Health and social justice: not all good things grow on the same tree*

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 (in)equality. 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.

2. Evidence

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]

The Great Divide:Health Inequality Research in the UK and the US

Two major health inequality reports were recently released, one in the UK and the other in the US. This is the final post in a series which seeks to better understand the health perspective of these reports. In the first post we talked about the implications of how researchers frame their studies. In the second post we discussed the challenges to building evidence on the social determinants of health (SDOH). In the third post we presented 8 principles which help overcome these challenges. Using these principles as a framework, we will now evaluate the health perspective of the two reports.

Action on the social determinants of health requires that evidence be generated using sound methodological approaches. These approaches must be appropriate to the research questions being asked which in turn should be derived from a specifically defined problem. We will first look at the background of the two reports to get an idea for their specific aims. We will then look at the reports’ adherence to the 8 principles in hopes of gaining a better understanding of each study’s health perspective.

Background of Reports:

County Health Rankings(CHR): CHR is a major component of the US-based Mobilizing Action Toward Community Health (MATCH) project and a collaborative effort between The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The CHR project was developed specifically to fulfill MATCH’s first objective: Increase awareness of the many factors that contribute to the health of communities. Researchers hope this increased awareness will ultimately catalyze multi-sector action that will improve health and reduce health inequalities within America.

The final report presents data for every county in each of the 50 States and ranks them both on measures of health outcomes and health determinants. Outcome data includes measurements of both mortality and morbidity. Specific health determinants were chosen across four broad categories, each weighted for its contribution to health: Health Behaviors (30%), Clinical Care (20%), Socio-economic Factors (40%) and Physical Environment (10%). Specific indicators were chosen “based on a review of the literature, expert opinion, and data analysis”.

Fair Society, Healthy Lives (FSHL): Fair Society, Healthy Lives was commissioned by the UK government to “assemble the evidence and advise on the development of a health inequalities strategy in England”. Enlisting the help of nine task groups, researchers relied on scientific evidence, but also “engaged widely with stakeholders and attempted to learn from their insights and experience”. Chair Commissioner, Michael Marmot, was keen to expose the ideological position behind the work, stating that health inequalities are unfair, and “putting them right is a matter of social justice”.

As can be judged from their backgrounds, both projects seek to reduce health inequalities in their respective countries. Both also emphasize the importance of multi-sector engagement. In a previous post we exposed 8 principles that provide a framework for developing evidence on the social determinants of health. By judging the projects’ adherence to these principles we hope to better understand the health perspective of these studies.

Health Perspectives:

The first principle emphasizes that research on SDOH should assert a commitment to equity and specifically the Right to good health for all populations. While FSHL strongly advocates that equality in health is “a matter of fairness and social justice”, it does not make the explicit claim that health is indeed a human right. CHR makes an even smaller commitment to the idea of equity. It exposes only broad health inequalities that exist across county lines and does so neither through a lens of fairness, social justice nor human rights.

Related to a studies’ degree of commitment to equity is the second principle that specifies the need to ensure that the right types of questions are being asked and that appropriate methods are being used to answer them. Both studies are concerned with the reduction of health inequalities. However, CHR’s lack of commitment to equity has serious implications for its entire methodological approach. For instance, CHR’s framework for compiling data neither expands our conceptualizations of evidence nor does it draw on wide range of research, both key components of the third principle. The report also completely ignores principle four by excluding from its analysis the systematic differences in health outcomes across various social groups. By contrast, FSHL incorporates evidence from a wide variety of stakeholders and focuses entirely on the the health gradient within the UK.

The fifth principle specifies that research should strive to move beyond descriptions of observations to the identification of causal mechanisms. CHR has a comprehensive model that incorporates the influence of programs and policies on health determinants but it is extremely linear and disregards the interplay and interaction of various determinants. Additionally, while CHR accounts for a lag time between determinants and their health impacts, this consideration pales in comparison to the emphasis placed on the lifecourse perspective in FSHL. In sum, while CHR assigns different weights to the health impact of clinical care, behavioral influences, socio-economic conditions, and the physical environment, FSHL explains how socio-economic conditions influence all of these determinants, from access to care to an individual’s choice to engage in unhealthy behaviors. FSHL also demonstrates how specific policies such as taxes and wage laws influence the structural determinants of health, something which is less explicit in CHR.

