Copyright © 2005 by the Johns Hopkins Bloomberg School of Public Health
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Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
Edited by Richard Hofrichter
ISBN 0-7879-6733-5, Jossey-Bass, San Francisco, California (Telephone: 877-762-2974, Website: http://www.josseybass.com/WileyCDA/), 2003, 688 pp., $55 (Paperback)
Health and Social Justice is a useful compendium of new and previously published chapters and papers describing different components of the social determinants of health. The contributors represent many disciplines, each providing an important perspective on the complex interplay of social, economic, cultural, political, demographic, and ethnic factors in influencing health status. Seven of the 27 chapters are new contributions for this volume. Most of the previously published chapters first appeared in the last several years with the exception of Beauchamp’s classic paper, "Public Health as Social Justice: Ideology of Market Imperatives," that first appeared in Inquiry in 1976. The contributors build very effectively on three important movements of the past several decades: the epidemiologic studies illuminating the social gradient in health, the descriptive and analytical studies of health inequalities, and the development of a rights-based approach to analysis of health and human rights problems.
The opening chapter, "The Politics of Health Inequities," is a new contribution by the editor. He provides a comprehensive review of a rich literature that sets the stage very effectively for the rest of the book. Weaving together information about the role of class, race, and gender, Hofrichter develops a compelling case for applying a social justice perspective to health. Most of the great improvements in reducing premature morbidity and mortality in the industrialized world in the past century came about by improvements in the safety and availability of food, potable water and sanitation, reform of child labor, protection of workers, and the introduction of vaccines. However, in the decades since World War II, the United States has emerged as the industrialized society with the greatest income and wealth inequality and a consequent increase in health disparities. The top quintile of Americans now command a greater share of wealth than at any time in 60 years, and almost one fourth of US children live in poverty. Asymmetries of power, ideology, persistent racism and sexism, and problems of environmental justice are exacerbated by growing inequalities of income and wealth. Ironically, our scientific understanding of the social determinants of health has deepened just as the negative influences have worsened. Working people are losing power, and the advances in wage security and workplace safety achieved by strong trade unions are eroding rapidly. The power of large corporations and wealthy individuals has increased to the detriment of health status among the poor. Disinvestment in poor communities, weakening of regulatory structures, tax subsidies for large businesses, constriction of social services, and other assaults on the safety net contribute to growing health disparities. The chapter concludes with a menu of policy options to help develop strategies for achieving health equity. Most are ambitious and would require a sea change of political will before being implemented. They do provide an inspiring vision of what could be done to "shift resources and power toward disadvantaged social populations" (p. 35).
The main body of the book is organized in three sections representing the three general themes that illuminate the links between social justice and health. The first section, "Social Forces Exacerbating Health Inequities," includes chapters describing the ways that health inequities linked to gender, race, and economic status emerge from social, political, and economic influences. Globalization of markets and the expansion of multinational corporations are linked to poverty and health inequity in the United States and around the world. Other chapters focus on zoning and land use as they influence health and the central role that income plays in creating the conditions in which people can be healthy.
The second section, "Theory, Ideology, and Politics: Critical Perspectives," examines the way in which the analysis of health inequalities has itself become a victim of the biomedical model, thus obscuring the underlying hegemonic influences of wealth and power. The contributors to this section examine the ideologies and theories that tend to restrict our ability to think critically about the root causes of health inequalities. Social justice provides a perspective that leads to consideration of the links among asymmetries of power, organization of work, and health inequalities and opens up the possibilities of more fundamental and wide-sweeping social change.
The final section, "Strategies: Perspectives on Social Policy and Practice," includes chapters proposing solutions to the problem of growing health inequalities. The emphasis is on confronting root causes and key determinants that are best understood by applying the principles of social justice. The authors make a compelling argument that structural and institutional changes have to occur to improve the health of vulnerable populations, to dismantle policies that create structural violence, and to reduce health inequalities. Strategies such as income redistribution, welfare services, and better employment opportunities target the root causes of the social determinants of health but often beg the question of how to generate the political will necessary for policy change. Lacking in this section is a detailed analysis of the adoption of a rights agenda to address health inequalities. Even though the United States has failed to ratify the International Covenant on Social, Economic, and Cultural Rights (ICSECR) (and several related covenants on the rights of women and children), many of the Covenant’s premises have taken on the power of customary law for the United States. Moreover, for the 149 nations that have ratified the ICSECR, it has become a centerpiece of international human rights law. The right to health cannot be fulfilled without a government’s commitment to respect and protect basic social and economic rights. The addition of a chapter dealing explicitly with the right to health would have strengthened an already-excellent book.
This book will be a valuable resource for students, teachers, and researchers in social epidemiology and for public health professionals engaged in developing strategies to reduce health inequalities.
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