A response to ‘The Social Determinants of Health: Why Should We Care?’

In a provocative and recently published article, philosophers Adina Preda and Kristin Voigt question policy recommendations which call for more equal distributions of social factors as a means of reducing social inequalities in health. The article has already been commented on from a variety of angles. In this blog post, I’ll briefly outline the authors’ arguments and then highlight some areas of the authors’ analysis which I find additionally problematic. I conclude that public health professionals should continue to advocate for more equal distributions of social resources.

Broadly speaking, the authors first question the normative assumptions about the fairness of health inequalities as described in the social determinants of health (SDH) literature, particularly in high-profile publications such as the Marmot Review. The specific normative assumptions identified are that (1) only avoidable health inequalities are unfair and (2) only socially caused inequalities are avoidable. The authors move to illustrate why natural/biological inequalities might also be unfair, an argument which, to me, seems sound and which I’ll leave aside here. The authors then identify two possible reasons why health inequalities resulting from social inequalities are unfair either because (1) social inequalities are themselves unjust or (2) health inequalities themselves are unjust.

The authors, while conceding that they themselves believe inequalities in the distribution of SDH are unjust, dismiss those that would appeal to the first reason. They argue that if social inequalities are unjust, then “[they] ought to be redressed because (social) justice requires it, rather than because of their effects on health”. The authors “do not deny that showing the effects of social inequalities on health may strengthen the argument for redistribution” but argue that “this cannot be put forward as the main reason for such redistribution” (p30).

In a challenge to the second reason, the authors ask whether “there is any reason to claim that health inequalities are unfair when they result from a fair albeit unequal distribution of social goods” (p30). Here, two philosophical accounts of social justice are reviewed, Rawlsian and luck egalitarian, but neither are found to offer an adequate answer to this question.

Finally, the authors argue that “even if it is the case that health inequalities are unfair, it does not follow that they ought to be redressed by altering the distribution of SDH” (32). This is argued primarily on the basis of empirical uncertainties about the effectiveness of redistributive policy interventions. For example, the authors point to evidence that health inequalities have persisted in countries where the state has otherwise reduced inequalities in income and wealth. The authors also draw attention to evidence that shows that improvements in peoples’ socioeconomic conditions are unlikely to result in immediate improvements in health.

It is hard to argue with the authors’ concluding call for greater theoretical development about the ethics of health inequalities. This is something also called for in public health literature. Moreover, greater collaborative attention to these issues between philosophers and public health researchers is, as they suggest, much needed. Overall however, I find important shortcomings with the authors’ conclusion that we should be weary of public health calls for more equal distributions of social resources.

To begin with, I wonder whether claims about the unfairness of health inequalities, which are based on the recognition that social inequalities themselves are unjust, can be dismissed so easily. While the authors acknowledge that such claims can add strength to petitions for social justice (p30) they also argue that they can detract from such claims (p34). But in what scenario would we see appeals for social redistribution on the basis of health inequalities detract from social justice appeals? It seems to me, any effort which focuses on social injustices (regardless if it is through a lens of health equity) is strengthening attention to those issues.

Here the authors might reply that attention to social justice may be detracted if redistribution does not actually lead to more equal health outcomes. Indeed, they source evidence which questions the link between redistributive policies and health. However, their choice of evidence in this regard seems problematically selective. For example, the authors point to evidence which shows that social inequalities in health have persisted in Scandinavian countries, where social policies are typically more redistributive than in other countries. The authors fail to point out however, that the same literature base which has supported this finding has also shown that countries with more redistributive social policies have better overall population health. As such, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since the authors themselves suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, it’s not clear why they would disregard this important dimension of the literature.

The authors also draw on evidence from the UK where they claim “there has been perhaps the most sustained effort to reduce social inequalities in health through large-scale social interventions” (p33). They note that such “efforts have had disappointingly small effects on social inequalities in health, with inequalities in some indicators not only stagnating but in fact widening” (p33). However, towards this end they cite work by Mackenbach (2010) who, in the very article they source, acknowledges that a potential reason why health inequalities have persisted in the UK is precisely because efforts were not aimed at broader redistributive policies. In other words, the large-scale social interventions the authors highlight were in fact not interventions involving broader redistributive policies. Mackenbach states: “One possible analysis of the causes of the failure of the English strategy to reduce health inequalities…then is that this failure is due to the fact that inequalities in income and wealth in England have remained unchanged or even widened” (p1252).

Preda and Voigt also flag evidence which shows that improvements in peoples’ socioeconomic position might not result in immediate improvements in health. But such evidence does not question the effectiveness of redistributive policies as the authors suggest; one could argue it rather highlights the pervasive damage poor socioeconomic position can have on health and the importance of using appropriate time-scales when evaluating interventions.

Even though the choice of evidence the authors focus on seems problematic for these outlined reasons, the authors do suggest that there may be more to the story. For instance, they recognize that “[o]ne possibility is that we simply have not yet seen large-scale social changes of the sort envisaged by proponents of the [health equity] model” (p33). In doing so, they leave room for uncertainty regarding the relationship between redistributive social policies and health. They also recognize that this relationship is complex and difficult to assess using standard medical standards of evidence. However, all these issues are framed problematically as well.

First, this uncertainty is used to argue against policy recommendations for a fairer distribution of social factors. However, how we treat uncertainty in public health is itself, a matter of public health ethics. As has been argued elsewhere, we need not rely on evidence of the sort generated by medical models of health. More importantly, the authors seem singularly concerned about the impacts of incorrectly advocating for redistributive policies (in the case that health inequalities will not improve as a result) but do not recognize the potential health dangers of not advocating for redistributive policies (in the case that such policies are necessary for reducing health inequalities). In epidemiological terms, the authors are more concerned about a type I error, a false positive, than a type II error, a false negative. This focus on type 1 errors, with little consideration of errors of the second kind, is often found in arguments claiming that more evidence is needed to take action on the social determinants of health.

If we consider the risks involved in each of these scenarios however, we find that what we risk in one case is worse than what we risk in the other. In the first case, if we advocate for redistributive policies, but are mistaken in our belief that health inequalities will be reduced, there is almost no evidence to suggest that a more equal distribution of social factors will harm anyone’s health. Health inequalities may indeed widen when everybody’s resources improve (since the better-off are often better able to take advantage of these resources), but again there is no evidence that makes us think that health would worsen for anyone because of a more equal distribution of social resources (it just may not improve as fast for everyone). Furthermore, if redistributive policies fail to reduce health inequalities, we are still left with greater social justice. This is an important consideration since, as the authors concede, current distributions of social resources are undeniably unjust.

In the second scenario however, if we fail to advocate for redistributive social policies (in the case that reducing health inequalities depends on this), not only is there the risk that social injustices persist, but here we have evidence which suggests that health inequalities may indeed widen and overall levels of health may decrease. Studies have for example, pointed to the damaging health impacts of current austerity agendas which serve to further increase unequal distributions of social factors.

Preda and Voigt are correct in that public health scholars do need to engage with philosophical debates surrounding health inequalities and the normative assumptions implicit in their work. For the reasons outlined above however, public health scholars should continue their calls for more equal social policies in the name of health equity.

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