International Journal of Epidemiology Volume: 33, Issue: 5, October 01,

2004, pp. 1159-1160

Gruskin, Sofia



Health and Social Justice: Politics, Ideology and Inequity

in the Distribution of Disease. Richard Hofrichter (ed.):

San Francisco, CA: Jossey-Bass, John Wiley and Sons, 2003,

pp. 688, £34.50 (PB) ISBN: 0787967335.



Health and Social Justice brings together a broad range of

contributions from many of the fields of public health

concerned with addressing health inequities. The book contains

both new and reprinted material, and is organized in four parts.

It is extremely comprehensive and its 27 chapters bring together

the writings of some of the most incisive and well-known

authors in the area. This volume is unapologetic in bringing

together readings that share a similar ideological construct—

that the determinants of health are more than individual

behaviour and the delivery of services but are grounded in

larger economic, political, social and cultural factors. No one in

the field could disagree with the book’s underlying premise or

motivation—a point of view this reviewer entirely shares. There

is, nonetheless, an assumption of common knowledge and a

common perspective evident throughout the text, and no

attempt is made to convince the sceptical reader.



An introductory essay by the editor forms the basis for the

book, and lays out the arguments and concepts picked up again

by authors in subsequent sections. The first selection of readings

is intended to bring together writings on health inequities as

they are influenced by political, economic, and social forces,

while the second claims to provide an exploration of some of

the key ideologies and paradigms that obscure the underlying

causes of these inequities and limit the potential for a

co-ordinated public response. The final section asserts a focus

on actions that can help to reduce or eliminate these inequities.



While authors come from a number of different countries, the

bulk of readings are focused on the US and Canada, even

as efforts are made throughout the text to bring to light the

linkages between the realities experienced in these countries

and those experienced by the rest of the world, as well as to

draw attention to the negative impacts on health in other parts

of the world resulting from US policies. Of note in this regard

are the ways in which, taken as a whole, the text manages to

show how out of step current US health policies are with those

of other governments, including other resource-rich countries.



The book is focused on politics and power and their influence

on inequities in health as well as their ultimate import in how

these inequities are addressed. The term social justice is presented

as the framework for understanding how to think about health

inequities as well as to define the strategies best suited to address

them. The opening essay presents social justice as ‘[ ] an ongoing

series of relationships that permeate everyday life,’ and frames

the application of a social justice framework in opposition to

inequality and support for the ‘empowerment of all social

members, along with democratic and transparent structures to

promote social goals’. This approach is interesting in that it goes

beyond traditional definitions of the term and opens the way for

attention to a range of disciplines and methods with concern for

the public’s health. That being said, it is very unclear why a reader

which implicitly draws so much from the human rights

framework in terms of analysis, process, and approach has given

no explicit space to what this framework can offer to addressing

health inequities. The text names some of the foundations for

health—food, shelter, safe water—all of which are recognized

rights constituting in one way or another the legal obligations of

every government in the world in relation to health and wellbeing.



It focuses also on the components that are central to the

application of a human rights framework to health programming:

equality, participation, transparent and functioning processes, and

the accountability of the institutions and structures that impact

on health. Yet not a single essay concerns the contribution that a

human rights framework can make to these issues, and even more

perplexing is the well-intentioned statement by the editor in the

opening essay of the need for a ‘rights-based approach to public

health [ ] one that sees health as a social and not merely an

individual right’ to help address inequities in health. This

statement is unfortunately presented with insufficient

understanding of what this entails, where there are parallels with

the approaches being put out, as well as where there are potential

disagreements. This is particularly puzzling given the 15 years or

so of scholarship in this area which elaborate many of the points

raised in the opening essay and throughout the reader.



The attention in both the opening piece and the chapters that

follow to the particular impact of inequities in class, race, and

gender on inequities in health is very much of its time, and is

clearly and appropriately the mantra of the decade. Nonetheless,

a more systematic exploration of how these forms of inequity act

in synergy with each other as well as with other forms of inequity

such as on the basis of age, disability, or pre-existing health status

is long overdue. As many of the pieces named the importance

of these linkages and their conceptualization for health, it was

disappointing to see that ultimately they ended up addressing

them separately. This quibble is not merely rhetorical, I fear even

the best of intended public health strategies will end up with less

than desired results until our multiple forms of identity and the

linkages between them are adequately addressed. Systematic

attention is needed as to how the combination of factors that

shape a person’s life can impact not only on what services are

made available to them but the constraints in their being able to

access these services even when they are available. This volume

presents many of the thinkers at the forefront of progressive

public health approaches, and my plea is for more individual and

collective attention to the need to systematically grapple with this

unfortunate reality.



Despite the issues raised here, the value of this text is clear.

Hofrichter is to be congratulated for assembling a reader that will

be of use not only to better understanding inequities in health,

but to critical thinking and approaches to better address them.

SOFIA GRUSKIN