An exchange in the most recent issue of the journal Sociology of Health and Illness (for the moment, at least, available for open access) provides a useful overview of theoretical debates about the sources of health inequalities. Graham Scambler's review article summarizes main themes in these debates, starting with a relatively familiar typology of behavioural, material and psychosocial orientations. (Readers who have run across these terms without explanation of their contrasting initial assumptions will find Scambler's summary especially useful.) He then argues that new research directions emphasizing the origins of health inequalities in social structures are needed in order to follow through on the agenda of the Commission on Social Determinants of Health, and rather breathlessly concludes that "there is a need for a political economy of health that transcends the nation-state ... National health inequalities can no longer be explained without reference to transnational social mechanisms." Some of us, of course, have been saying this for quite a long time.

A homeless woman and her 14-year-old daughter beg for money in a Moscow metro station,
December 17, 1999.
Photo: Mark Milstein, Getty Images News, Getty Images.

There follow two brief responses. William Cockerham takes a skeptical view of Scambler's emphasis on structures. Then again, since Cockerham has attributed the mortality crisis that followed the collapse of the former Soviet economy to the lack of a "stable and resourceful middle class [that] has served as a powerful social carrier of a positive health lifestyle capable of penetrating the boundaries of other classes" (1, p. 469) – forget about a 50 percent decline in national economic product, official poverty rates over 40 percent and massive capital flight - this is perhaps to be expected. Canadian scholar David Coburn, on the other hand, lauds Scambler's focus on structural influences and indeed argues for a more explicit focus on how the operations of the global market economy magnify economic inequalities and therefore disparities in the chance to lead a healthy life.

I agree with Coburn that "structural analysis too often stays at high levels of abstraction," neglecting what philosopher of science Jon Elster has called the texture of everyday life, which is crucial to understanding how structural influences manifest themselves in the household and the neighbourhood. On this point, my main quarrel with Scambler is his apparent belief that sociology is all there is to the social science of health disparities. Political science and anthropology, to name just two other fields, have a lot to say as well – and the latter discipline, in particular, has done rather a better job of explicating the necessary macro-micro connections. A recent article by James Quesada and colleagues on the situation of Latino migrant labourers in the United States provides just one illustration among many.

(1) Cockerham WC (2007). Health lifestyles and the absence of the Russian middle class. Sociology of Health and Illness, 29, 457-473.