Is Inequality Bad for Our Health?

by DANIELS, NORMANCOHEN, JOSHUA

• ISBN13: 9780807004470
• ISBN10: 0807004472
• Format: Trade Paper
• Copyright: 2001-09-01
• Publisher: Beacon Press

Summary

In this election year, health care again proves to be one of our nation's most urgent issues. Daniels, Kennedy, and Kawachi shift the focus of the debate, forcing us to take a closer look at how our health is affected by social injustice and inequality. Arguing that it isn't enough to increase access to doctors, they call for improving social conditions-such as poverty, lack of education and affordable housing, and harmful work environments-that damage our health. By urging us to work toward equality of opportunity for all, the authors situate health care reform among the larger social problems we must face. The authors' argument for reform in early childhood development, nutrition, work environment, and distribution of income is certain to spark debate. The editor of The New England Journal of Medicine and World Health Organization officials respond. Praise for the New Democracy Forum series: "The New Democracy Forum series is a civic treasure. . . . A truly good idea, carried out with intelligence and panache."-Robert Pinsky NEW DEMOCRACY FORUM A series of short paperback originals exploring creative solutions to our most urgent national concerns. The series editors (for Boston Review), Joshua Cohen and Joel Rogers, aim to foster politically engaged, intellectually honest, and morally serious debate about fundamental issues-both on and off the agenda of conventional politics.

Table of Contents

Foreword	vii
Armartya Sen
Editors' Preface	xix
Joshua Cohen
Joel Rogers
1
Justice Is Good for Our Health	3	(34)
Norman Daniels
Bruce Kennedy
Ichiro Kawachi
2
Do Inequalities Matter?	37	(5)
Michael Marmot
Pockets of Poverty	42	(6)
Marcia Angell
Equal Opportunity	48	(5)
Sudhir Anand
Fabienne Peter
Policy Options	53	(6)
Ted Marmor
Political Problems	59	(8)
Ezekiel Emanuel
Primary Care	67	(4)
Barbara Starfield
A Health Agenda	71	(8)
Emmanuela Gakidou
Julio Frenk
Christopher Murray
Lost in Translation	79	(6)
Steffie Woolhandler
David Himmelstein
3
Reply	85	(10)
Norman Daniels
Bruce Kennedy
Ichiro Kawachi
Notes	95	(3)
About the Contributors	98

Excerpts

Foreword

AMARTYA SEN

Dr. Samuel Johnson has argued, disputing the claims of equality, that "it is better that some should be unhappy than that none should be happy, which would be the case in a general state of equality." The remark, as it stands, is slightly puzzling, since it is not at all clear why equality must necessarily take the form of everyone being unhappy, rather than everyone being happy. But the remark is also open to another interpretation. Dr. Johnson's point could have been that even though everyone being unhappy would be a state of equality, it would be wrong to celebrate that achievement on that ground, compared with an unequal state where many people are happy though not everyone is (despite the inequality involved). So equality cannot be an adequate basis of judgment, nor a sufficient guide to policy.

    The point, seen in this way, seems fair enough. It would indeed be hard to sing the praise of equality if that meant equal misery for all. However, Dr. Johnson's observation, even when it is interpreted in this more plausible form, raises two other questions.

    The first question is empirical. Can equality be achieved only by making everyone miserable and deprived? Or, more relevantly for practical policy, can inequality be reduced only by making everyone more miserable and deprived? Extending that inquiry, we can also ask: how pervasive is the alleged conflict between distributive and aggregative concerns? Insofar as Dr. Johnson's criticism is meant to be a general indictment of equality (rather than a particular judgment in a specific--and highly specified--case), much would depend on whether the reduction of inequality tends, in general, to make it harder to maintain and enhance efficiency, in the form of aggregative achievements. Dr. Johnson himself was inclined, it would appear, to believe in this kind of a conflict. For example, he responded to Boswell's frustration that "there was no civilized country in the world, where the misery of want in the lowest classes of the people was prevented," by prefacing his remark, quoted earlier, by the observation: "I believe, Sir, there is not." There is an important issue to discuss here about the nature of the world in which we live, about how deep the tensions really are between aggregative and distributive concerns.

