Wednesday, March 17, 2010

Justice, Inequality & Health

The sociologist, New Left veteran, and my former teacher, Richard (‘Dick’) Flacks,* wrote the following in his important book, Making History: The Radical Tradition in American Life (1988):
“Virtually all of the debates about strategy that have divided the American left in the twentieth century were rooted in false dichotomies; most of the sides in most of these debates were expressing valid understandings of partial truths. These debates—about ‘politics’ vs. ‘direct action,’ about ‘confrontation’ vs. ‘permeation,’ about ‘independent political action’ vs. ‘coalition…about ‘integration’ vs. ‘black power,’ about ‘reformism’ vs. ‘revolutionism’—occurred not because some leftists were morally pure and others were ‘revisionists,’ nor because some were ‘crazy’ and others ‘rational,’ but because there were fundamental differences in the perceptions leftists had of social reality, differences made inevitable by the complexity of that reality. What was mistaken, then, was not this view or that, but the assumption that only pole of each of these debates could be right, or that there was one ‘correct path’ that all organized leftists had to find and follow.”
The point I’d like us to consider is that the current health care debate, including the urgency of passing health care reform legislation, should not be an occasion for forgetting or ignoring the significance of larger and thus more inclusive questions concerning the relation between health, inequality, and social justice. At the same time, and after Flacks, I’m not intending to pose a “false dichotomy” between health care reform and a more theoretical approach that relies on understanding the relevant causal variables linking individual and population health, inequality, and the quest for social justice (although neglect of the latter might plausibly be said to distinguish a Liberal from a Leftist). Rather, I’m simply imploring us not to forget the wider possible social determinants of health, a discussion of which goes far beyond the parameters of the current health care debate, the former necessarily encompassing the latter. In his invaluable entry on “Justice, Inequality, and Health” in the Stanford Encyclopedia of Philosophy (linked below), Gopal Sreenivasan explains that a “social determinant of health is a socially controllable factor outside the traditional health care system that is an independent partial cause of an individual’s health status. Candidate examples include income, education, occupational rank, and social class.” Therefore, writes Sreenivasan,
“Health care (personal medical care and public health) is clearly an additional socially controllable determinant of health. Nevertheless, for different reasons, in both the empirical and the philosophical literatures, health care is something of a separate topic. In the public health literature, variations in access to health care are not regarded as a significant contributor to inequalities in health. But to recognise that there are social determinants of health, in the sense we have defined, is not to deny the importance of health care as another partial cause.”
Consider, for instance, the following quotes from some of the leading analysts in the literature on on health, inequality and social justice:
“Inequalities in health are...closely tied to inequalities in the most basic freedoms and opportunities that people enjoy.”—Sudhir Anand
“We have known for over 150 years that an individual's life and death are patterned according to social class: the more affluent and better educated people are, the longer and healthier their lives. These patterns persist--even when there is universal access to health care--a finding quite surprising to those who think financial access to medical services is the primary determinant of health status. In fact, recent cross-national evidence suggests that the greater the degree of socio-economic inequality that exists within a society, the steeper the gradient of health inequality. As a result, middle-income groups in a more unequal society will have worse health than comparable or even poorer groups in a society with greater equality. Of course, we cannot infer causation from correlation, but there are plausible hypotheses about pathways which link social inequalities to health and, even if more work needs to be done to clarify the exact mechanisms, it is not unreasonable to talk here [after Michael Marmot] about the social ‘determinants’ of health.” —Norman Daniels, Bruce Kennedy, and Ichiro Kawachi
“If we have obligations of social justice to provide equality of opportunity, as in Rawls's robust notion of fair equality of opportunity, then we have social obligations to promote normal functioning [i.e., to prevent significant mental or physical pathology] and to distribute it equitably within society by designing our institutions properly. [….] The broad determinants of health and its distribution in a population include income and wealth, education, political participation, the distribution of rights and powers, and opportunity. These are quite centrally the goods that any general theory of social justice is concerned about. We cannot achieve effective promotion of health in a society as well as its fair distribution without a just distribution of these other goods. Putting together the key results from the epidemiology literature with Rawls's principles of justice as fairness, we learn why justice is good for our health and we get a general answer to the question ‘When is a health inequality unjust?’”—Norman Daniels
“Many kinds of social institutions can substantially contribute to the incidence of medical conditions. Of these, economic institutions--the basic rules governing ownership, production, use, and exchange of natural resources, goods, and services—have the greatest impact on health. This impact is mediated, for the most part, through poverty. By avoidably producing severe poverty, economic institutions substantially contribute to the incidence of many medical conditions. Persons materially involved in upholding such institutions are then materially involved in the causation of such medical conditions. [….] In our world, poverty is highly relevant to human health. In fact, poverty is far and away the most important factor in explaining health deficits. Because they are poor, 815 million persons are undernourished. 1,100 million lack access to safe drinking water. 2, 400 million lack access to basic sanitation, more than 880 million lack access to health services, and approximately 1,000 million have no adequate shelter. Because of poverty, ‘two out of five children in the developing world are stunted, one in three is underweight and one in ten is wasted.’ [....] One-third of all human deaths are due to poverty-related causes.”—Thomas Pogge
“In the United men in deprived areas have twenty years’ shorter life expectancy than richer white men. The major contributors to this excess mortality are violent deaths, HIV/AIDS, and cardiovascular disease. Poverty of material conditions does not provide a ready biological explanation for the causes of shortened lives. [....] In so far as material deprivation can be seen to cause homicide or risky sexual behavior or drug use, its effects are likely to be through psychological pathways. To be clear, we have had pathways linking material circumstances to disease via exposure to cold, infections, malnutrition. More recently, these have been supplemented by behaviours such as smoking, diet, and physical activity. The psychosocial approach emphasizes subjective experience and emotions that produce acute and chronic stress which, in turn, affect biology and, hence, mental and physical illness. Our growing understanding of psychological factors points to ways that the social environment can have a powerful influence on health. All three types of pathways—material, behavioral, and psychosocial—should be within our focus.”—Michael Marmot
So, by way of a modest contribution to helping us keep in mind the various social determinants of individual and population health, the effects of inequality on health, and their relation to social justice, I’m providing links to two essential articles by Norman Daniels and Gopal Sreenivasan respectively from the Stanford Encyclopedia of Philosophy; Anup Shah’s page, “Poverty Around the World” from his Global Issues website; and my bibliography, “Health: Law, Ethics & Social Justice.”
Daniels, Norman, “Justice and Access to Health Care,” The Stanford Encyclopedia of Philosophy (Winter 2008 Edition), Edward N. Zalta (ed.):
Sreenivasan, Gopal, “Justice, Inequality, and Health,” The Stanford Encyclopedia of Philosophy (Spring 2009 Edition), Edward N. Zalta (ed.):
Poverty Around the World (with a section on ‘inequality and health’)
*For Flacks’ formative role in the Students for a Democratic Society (SDS) and the New Left generally, please Kirkpatrick Sale’s SDS (New York: Random House, 1973) and James Miller’s “Democracy Is in the Streets:” From Port Huron to the Siege of Chicago (New York: Simon and Schuster, 1987).

Cross-posted at


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