The Health of Populations : General Theories and Particular Realities . First Edition By Stephen J . Kunitz

Among major works on population health, this one by Stephen Kunitz belongs in the same general category as those by McKeown (1), Riley (2), Wilkinson (3), Cairns (4), and Easterlin (5). Some of those authors, such as McKeown and Wilkinson, would fit Isaiah Berlin’s definition of hedgehogs (6). Kunitz declares himself to be a fox. In the image of the intellectual world developed by Berlin in The Hedgehog and the Fox (6), hedgehogs are those who know one big and important thing, while foxes are those who know many things, each one perhaps of not that much importance in itself. In The Health of Populations, Kunitz substantiates his claim to foxhood by examining many things; he believes ‘‘big theories’’ on population health always have shortcomings and exceptions. He draws on sources from a wide variety of fields, including sociology, epidemiology, psychology, public affairs, economics, anthropology, and international relations. Kunitz is a social scientist in the best sense of the term: He does not hesitate to cross disciplinary borders when the theories or evidence about an issue under discussion come from diverse fields. The book is structured in two parts including seven chapters and five appendices. The first part of the book is titled ‘‘Epistemology, Ideology, and Epidemiology’’ and contains two chapters, ‘‘Two Revolutions’’ and ‘‘Counterrevolution.’’ The ‘‘revolutions’’ Kunitz alludes to are the industrial revolution and the epistemologic revolution, in which the germ theory of disease started a new way of thinking about causal processes. The ‘‘counterrevolution’’ was the one initiated by authors believing that the germ theory and similar theories applied to noninfectious diseases are oversimplified schemes that ignore the importance of host resistance and host susceptibility. The second part of the book concerns the social determinants of mortality and morbidity, with chapters on standards of living, inequality, community, and globalization. The final chapter, titled ‘‘Masterful Images,’’ uses AIDS as an example of how inherited ideas embodied in political ideologies help to shape our explanations about health and disease. The book concludes with five brief appendices and a useful index of subjects and authors. Throughout the book, Kunitz’s discussions are precise and nuanced. He generally presents major theories in the words of their creators, citing passages from their work; then he discusses whether and how the evidence produced favors a theory or its competitors. The chapters on inequality and community (chapters 4 and 5) are perhaps the best. Kunitz cautions the reader that studies of social inequalities in health ‘‘are often written as if behavior and culture are simply what happens when people don’t have enough money or are not well enough educated to make rational choices regarding their health. They miss the ways in which communities at all income, educational, and occupational levels shape behavior, assuming instead that choices are an individual matter constrained (or made possible) only by income and education (or their absence)’’ (p. 89). Presenting in a quite detailed way the fuzzy concept of social capital (perhaps tongue-in-cheek, Kunitz refers to the supporters of this theoretical concept as ‘‘social capitalists’’), Kunitz strongly suggests that many theories on ‘‘social capital’’ do not fit well with the empirical evidence. He devotes several pages to a discussion of Putnam’s ideas, including Putnam’s recommendation that, if you are a smoker and want to improve your health, you should either quit smoking or join some kind of club or association. Any of these two will provide approximately equal rewards in terms of health, because joining a group will increase your social capital and raise your life expectancy by more or less the same amount as quitting smoking. Kunitz is particularly blunt in his rejection of this recommendation, which, in his view, ‘‘is clever rhetoric but bad—indeed irresponsible—advice’’ (p. 125). The sour controversies that have taken place in recent years on the potential role of inequality in diminishing population health are cleverly summarized by Kunitz, though it is likely that there will be disagreement on the fairness with which Kunitz presents them. In this context, Kunitz also makes an interesting case for the potential contribution of spatial autocorrelation as a factor inflating support for the hypothesis that inequality has a harmful influence on health. (Spatial autocorrelation as a statistical issue is nicely discussed by L. J. Layne in appendix 4, the only part of the book not authored by Kunitz.) Less compelling is Kunitz’s discussion of exceptions to the gradient of health by social class that has often been found in both old and modern societies. At any rate, in discussing that gradient, Kunitz also presents an impressive array of studies, and his comments and reflections on them are always interesting and thought-provoking. The fact that Kunitz is a physician with a sociologic background is revealed by the attention he devotes to theories that we might consider rather sociologic or anthropologic. In both quality and extent, they are presented better than, say, economic theories. For instance, he bluntly asserts that