Critical Perspectives in Public Health

Judith Green, Ronald Labonté, Judith Green, Ronald Labonté, Judith Green, Ronald Labonté

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134130795
• Edition: 1
• Topic: Medicine
• Subtopic: General Health

This book explores the concept of 'critical' public health, at a point when many of its core concerns appear to have moved to the mainstream of health policy. Issues such as addressing health inequalities and their socioeconomic determinants, and the inclusion of public voices in policy-making, are now emerging as key policy aims for health systems across Europe and North America.

Combining analytical introductory chapters, edited versions of influential articles from the journal Critical Public Health and specially commissioned review articles, this volume examines the contemporary roles of 'critical voices' in public health research and practice from a range of disciplines and contexts. The book covers many of the pressing concerns for public health practitioners and researchers including:

• the implications of new genetic technologies for public health
• the impact of globalization on local practice
• the politics of citizen participation in health programmes
• the impact of car-centred transport systems on health
• the ethics of evaluation methods and the persistence of health inequalities.

Critical Perspectives in Public Health is organized into sections covering four key themes in public health: social inequalities; evidence for practice; globalization; technologies and the environment. With contributions from a range of countries including the United States, Canada, the UK, Australia and South Africa, it provides an accessible overview for students, practitioners and researchers in public health, health promotion, health policy and related fields.

Part I
Unfair cases: social inequalities in health

Introduction

Ronald Labonté, John Frank and Erica Di Rug giero

When inequalities become too great, the idea of community becomes impossible.

(Attributed to Raymond Aron)

Neither inequalities in health nor policy and practice attention to their causes and consequences are new. In recent Western history this attention has flared brightest when social inequalities have been greatest: the Industrial Revolution of the nineteenth century (during which Rudolf Virchow, whose hagiography introduced this book, was but one of many radical health reformers), the cyclic crises of capitalism leading to severe economic recession or depression such as the ‘Dirty 30s’ (when texts on poverty and health were commonplace), and the worldwide irruptions caused by rapid economic globalisation beginning in the 1980s, accelerated by the collapse of the Soviet Union. Often this attention distils to a patronising concern for the poor, fomenting ideologically driven debates about whether poverty should be considered in absolute or relative terms (empirical evidence supports the importance of both notions although ‘absolute’ poverty elides most closely with the welfare minimalism of today’s free marketers) or what amount of inequality is good or bad for society or the economy as a whole (too much inequality can cause social disintegration and costly policing intervention, too little can dampen entrepreneurial incentives, leading to slower rates of growth; Anderson and O’Neil 2006), though how much growth is environmentally sustainable is a different and vastly more important question usually bracketed in such debates. David Woodward and Andrew Simms of the UK-based New Economics Foundation, as exceptions to this rule, calculate that during 1990–2001, only 0.6 per cent of global economic growth contributed to poverty reduction, compared with 2.2 per cent in the previous decade. Most of the benefits of growth were captured by elites in wealthier countries, yet the environmental costs of that growth were, and continue to be, borne disproportionately by the world’s poor. The evidence, they conclude, firmly establishes wealth redistribution, rather than continued growth, as the most important means for ‘levelling up’ health equity via poverty reduction (Woodward and Simms 2006).

From inequality to inequity

Woodward’s and Simms’ conclusion has compelling moral argument as well as evidence behind it, but in appraising both we need first to distinguish between inequality and inequity. The former is a stochastic measure of sameness or difference; the latter is a normative valuation of whether the difference is fair or morally acceptable. Health equity is not the same as health equality, since some health inequalities cannot reasonably be described as unfair (e.g., genetic variation, biological sex differences), and some are neither preventable nor remediable, at least given the state of current knowledge. In public health discourse, health equity generally refers to the absence of avoidable or remediable differences in health among populations or groups defined socially, economically, demographically or geographically (Solar and Irwin 2005).

