Health & Social Justice: The Inexcusably Elusive Pursuit of Welfare and Well-Being

(Unemployed handyman Napoleon Leonard stands in front of the shed where he keeps his belongings at the spot where his house once stood before it was destroyed by fire May 6, 2009 in Marks, Mississippi.)

At the HealthLawProf Blog, David Orentlicher draws our attention to a New York Times Sunday Magazine piece that

“provide[s] a profound reminder about the disparities in health and health care in the U.S. While many Americans may have access to the best health care in the world, that is not the case for the rural poor in Mississippi. And giving them access to care is only a small part of the solution. The health care system does little to address the causes of illness that bring the rural poor to the hospital.”

As the author Suzy Hansen writes,

“Mississippi has some of the worst health statistics in the country. A Mississippi black man’s life expectancy is lower than the average American’s life expectancy was in 1960. Sixty-nine percent of adult Mississippians are obese or overweight, and a quarter of the state’s households don’t have access to decent, healthful food. Adequate grocery stores can be 30 miles away. In one of the country’s most fertile regions, people sometimes have to shop for their groceries at the gas station. Consequently, Mississippians are dying from diabetes, hypertension, congestive heart failure and asthma. Shirley points out that in the 1960s people starved, and today they die from food.”

While Professor Orentlicher highlights an important generalization made by Hansen, namely, that “American health care is not preventive, and it’s not a system,” there’s an even wider lesson we might learn from such data, one that’s been around for some time now but has been obscured by the debate, constitutional and otherwise, over the The Patient Protection and Affordable Care Act (PPACA). That lesson is brought home within the framework of “health justice” or the endeavor to understand the relations between justice, health, and health policy, an endeavor that takes us considerably beyond the current focus (however important) on health care as such. This enlarged view, if you will, raises in the first instance questions concerning the “social determinants of health,” defined in the singular as 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” (Gopal Sreenivasan). In the words from a collaborative article by Norman Daniels, Bruce P. Kennedy, and Ichiro Kawachi:

“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 about the social ‘determinants’ of health. Justice requires that we ask whether these social determinants of health are fairly distributed, and where they are not, that we take steps to address these sources of inequality.”

With some notable exceptions, and these owing to attempts to make sense of the current global economic crisis of neoliberal turbocapitalism, we should not expect our politicians, policy makers, pundits, let alone the hoi polloi, to vigorously and frankly confront questions of race and class, social determinants, equality/inequality, and distributive justice, especially as they relate to each other in a systematic manner or as parts of a complex web of socio-economic causality. In the introduction to his book, Just Health: Meeting Health Needs Fairly (2008), Norman Daniels argues 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.” To answer the question, “When is a health inequality unjust?,” Daniels relies on Rawls’s “justice as fairness” conception together with “key results from the social epidemiology literature.”

These “broad determinants” operate in large measure through social institutions which, Thomas Pogge explains,

“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.”

References and Further Reading:

• Anand, Sudhir, Fabienne Peter, and Amartya Sen, eds. Public Health, Ethics, and Equity. New York: Oxford University Press, 2004.
• Asada, Yukiko. Health Inequality: Morality and Measurement. Toronto: University of Toronto Press, 2007.
• Bartley, Mel. Health Inequality: An Introduction to Theories, Concepts and Methods. Cambridge, UK: Polity Press, 2004.
• Bhopal, Raj S. Ethnicity, Race, and Health in Multicultural Societies: Foundations for Better Epidemiology, Public Health, and Health Care. New York: Oxford University Press, 2007.
• Buchanan, Allen. Justice and Health Care: Selected Essays. New York: Oxford University Press, 2009.
• Daniels, Norman. Just Health Care. New York: Oxford University Press, 1985.
• Daniels, Norman. Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press, 2008.
• Daniels, Norman, Donald W. Light, and Ronald L. Caplan. Benchmarks of Fairness for Health Care Reform. New York: Oxford University Press, 1996.
• Daniels, Norman, Bruce Kennedy, and Ichiro Kawachi. Is Inequality Bad for Our Health? Boston, MA: Beacon Press, 2000.
•  Daniels, Norman and James E. Sabin. Setting Limits Fairly: Can We Learn to Share Medical Resources? New York: Oxford University Press, 2002.
• Drèze, Jean and Amartya Sen. Hunger and Public Action. Oxford, UK: Clarendon Press, 1989.
• Drèze, Jean, Amartya Sen and Athar Hussain, eds. The Political Economy of Hunger. Oxford, UK: Clarendon Press, 1995.
• Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley, CA: University of California Press, 1999.
• Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, CA: University of California Press, 2003.
• Gostin, Lawrence O. Public Health Law: Power, Duty, Restraint. Berkeley, CA: University of California Press, 2000.
• Gostin, Lawrence O., ed. Public Health Law and Ethics: A Reader. Berkeley, CA: University of California Press, 2002.
• Kawachi, Ichiro, Bruce P. Kennedy, and Richard G. Wilkinson, eds. The Society and Population Health Reader: Income Inequality and Health. New York: The New Press, 1999.
• Kawachi, Ichiro and Lisa F. Berkman, eds. Neighborhoods and Health. New York: Oxford University Press, 2003.
• Kawachi, Ichiro and Bruce P. Kennedy. The Health of Nations: Why Inequality is Harmful to Your Health. New York: The New Press, 2006.
• Kawachi, Ichiro and Sarah Wamala, ed. Globalization and Health. New York: Oxford University Press, 2007.
• Kawachi, Ichiro, S.V. Subramanian, and Daniel Kim, eds. Social Capital and Health. New York: Springer, 2008.
• Marmot, Michael. Status Syndrome: How Social Standing Affects Our Health and Longevity. New York: Owl Books/Henry Holt, 2004.
• Marmot, Michael and Richard G. Wilkinson, eds. Social Determinants of Health. New York: Oxford University Press, 2nd ed., 2006.
• Navarro, Vicente, ed. The Political and Social Contexts of Health. Amityville, NY: Baywood, 2004.
• Navarro, Vicente, ed. Neoliberalism, Globalization and Inequalities: Consequences for Health and Quality of Life. Amityville, NY: Baywood, 2007.
• Navarro, Vicente and Carles Muntaner, eds. Political and Economic Determinants of Population Health and Well-Being. Amityville, NY: Baywood, 2004.
• Nussbaum, Martha C. and Amartya Sen, eds. The Quality of Life. New York: Oxford University Press, 1993.
• Sen, Amartya. Poverty and Famines: An Essay on Entitlement and Deprivation. New York: Oxford University Press, 1981.
• Wicks, Elizabeth. Human Rights and Health Care. Portland, OR: Hart, 2007.
• Wilkinson, Richard G. Unhealthy Societies: The Afflictions of Inequality. New York: Routledge, 1996.
• Wilkinson, Richard G. The Impact of Inequality: How to Make Sick Societies Healthier. New York: Routledge, 2005.