Health and social justice

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How can we understand the relationship between health and social justice? The best place to begin is with our understanding that health is created and distributed in society and not only in the hospital, clinic or research laboratory.

If health is created and distributed in society, what are the ethical implications for that? A profound amount of knowledge has been produced in the field of social epidemiology, a sub-discipline of epidemiology (though some would say that all epidemiology is social). What social epidemiologists study is the causes and distribution of disease and health in people.

Does wealth equal health?

The causes of sickness tend not to be simply biomedical or proximate but include the conditions in which people are born, the conditions that a pregnant woman experiences, the quality of life of a child’s first two years, the households and neighbourhoods in which people grow up, the different political and economic conditions in a particular region, society or state and global factors such as trade and international relations.

What we are finding is that these broad social determinants have a very profound impact on both the causes and the distribution of disease within a society. One of the most profound discoveries over the last three or four decades is that health is distributed in society along a social gradient which parallels what we would call the socioeconomic gradient. If you were to divide up a society into four or five socioeconomic classes according to who has the most power and resources, you’d find that health outcomes are also parallel to that gradient.

A lot of people think about equity and social justice in terms of inequality of resources or power. What we are now also doing is incorporating our understanding of the distribution of health in our societies along this gradient – and making it a question of justice. We need to think about the ethical implications of these health inequalities in society, not just between individuals but between social groups along this gradient.

Obesity and environment

Let’s take as an example the high propensity of obesity in certain cultures. If we only take the view that obesity is about what an individual is eating or drinking and their lack of exercise, our interventions are only going to be about trying to get that individual to change their behaviours and their beliefs. What we mean by addressing social determinants and trying to change the social gradient is that you actually change the environment around those individuals who are affected by obesity.

Do they have access to nutritious food? Or are they eating high-density, high-caloric food because it’s cheaper? In many poor neighbourhoods in the United States, that may be the only type of food people have access to. They may not live near a grocery store that sells nutritious food, but there will almost certainly be places that will sell them cheap food that’s high in carbohydrates and processed sugars. The restaurants may also tend to be poor, nutrition-wise, but they will serve large quantities of affordable food. Therefore, the idea is to change the social conditions so as to improve the options for different individuals, with positive results for their weight, nutrition and exercise levels.

Smart health interventions

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One of the most profound examples of this is the regulation of tobacco, particularly in rich countries such as Australia, the United Kingdom and the United States. Rather than telling individuals to stop smoking and expecting that to be enough, governments have enacted laws that make it impossible or very difficult for cigarette companies to sell tobacco to minors. They are also no longer allowed to advertise cigarette products. These population-level interventions have reduced the number of smokers in these societies by significant levels. That is what we would call a social-level intervention to address a social determinant of disease.

Think about seat belt laws. Rather than telling each individual to wear a seatbelt for their own benefit, when you actually change the background, social norms and conditions, it becomes a successful intervention. Or think about infectious diseases such as HIV and AIDS. One of the things that was profoundly successful was that it wasn’t simply about telling individuals to protect themselves and wear a condom. There were lots of social and structural changes. For example, when it came to gay men at risk of HIV, there were health and medical care services that were specifically targeted at them. The social norms in that community changed so that the use of condoms actually increased.

Re-imagining the causes of health and disease

Rather than emphasising the idea that health is something that happens in the clinic, in the hospital or in the research lab, we should make it clearer that health is actually something that happens in daily life. Then, people will understand the importance of what it is in their neighbourhoods, households and communities that is healthy or that causes diseases.

At the same time, there’s very little an individual or a household can do if they live near a profoundly toxic environment – particularly if their government does not value the health of its people or wish to address health inequalities. Furthermore, there’s very little even a country can do if there are international trade systems that are not supportive of improving health equity in a country. So, while people need to re-imagine and re-understand the causes and distribution of health in their daily lives, the points of intervention actually have to happen at different places. That’s where ethics comes in. An ethical approach facilitates a greater understanding of the places where interventions are needed and increases the chances that such interventions will be successful.

What the WHO can’t do

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Because of the way we have organised our international system, bodies like the World Health Organization can do very little to address these issues. Many people assume that because the WHO is the pinnacle of a health organisation it has a lot of power to determine what countries, organisations or corporations can do; but, in fact, the WHO has very little power. It was set up to give technical assistance to countries and to provide advice on what they can do to improve the health of their citizens. It has very little power to transform international trade regulations, or the way that countries relate to one another, how they conduct war, or how they import or export harmful goods such as tobacco or high-fat food.

An idealistic vision of the healthy society

Now that we are focusing more on society, social organisations and the way that we are being affected by economic policies and political events, the concern for health is becoming a more important part of the democratic process – and a result becomes entangled in political interest groups, power inequalities, historical social inequities and so on.

What can we do? One of the reasons I work in political philosophy and with theories of justice is that we don’t just think about how to achieve a goal like any other lobby group. Rather, we want to raise the debate and the conversation about what a good society looks like and the role of health in that. How can we make sure that health is valued and aspire to move our society in that direction?

Some people believe that this is too idealistic and that we need to be thinking about more political stuff. But one could argue that without an understanding of the ideal in terms of health equity and a society that takes its health seriously, we’re not going to understand what we’re trying to achieve in the short term, in regard to the political fights, addressing lobbying groups and trying to fight interests that are bad for health.

Discover more about

health inequalities in modern society

Venkatapuram, S., Bell, R., & Marmot, M. (2010). The Right to Sutures: Social Epidemiology, Human Rights, and Social Justice. Health and Human Rights, 12(2), 3–16.

Venkatapuram, S. (2013). Subjective wellbeing: a primer for poverty analysts. Journal of Poverty and Social Justice, 21(1), 5–17.

Venkatapuram, S. (2019). Health Disparities and the Social Determinants of Health: Ethical and Social Justice Issues. In A. Mastroianni, J. Kahn, & N. E. Kass (Eds.), The Oxford Handbook of Public Health Ethics. Oxford University Press.

Health inequalities and social justice