The classic sociological problem of structure and agency is well exemplified in this collection. Health inequality research needs to acknowledge that it is not just the nature of the social environment, but its dynamics which must be understood. Modern industrial economies work by getting at least some people to produce more than the value of the wages they are paid. This surplus is retained by employers (or ruling bureaucracies) and forms the basis of profit, the driving mechanism of the economic system. The fact that some citizens are poorer than others is therefore not an accident of bad planning or even individual greed. The reason for increasing numbers of ‘excluded’ people in late 20th century advanced industrial society is the increasing power of technology to produce ever more goods with ever fewer human workers. One result is ‘social exclusion’. Like the Native Americans in the 19th century (Higgs and Scambler 1998), the traditional (especially male) working class is becoming surplus to economic requirements in the late 20th century. The native American people were confined to reservations and granted small amounts of land and welfare payments: significantly the destruction of their communities was brought about in its later phases not by overt genocide but by the health consequences of utter demoralisation. Although inequality may take new forms, the chapters in this book show the implausibility of the idea that ‘class has disappeared’. They add to the evidence of large social differences in quality of residential environment, political attitudes, voting, car and home ownership as well as the very different patterns of educational and career attainment among children from different social backgrounds. People from mining areas may no longer wear cloth caps, but the waning of stereotyped cultural signals co-exists with a wide belief that class distinction is alive and well in Britain today (Marshall et al. 1988).