Excluding the many axes of differentiation in a society from its analysis, CHR also fails to meet both principles 6 and 7 which emphasize the need to accurately describe dynamic social structures. In contrast, FSHL integrates into its report a framework for both reducing and monitoring reductions in health inequalities across time and various axes of differentiation.

The eighth and final principle, highlights the need for bias to be explicated in a way which allows us to understand any political biases inherent in the research. This permits us to determine to what level these biases have influenced the selection and interpretation of the evidence. FSHL’s ideologic premise is eagerly explicated early on the report. However, while CHR does a good job of making it’s scientific methodology transparent and its evidence easily accessible, no political biases are acknowledged.

Understanding variations in how health inequality research is pursued is important because different health perspectives can undermine attention to the broader determinants of health inequalities and hinder the development of healthy public policies.

Implications of Health Perspectives:

There are three main implications of CHR’s health perspective. First, with no acknowledgment of the Universal Right to Health, CHR sets no precedent for health campaigns to approach health as a governmental responsibility.

Second, without highlighting the social gradient in health, the report fails to direct appropriate attention to the upstream decisions and institutions responsible for the unequal distribution of resources necessary for health.

A third implication is that while CHR may catalyze action that improves health on a population level, it is possible that large inequalities across social groups will persist. The social determinants of health are not necessarily the same as the social determinants of health inequalities.  Health inequalities are linked to social disadvantage. Social disadvantage is systematically distributed and responsible for the social gradient in health, which remains consistently under reported in CHR.

CHR intends to be a “call to action”, helping “community leaders see that where we live, learn, work, and play influences how healthy we are and how long we live”. Therefore, it may be argued that exposing health inequalities across social gradients was not the intention of the report. Indeed the issue is indirectly addressed in the FAQ section of their website with a question that asks: How do you account for the fact that a number of the measures used may hide disparities that exist in the county? CHR responds by encouraging “communities to use the Rankings as a starting point to delve more deeply into data that may highlight the disparities within counties”.

Community-driven solutions to health inequalities are essential. However, in order to identify and tackle the social determinants of health inequalities, communities must first know what they are and be able to accurately describe them. CHR offers little strategic or comprehensive direction in this regard.

FSHL manages to tackle each of the eight principles. While it doesn’t explicitly acknowledge health as human right, it does show a strong commitment to equity.  Like CHR it emphasizes the role communities play in reducing inequalities. Outlined in the UK report however is a much more comprehensive strategy for various communities to work from. One that encourages policies which have a “proportionate effect across the social gradient” as well as the lifecourse.

Conclusion:

The true policy implications of both reports remains to be seen. The differences between the two reports and how health inequalities are approached is however, astounding.

Michael Marmot, Chair of the FSHL project, also chaired the WHO’s Commission on Social Determinants of Health (CSDOH). He had a significant role in the release of CSDOH’s final report: Closing the Gap in a Generation, released in August 2008. Fair Society, Healthy Lives is the UK’s response to this report. It could therefore be argued that his perspective is better aligned with the principals of developing research on health inequalities than researchers of CHR. However, Dr. Gail Wilensky is an advisor to the Robert Wood Johnson Foundation and was also a Commissioner on the WHO’s CSDOH.

Moreover, evidence linking social disadvantage to health is not new. It is widely available and in fact, much of the evidence comes from the US. In a background report CHR even makes reference, albeit scant, to the social gradient and Michael Marmot’s work.

Despite their difference in perspective, both reports deserve attention and discussion.

8 Principles for Developing Evidence on the Social Determinants of Health

Two major health inequality reports were recently released, one in the UK and the other in the US. This post is the third in a series which seeks to better understand the health perspective of these reports. In the first post we talked about the implications of how researchers frame their studies. In the second post we discussed the challenges to building evidence on the social determinants of health. In this post we will present 8 principles which help overcome those challenges. These principles will provide the framework by which future posts in the series will evaluate the two reports.