    The second issue is evaluational rather than empirical. Dr. Johnson talked about equality of happiness. Is happiness the best focus of attention in discussing equality? Or should it be income, wealth, opportunities, freedoms, or something else? The demands of equality in one "space" need not coincide with--and may even contradict--the requirements of equality in another space. In talking about needs of equality and their implications, we have to be clear what kind of equality should be the focus of our attention. Both issues--aggregative/distributive and the choice of focus--are quite central to the analysis of equality.

Health Equity and

Socioeconomic Inequalities

The essays in this book make a significant contribution to both these issues. It is, in a broad sense, concerned with equity of health and health care. There is no suggestion that this is the only possible focus for analyzing equality, but plenty of reasoning which indicates, directly or indirectly, that this is an important ethical and political issue. The chosen point of departure of the book is the nature and determinants of health equity. In this sense, the collection of essays here is geared to investigating the implications of a particular answer to the "focal choice" question.

    However, the empirical investigation of these implications takes us immediately from one focal space to another. In the principal paper of the volume, Norman Daniels, Bruce Kennedy, and Ichiro Kawachi criticize the tendency of "academic bioethics and popular discussion of health care reform" to concentrate too narrowly on "medicine at the point of delivery," as a result of which they have "inadequately attended to determinants of health `upstream' from the medical system itself" (pp. 32-33). In contrast, they argue, with much evidence, that the social and economic determinants of health are very powerful, and "to act justly in health policy, we must have knowledge about the causal pathways through which socioeconomic (and other) inequalities work to produce differential health outcomes" (p. 19).

    Thus the focus on health equality leads, through causal connections, to a concern for social and economic equalities. In the context of investigating health equity, the interest in the social and economic spaces is derivative, but given the strength of the relations, as Daniels, Kennedy, and Kawachi see them, the need for reducing social and economic inequalities emerges very powerfully for health reasons as well, in addition to its other merits. Also, on this analysis, the tension between choosing one focal space or another tends to be reduced to the extent that equality in one space seems to help promote equality in another.

    In fact, Daniels, Kennedy, and Kawachi provide interesting analyses in linking their empirical conclusions to the influential reasoning on justice and equity presented by John Rawls, whose claim to being the preeminent moral philosopher of our times would be difficult (I believe, almost impossible) to dispute. Daniels, Kennedy, and Kawachi point out that Rawlsian analysis leads to the conclusion that "a social contract designed to be fair to free and equal people would lead to equal basic liberties and equal opportunity and would permit inequalities only when they work to make the worst-off groups fare as well as possible" (p. 17). By combining this view of social justice with the empirical connections between socioeconomic inequalities and health equity, the principal authors identify a "striking result": to wit, "social justice is good for our health" (p. 33).

    There is indeed a striking connection here. But we need to be careful in stating its precise content and implications. To that critical issue, I shall soon return, but first I want to comment on the "aggregative-distributive tension."

Distributive Achievements and

Aggregative Goals

The empirical relationship between social and economic inequalities, on the one hand, and inequalities in the achievement of health, on the other, has received much attention in recent years. As it happens, some of the leading researchers in this field are among the contributors in this volume. As the propositions advanced by Daniels et al. get examined, the nuances of the identified connections receive pointed attention. One aspect of the findings that is particularly relevant is, as Sir Michael Marmot puts it, "where health inequalities are greatest, overall health status of the population is lower." Indeed, it is "difficult to lower the coronary heart disease mortality of the population if only part of the population is experiencing improvement" (Marmot, "Do Inequalities Matter?," p. 38).

