In this guest post, Adina Preda and Kristin Voigt respond to a Healthy Policies piece which discusses their recent article ‘The Social Determinants of Health: Why Should We Care’.
We would like to thank Courtney for featuring our paper, ‘The Social Determinants of Health: Why Should we Care?’, on this blog and for offering a number of constructive criticisms of our argument. Part of the aspiration for our paper was to encourage more dialogue across disciplines about the normative questions surrounding health inequalities, and we are very pleased to have the opportunity to contribute to it here.
We identified two main concerns that Courtney raised about our argument: one to do with the grounds for advocating a redistribution of the social determinants of health and the other with our use of the evidence.
1. What should health professionals advocate for, and why?
One point of agreement between Courtney and us is that the current distribution of the social determinants of health is unfair and needs to be rectified. However, we think it is crucial that we think more critically about the grounds on which redistribution of the SDH is called for. Our AJOB paper expressed concern about the fact that much of the SDH literature argues for a more equal distribution as a means to reducing health inequalities. As we emphasised in the paper, economic redistribution and other (egalitarian) policies are required by social justice. For example, giving all children an equal start in life, as the SDH literature calls for, is required in and of itself, not because of any contribution it makes to health equity. Accordingly, we think it would be better if health professionals (and others) were to argue for egalitarian policies as a matter of social justice, regardless of any impact such policies might have on health inequalities.
This is important for a number of reasons. One reason is that, as a matter of principle, it remains important to emphasise that egalitarian policies are required as a matter of social justice, not just because of any effects they might have on other goals. Furthermore, as we already mentioned in the paper, if we argue for redistributive policies on the grounds that they will bring about more equal health outcomes but then they fail to do so, these policies might be conceived as having failed, even if they achieved a more equal distribution of the SDH. If, however, we argue for these policies as rectifying broader social injustices (and perhaps in addition offering some plausible possibility of bringing down health inequalities), they would still be considered a success to the extent that they achieve a fairer distribution, even if health inequalities remain unaffected. (We explain this in more detail in our rejoinder in AJOB.)
Courtney assumes that social justice and justice in health go hand in hand and asks in what context calls for social redistribution for the sake of health inequalities could detract from social justice more broadly. We agree that in general this should be the case but we think there are instances where these two goals might pull in different directions. One such instance is gender equality: Policies that seek to address inequalities between men and women – the pay gap, for example – might benefit women’s health and thus ‘exacerbate’ existing health inequalities between men and women. In such instances, it is plausible to argue that gender equality should take priority even though it might increase a health inequality that we don’t regard as fair.
If we could move to an ideally fair distribution right away, this would likely have positive effects on health inequality. For policy purposes, however, the decisions we have to make tend to be on a much smaller scale. We are not moving straight to a fully equal society but, rather, we may be considering different steps we could take towards such a society, such as early education programmes or policies addressing poor housing. The types of policies that most effectively contribute to the reduction of health inequalities may not be the ones that most effectively contribute to social justice, and vice versa. The way the connection between equality in health on the one hand and justice and equality on the other is framed in the SDH debate tends to obscure these possible difficulties.
To sum up, we are concerned that an undue emphasis on health and health inequalities may detract from the main reason for redressing existing inequalities including inequalities in health, which is justice.
Courtney is also concerned that we are not paying sufficient attention to the literature showing that ‘countries with more redistributive social policies have better overall population health’. As such, she argues, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since, in our AJOB paper, we ‘suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, we do not think we disregarded this important dimension of the literature although, as we explain below, this was not the most relevant issue for our argument.
We have a number of concerns about Courtney’s line of reasoning here. First, the ‘dramatic’ figures cited in the SDH literature relate to differences in life expectancy between rich and poor countries, not between countries with different levels of redistribution/economic inequality – though there are of course also significant differences in health outcomes across different countries with similar levels of wealth.
Second, Courtney switches here from talking about (reducing) social inequalities in health and improving overall health. As we emphasised in the paper, we think it is important to keep these two goals distinct. Improvements in overall population health are perfectly consistent with increased health inequality (as Courtney acknowledges as well). Our concern in the paper – and the claim we were examining – was that redistributive policies would not reduce health inequalities.
Third, as we pointed out, it is problematic to assume that the best way to redress a health inequality is to remove or alter its (ultimate) cause. Even if one of the causes of health inequalities is social or economic inequality, it does not follow that the best way to address health inequalities is greater social or economic equality.
Courtney also suggests that we are more concerned about the possibility that we could implement policies might fail to reduce health inequalities (a type I error) than we are about the possibility that we could fail to argue for policies that could, after all, reduce health inequalities (a type II error). Further Courtney claims that even if such policies will not have the desired effect, they are, as it were, ‘risk-free’ because ‘they will not harm anyone’s health’ (emphasis added). This, however, is precisely the kind of over-emphasis on health we caution against. We do not think that such policies should be evaluated only in terms of their effects on health. Thinking of risk purely as health risk obscures other important considerations. Health is, of course, valuable but it cannot be the only thing that matters. We are not concerned that redistributive policies have bad effects, we are concerned about advocating for them because of their effects and the opportunity costs involved in selecting one policy over another.
At this point, we think, it is just not sufficiently clear that what social justice requires is what justice in health requires: we do not as yet have a good understanding of what justice in health requires, and of the means through which it would be best achieved. This is precisely what this multi-disciplinary dialogue should aim to clarify.
*We borrow this expression from Gopal Sreenivasan. [http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=842]