Shim, J. K. Heart‐Sick: The Politics of Risk, Inequality, and Heart Disease. New York: New York University Press. 2014. 288pp £16.99 (pbk) ISBN 978‐0‐8147‐8685‐7

Abstract

Heart disease is a significant cause of death worldwide. According to the World Health Organisation, 46 per cent of all deaths from non-communicable diseases in 2012 were caused by cardiovascular disease, and coronary heart disease was the leading cause of premature death in 2014. It is the leading cause of death in both the USA and the UK, and despite advances in understanding and treating heart disease, and substantial investments in research and treatment, inequalities persist in terms of ‘who develops it, who lives with it, and who dies from it’ (p. 191). Janet K. Shim is an associate professor of sociology in the School of Nursing at the University of California, San Francisco, who is interested in social inequalities in health, science, technology and medicine studies, and race, gender, and class. She brings all these interests into play in this fascinating book which explores the different meanings that heart disease has for different groups of people. In particular, her focus is on how epidemiologists studying heart disease and ‘people of color’ (p. 25) experiencing heart disease differ in the way they explain who gets it and why. Her key argument is that conventional accounts of inequalities in cardiovascular health are inadequate and unconvincing, resulting in many of the fundamental causes of those inequalities being ignored in public health interventions. The book begins with Shim clearly setting out the theoretical bases for her study in some detail. In her discussion of the politics of disease causation, she outlines and explains the role of her key concepts: biopower and biopolitics, intersectionality, and fundamental causality. These concepts intertwine in quite complex ways as she then examines the development of epidemiology in what she refers to as a ‘selective contemporary history of cardiovascular epidemiology’ (p. 48). Her discussion of the way the Framingham Study began and expanded is fascinating, particularly her documentation of the shifts in study objectives and methods over time. She argues that it breached many of what would now be regarded as fundamental research principles, which is remarkable for such a significant study, in terms of the history of epidemiology and the contribution it made to the understanding of cardiovascular disease. She also argues that it pioneered an expansion of surveillance and intervention, a point she returns to later in the book in her discussion of the ever widening role of epidemiology and its influence on self-care, self-monitoring and self-knowledge which risks the exacerbation of widening inequalities and social stratification of risks. The core of the book comprises three chapters where Shim discusses the significance of race, gender and class as competing explanations for the differing incidence of heart disease across different groups in America, with a chapter devoted to each of these classifications. She argues that there is a fundamental flaw with epidemiology in the way it accepts race, gender and class as unproblematic classifications, seeing them as ‘the usual suspects’ (p. 18) in relation to the way that epidemiologists regard them as individual and often separate explanations for the cause of heart disease. Indeed, she argues that even when individual epidemiologists see problems with the way the ‘usual suspects’ are deployed, they still fall back on using them. Alongside this critique of conventional epidemiological approaches to understanding heart disease, Shim specifically explores the intersectionality of causes of and explanations for heart disease, and makes the suggestion that the people she spoke to for her study, all ‘people of color’, had a more complex and nuanced understanding of how gender and class were inextricably linked to race in their experience of heart disease. A particularly interesting aspect of Shim's approach is the way she has carried out research with epidemiologists (interviews, observation, attending relevant conferences) and with people who have heart disease, and the contrasts she draws between the ways different groups talk about disease; in particular, lay views appear to be much more at ease with complex understandings of the intersectionality which Shim focuses on so well. The book is very much focused on the USA. It would be interesting and useful to place the USA in a broader international context, particularly given the significance of heart disease as a cause of death worldwide, and this would give the book a broader appeal to an international audience. It would also be interesting to compare research on inequalities in health in the USA with some of the enormous body of work that has been carried out in the UK and more widely in the EU on social determinants of health. However, even without an international focus, this book is well worth reading for anyone interested in inequalities in health.