American Journal of Epidemiology 2005 161(4):399-400;

Lawrence, R. S.



BOOK REVIEWS



Health and Social Justice: Politics, Ideology, and Inequity in the

Distribution of Disease

Robert S. Lawrence

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.