial magnitude. Does this mean that the Swedish welfare state has been unsuccessful in protecting its citizens' physical and mental health and functioning? The book cannot provide a full answer, but one conclusion regarding the welfare state can be drawn from the analyses presented. The economic crisis of 1990s gave rise to poorer health in general, but mostly, inequalities in health have not increased. This suggests that the welfare state cushioned the immediate impact of the crisis, and the policies seem to be protective for the most vulnerable segments of the society likely to be affected by the economic downturn.

The book takes the middle ground between the psychosocial versus neomaterial explanations for the generation of health inequalities, by arguing that increased command over resources, both material and intangible, is central for health. This has relevance beyond the Swedish context and thus the book makes an important contribution to the discussion on the impact of policies on health.

References

1. Krieger N, Williams D R, Moss N E. Measuring social class in US public health research: Concepts, methodologies and guidelines. Annu Rev Public Health 1997. 18341–378.378 [PubMed]

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