    This class of findings bears directly on the aggregative-distributive tension. Aggregate health is often best advanced by concentrating on the poorest, since this is where there is most scope for gaining further ground; but that very policy will have the effect of reducing distributive inequality as well. Thus the alleged tension between the two objectives may be far weaker than is often presumed. When we add to this the further fact that some ailments are linked through infectious spread (from cholera to AIDs), or through shared behavioral modes where one person's conduct influences another's (from smoking to high-fat food habits), it is easy to see that the complementarity between distributive and aggregative concerns can be even stronger. The attention that is frequently heaped on the allegedly pervasive implications of the distributive-aggregative tension may not always be justified.

Health Equity and Overall Justice

Even though most of the commentators are broadly in agreement with the empirical basis of the arguments presented by Daniels et al., the commentators have presented some interesting questions about the main conclusions of the principal authors, who in turn have provided a spirited response. The disputations are clear and engaging, and I leave the reader to judge what they make of these critical--and invariably interesting--arguments.

    However, I should briefly return to the "focal choice" issue. It is possible to argue that the principal authors may be a little too readily inclined to conclude that all roads lead to Rome, which in this case is John Rawls's theory of justice. Michael Marmot ("Do Inequalities Matter?") as well as Sudhir Anand and Fabienne Peter ("Equal Opportunity") have commented on some distinctions that the principal authors seem to overlook or underplay, and to those observations, the principal authors have given their reply. While readers will have to judge for themselves whether they are more convinced by the questions raised or by the answers given, I may take the liberty of commenting on some distinctions that, I would argue, should not be lost, or even distanced.

    First, John Rawls's focus in his distributive maxim (the Difference Principle) is primarily on the distribution of resources (or "primary goods," as he calls them, such as income or health care), rather than the consequent achievements or the resulting freedoms of the individuals involved (such as good health or the capability to achieve good health). There is a significant distinction here that does not vanish merely because income, health care, and other resources tend to enhance health. Indeed, it is precisely because of these general connections between resource and achievements that resources are regarded as valuable at all. However, other factors, such as individual characteristics, climatic surroundings, regional epidemiology, etc., also influence health achievements. The fact that many of these influences cannot be picked up in some types of statistical analyses involving grouped data (particularly when the grouping is not linked to categories of epidemiological significance) is neither here nor there. But it could not be assumed that the elementary linkage between socioeconomic inequality and health achievement entails that there are no other influences on the achievement of health. An adequate policy approach to health has to take note not only of the influences on which this book concentrates, but also of a variety of other parameters, such as individually inherited proneness to disease, individual characteristics of disability, epidemiological hazards of particular regions, the influence of climatic variations, and so on.

    Generally speaking, in making health policy, there is a need to distinguish resource-orientation from result-orientation, and in particular between equality in health achievements (or corresponding freedoms) and equality in the distribution of what can be generally called health resources. Daniels's own attempt to include something of the former within the domain of "equality of opportunity" has many commendable features. But it does not eliminate the fact that the two perspectives of "resource-orientation" and "result-orientation" can sharply differ. This empirical recognition is completely independent of which perspective--whether Rawlsian or not--that we use to interpret any particular dictum of the theory of justice.

    Second, some difference is made also by how exactly inequality is seen. In the Rawlsian approach, the focus is entirely on the worst-off individuals. In comparing two groups, only if the worst-off individuals in the two groups happen to be equally badly off are we allowed to look at the distributional characteristics of others in the respective groups. But as the famous Black Report in Britain had brought out, and indeed as Daniels, Kennedy, and Kawachi summarize it, "differences in health outcome are not confined to the extremes of rich and poor but are observed across all levels of socioeconomic status" (p. 11). Concentrating merely on the worst-off individuals (or groups of individuals) gives us, therefore, a less sensitive measure of inequality than we need for relating socioeconomic inequality to health inequality.

    Third, the different components of socioeconomic affluence do not always move together. As Michael Marmot's work has shown, and as is rightly quoted by Daniels, Kennedy, and Kawachi, "steep gradients have been observed even among groups of individuals, such as British civil servants, who all have adequate access to health care, housing, and transport" (p. 11). It is, of course, possible to aggregate the socioeconomic advantages exclusively in terms of their health effects (as if social and economic inequality matters only for their induced effects on health), but since these advantages also differentiate our lives in other ways as well, the health-effect-based aggregation need not coincide with other ways of taking note of economic affluence or social advantage. In this sense, the conclusion of the principal authors that "health is the by-product of justice" (p. 32) oversimplifies the demands of health equity vis-à-vis the extensive requirements of social justice. There are choices that remain, and they demand recognition.

