United States health-care spending is the highest in the world, yet millions of Americans are uninsured, and there are great disparities in access to care and health status. This situation, according to Fine and Peters, is the result of two closely related problems. First, we in the USA have ‘largely wiped out community’, a necessary condition for health. Secondly, the medical care services we purchase are designed to extend life (and produce vast profits for pharmaceutical, medical device companies and others), but not to produce health. This book argues that the US health-care system is focused on life extension, rather than the promotion of health. Health, the authors argue, ‘is the biological, social, and psychological ability that affords an equal opportunity for each individual to function in the relationships appropriate to his or her cultural context at any point in the life cycle’ (p. 136). The book's definition shifts attention away from a narrow focus on health care and the extension of life – and toward a focus on community health and social relationships. The authors argue that we must invest in communities and improve our social and physical environments. On these points, the book is compelling, but the discussion of social and environmental determinants frequently ignores conflicting evidence.

The book's discussion of health and urbanisation, for example, leaves out a large body of research that has concluded that cities do not necessarily promote isolation or impoverish our social capital. Indeed, over the past century, sociologists and anthropologists have studied the effects of urbanisation on social interaction among city residents, and most of the evidence suggests that urban residence is not associated with social isolation. Another example of the book's selective use of evidence on the subject of social determinants relates to claims about the relationship between inequality and health. There has been a rigorous debate in the public-health literature on this topic. Some studies suggest a causal relationship, but others claim that, once you control for income, the relationship between inequality and health disappears. The authors are correct to emphasise the failure of the US to address social and environmental determinants of health – but the book would be stronger if the authors acknowledged these debates rather than presenting a portion of the evidence and treating these as settled questions.

Fine and Peters also claim that spending on medical care limits investments in social and environmental factors that improve health. To help address this problem, the authors call for a radical reform of the health-care system, which includes a proposal to eliminate public spending on medical services after an individual reaches the average life expectancy age. Once people reach this age, health-care services should be treated as a ‘consumer good’ and receive additional services only if they are willing and able to pay for them with their own resources. The assumption that poor access to adequate housing, food, education and a built environment that encourages physical activity and other social determinants of health are the result of excessively high spending on high-tech medical services and drugs is not well supported. It is sensible to evaluate carefully the use of medical technology, but as Dan Brock (1989) put it in his review of Daniel Callahan's version of this proposal, ‘the shameful inadequacies in many of our social welfare programs, including those designed to ensure that all citizens have basic goods such as food and shelter, as well as health care, are results of failures of political will, not of our failure to adopt strong age rationing of life-sustaining health care’ (p. 312).

Even if we accept the notion that spending on health-care services limits investment in other socially useful programmes and services that produce health, it is still difficult to justify the proposal to eliminate public spending on health care for people who live beyond the average life expectancy. In contrast to claims about the cost of dying frequently repeated in the press, expenditure on acute care at the end of life falls as the age at death increases and end-of-life care represents only about one per cent of the US Medicare programme budget. It seems unlikely, therefore, that the book's proposal could generate sufficient savings to overcome the vast disparities in access to decent housing, food, education and other factors that contribute to the health of individuals and communities. It could, however, lead to socio-economic and racial disparities in access to life- extending medical technology within the older population. This book is worth reading because it raises important questions about the goals of health- care spending, but is also a reminder that diagnosing problems is easier than identifying workable solutions.