1. A Commitment to the Value of Equity. Research should assert the Right to good health for all populations. Implementation of a human rights approach in health ensures a focus on the broader social determinants of health by establishing a precedent for health campaigns to approach health as a governmental responsibility.

2. Taking an Evidence Based Approach. While the need to take an evidence based approach seems fairly obvious, this principal emphasizes the need to ensure the right types of questions are being asked and appropriate methods are being used to answer them.

3. Methodological Diversity. By nature, the social determinants of health require a wide range of stakeholder efforts. In order to translate evidence into action we need data that demonstrates not only what works, but how and in what circumstances. By expanding our conceptualizations of evidence and drawing on a wide range of research, we are more likely to achieve this.

4. Gradients and Gaps. The starting point for all health inequality research should be the gradient in health equity in a society. Directing attention to the health gradient allows for a focus on all members of society and encourages a societal wide approach to systematic differences in life chances.

5. Causes: Determinants and Outcomes. Addressing health inequalities requires the implementation of specific policies and interventions. For this reason, research should strive to move beyond descriptions of observations to the identification of causal mechanisms which can inform the development of healthy public policy.

6. and 7. Social Structure and Social Dynamics. There are many axes of differentiation in a society. For this reason, Principle 6 emphasizes the need to accurately describe social structures. Principal 7 complements Principle 6 by highlighting the fact that social structures are constantly changing and thus lays the imperative for research to lend itself to that dynamic quality.

8. Explicating Bias. All research is socially constructed and thus subject to bias, from the methodologies chosen to the political value system of the writer.  All biases should be explicated in a way which allows us to understand any political biases inherent in the research, and to determine to what level these biases have influenced the selection and interpretation of the evidence.

These principals were developed by the World Health Organization’s Commission on the Social Determinants of Health, more information can be found here.  In the next post we will begin to look at to what degree Fair Society, Healthy Lives and County Health Rankings adhere to these principles.

Six Challenges that make Developing Evidence on the Social Determinants of Health Difficult

This post is the second post in a series which looks at differences between health inequality research in the UK and the US. The first post in this series can be found here.

Establishing an evidence base on the social determinants of health is essential for the development of responsible public policy. This is because  upstream, macro-level factors operate at a level highly familiar and relevant to the concerns and influence of policy makers. Micro-level determinants of health, like individual behaviors, are in contrast quite removed and of little use to policy makers. In this post we will present six conceptual and theoretical challenges associated with generating, synthesizing and interpreting evidence on the social determinants of health:

  1. While the social determinants of health are systematically associated with a wide variety of health outcomes, the specific casual pathways in which this relationship is maintained are not precisely understood.
  2. Health inequalities are linked to social disadvantage, therefore even when health is improved on a population level, healthy inequalities may persist. This is because the social determinants of health are not necessarily the same as the social determinants of health inequity.
  3. In order to identify and tackle the social determinants of health, we must first know what they are and be able to accurately describe them. However, social differences may be manifested across a variety of axes such as income, education, sex, gender, etc.  These axes intersect, interact, overlap and cluster together in their effect. They change over time and vary across populations. Accurately describing the structure of societies is thus a great challenge.
  4. Evidence on health inequalities is often specific to the context where research is carried out. This makes the transferability of studies difficult. Research carried out on a local level may not be relevant in the context of global inequalities. Alternatively, research carried out with global data makes the application of evidence in a local context equally difficult.
  5. While social hierarchies exist in every society, the steepness of the differences between those at the top and those at the bottom greatly differ. Therefore, the policy implications of  social gradients will too vary considerably.
  6. Knowledge on the social determinants of health must be translated into action. This requires strong commitments at the community level,  multi-disciplinary efforts and focused intentionality.

In the next post, we will identify eight principles which help overcome these difficulties and move the measurement of the social determinants forward. We’ll then use these principles to evaluate two major reviews of health inequalities that were recently released,one in the UK and the other in the US.

Source: here