    Finally, even though the principal authors are right to stress the need to avoid overconcentration on "medicine at the point of delivery" (paying inadequate attention to the "determinants of health `upstream' from the medical system itself"), there are policy decisions to be made on the relative emphases to be placed on the two different kinds of determinants of health. Some countries or regions--from Costa Rica to Kerala in India--have achieved spectacular results in health improvement by enhancing health delivery (despite low income levels), and this issue remains alive today in the world, not least in the United States, where the entitlement to health delivery is still very unequally organized. This has some connection, along with other factors, with the remarkable fact that the people of Kerala, who are extremely poor in comparison with many American groups (including African-Americans), still live longer than these more economically affluent groups do. In emphasizing an underemphasized route to good health, we should not undermine other routes that also need attention.

A Concluding Remark

The point of making these distinctions is not, in any way, to reduce the importance of the empirical connections on which Daniels, Kennedy, and Kawachi base their analysis, nor to slight the important point that many of the tensions that are discussed abstractly in political philosophy or in policy making are substantially reduced in reality by the presence of these positive relations. Both the focal choice question and the distributive-aggregative tension are made less divisive as a result of these findings, on some of which I have commented. This is a more modest recognition than some claims that the principal authors have advanced, but it is nevertheless an extremely important part of an adequate understanding of the demands of health policy.

    Many further distinctions remain, and the conflicting demands on policy making are not eliminated by the connections identified. But the principal authors are entirely right to argue that the conflict's may be far less severe than is frequently presumed. The complementarity between health equity and other kinds of justice is also a striking recognition. There is no real congruence here, but complementarity is itself an important connection.

    In this timely and important book, the principal authors and the commentators have significantly enriched our understanding of the complementarities involved and their extensive implications for policy as well as theory. We have much reason to be grateful.

Preface

EDITORS' PREFACE

JOSHUA COHEN AND JOEL ROGERS

Reforming America's exclusionary health care system was one of Bill Clinton's first priorities as president. Clinton's plan collapsed, and eight years later more than 4o million Americans are still uninsured. But if this New Democracy Forum's lead article by Norman Daniels, Bruce Kennedy, and Ichiro Kawachi is right, something worse than the defeat of health care reform happened to public health over the past decade.

    Drawing on a wide range of epidemiological studies, Daniels, Kennedy, and Kawachi argue that socioeconomic inequality itself is bad for our health: it is healthier to have higher income and live in a wealthier country, but also to live in a more equal society . So inequality--which has grown substantially since the 1970s--is arguably the dominant public health problem. From this striking assertion it follows that we need to broaden the terms of the health care debate, to shift away from an exclusive focus on expanding access to care (as important as that is) and toward redressing underlying socioeconomic inequality--through early childhood intervention, improved nutrition, better working conditions, and income redistribution.

    The respondents to Daniels, Kennedy, and Kawachi dispute their analytical claims and political conclusions. Analytically, respondents ask how exactly inequality--as distinct from concentrations of poverty--produces bad health. And they also question the importance of inequality, as opposed to access to care, in explaining public health. On the practical side, several argue that changing the distribution of income maybe far less feasible than improving access (especially to primary care). So even if economic justice might deliver greater gains, we are more likely to get improvements by concentrating on better access. These critics suggest that Daniels, Kennedy, and Kawachi are making the best the enemy of the good.

    This disagreement is important. More important, though, is a point of agreement: that great social inequalities are unhealthy. And yet, for all the present talk of "health care reform" and the importance of the issue for Americans, this basic point is virtually absent from public debate.

Copyright © 2000 Joshua Cohen and Joel Rogers. All rights reserved.