There are many models of equity. One of the simplest distinguishes horizontal from vertical equity. Horizontal equity means that equals are treated the same. For example, as citizens with equal entitlements, all Canadians have the right to access publicly insured health services without financial barriers. They also share equality before the law (though the value of the legal advice they might purchase remains an inequitably allocated market commodity), and the right to cast one, and only one, ballot in an election. Popularised under the rubric ‘equality of opportunity’, horizontal equity pays little attention to gradients of inequality (preferring instead a minimal avoidance of absolute deprivation), and ignores that equal opportunity is only morally justified when individuals have equal pre-existing endowments (which they never do). In real-life conditions, equal opportunity produces increasingly unequal outcomes by positively discriminating in favour of those who already have more resources. Vertical equity, in contrast, enriches horizontal equity (which remains important despite its limitations) by stating that unequals are treated differently. Poorer Canadians suffer poorer health; therefore their average use of health services should be proportionately greater (unequal) than for wealthier Canadians, reversing the well-documented ‘inverse care law’ fi rst noted by Julian Tudor Hart in the UK to describe how the wealthier and healthier consume a disproportionate amount of publicly financed services (Hart 1971). An example of combined horizontal and vertical equity exists in the risk-pooled cross-subsidisation principles for fairness in healthcare financing: the rich and healthy, through taxes or premiums, subsidise the poor and sick (World Health Organization 2000).

Beneath these principles of equity lie arguments rooted in ethics. The public health literature has been substantially enriched in recent years by an expansion of ethics theories that move beyond the individual and biomedical level (with its axioms of beneficence, non-maleficence, autonomy and dignity) to the social and political economy level (where human rights conventions and theories of capabilities, cosmopolitanism and relational justice, to name a few of the more dominant ones, create a messier terrain of social duties or obligations). A rights-based approach bases itself on various legally binding but unenforceable human rights treaties, although such treaties become judiciable when written into national laws (Hunt et al. 2002). Several of these treaties impose obligations on states with respect to health and most of its underlying social determinants (e.g., food, housing, water and environmental and working conditions). Importantly, these treaties do not guarantee a right to health per se; rather, they obligate states and other actors to ensure that all people have fair access to the resources required for health.

In this respect, the rights-based approach resembles the ‘capabilities’ argument advanced by such writers as the Nobel economist Amartya Sen (1999) and the feminist ethicist Martha Nussbaum (1992). This argument urges provision of a number of capabilities essential for people to be healthy. The list of these capabilities reads similarly to the conditions defined under human rights treaties (e.g., reproductive health, adequate nourishment and shelter, adequate education), but with a few novelties: the ability to use one’s imagination, engage in meaningful relationships, emotional development, self-respect/dignity, the ability to play, and control over one’s political and material environments (Nussbaum 2000:78–80). What people do with these capabilities resides in their freedom of choice. Inequalities in health may arise from these choices, but inequities in health are firmly instantiated in unequal access to these capabilities (or, more accurately, to the social basis of these capabilities, which represent the duties of governments and their citizenry). As Nussbaum (2000) comments: ‘The capabilities approach insists that this requires a great deal to make up for differences in starting point that are caused by natural endowment or by power’ – that is, levelling up to compensate for historic inequalities. (‘Levelling up’ refers to lifting the bottom nearer to the top, since improving health equity by levelling those with better health down, towards a median, is both unethical and unlikely.)

Cosmopolitanism extends the fair provision of these capabilities across national borders, positing that ‘principles of justice apply to all persons regardless of wherever they are in the cosmos; and varies from strong demands for fair terms of cooperation on a global scale to at a minimum adherence to the no harm principle’ (Ruger 2006:999). This directs attention to global asymmetries in wealth and power, and a major weakness in our current social order described in the reading by Labonté and Torgerson in Chapter 10: that economic power is global while political power – at least in its formal government rather than governance sense – remains national. Thomas Pogge’s theory of relational justice offers perhaps the most comprehensive synthesis of political economy and philosophical reasoning for consideration at both national and global levels. He argues that a concern with the social distribution (and hence equitable provision) of the prerequisites (or capabilities) for health is insufficient in itself. These inequities did not arise from nothing; they were socially created and are socially maintained. Individuals therefore have a moral obligation to be concerned with their own role in creating and maintaining these inequities through interrogation of evidence and argument about their causal patterns. The stronger an individual’s (or nation’s or other population aggregate of individuals’) involvement in bringing about adverse health outcomes, the greater is their moral obligation to redress them (Anand and Peter 2004:6).

By avoidably producing severe poverty, economic institutions substantially contribute to the incidence of many medical conditions. Persons materiall...

Table of contents

• Contents
• List of illustrations
• Contributors
• Preface: public health as social activism
• Acknowledgements
• Part I Unfair cases: social inequalities in health
• Part II Making traces: evidence for practice and evaluation
• Part III Colonising places: public health and globalisation
• Part IV Edgy spaces: technology, the environment and public health
• Index