The present article identifies how social determinants of health raise two categories of philosophical problems that also fall within the smaller domain of ethics; one set pertains to the philosophy of epidemiology, and the second set pertains to the philosophy of health and social justice. After reviewing these two categories of ethical concerns, the limited conclusion made is that identifying and responding to social determinants of health requires inter-disciplinary reasoning across epidemiology and philosophy. For the reasoning used in epidemiology to (...) be sound, for its scope and (moral) purpose as a science to be clarified as well as for social justice theory to be relevant and coherent, epidemiology and philosophy need to forge a meaningful exchange of ideas that happens in both directions. (shrink)

On August 28, 2008, Michael Marmot, Chair of the Commission on Social Determinants of Health, formally handed over the Commission’s Final Report to Margaret Chan, the Director-General of the World Health Organization, at the Palais des Nations in Geneva. It was a significant moment. Dr. Chan addressed a hall packed with representatives of the world’s communications media in a speech that was remarkably direct. Dr. Chan reiterated the Commission’s position that to improve health and health equity action needs to (...) be taken not just across the health sector but across all social and economic policy areas, and stated, “Social deprivation is not a matter of fate. It is a marker of policy failure.” This was a bold statement from one of the world’s leading diplomats. Policy failure! The phrase echoes the Commission’s assertion that “a toxic combination of poor social policies, unfair economic arrangements and bad politics is killing people on a grand scale.” The Commission’s messages are far reaching. (shrink)

In May 2009 the World Health Assembly passed a resolution on reducing health inequities through action on the social determinants of health, based on the work of the global Commission on Social Determinants of Health, 2005–2008. The Commission's genesis and findings raise some important questions for global health governance. We draw out some of the essential elements, themes, and mechanisms that shaped the Commission. We start by examining the evolving nature of global health and the Commission's foundational inspiration – the (...) universal pattern of health inequity and the imperative, driven by a sense of social justice, to make better and more equal health a global goal. We look at how the Commission was established, how it was structured internally, and how it developed external relationships – with the World Health Organization, with global networks of academics and practitioners, with country governments eager to spearhead action on health equity, and with civil society. We outline the Commission's recommendations as they relate to the architecture of global health governance. Finally, we look at how the Commission is catalyzing a movement to bring social determinants of health to the forefront of international and national policy discourse. (shrink)

Research Group in Global Health: Ethics, Culture and Economics, Department of Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018The WHO Commission on Social Determinants of Health has documented pervasive inequalities in health in many countries. These are clearly associated with unfair distribution of the social determinants of health. Policies directed at reducing this unfair distribution should be promoted across all sectors and institutions responsible for securing equal opportunities and freedom for all citizens. This article argues that such (...) policies will need to balance the competing goals of reducing social group inequalities in health and improving average health. We need a public debate about how to make such difficult choices. This paper outlines a framework that can help us structure our thinking about this dilemma. CiteULike Connotea Del.icio.us What's this? (shrink)

Disparities in socioeconomic status correlate closely with health, so that the lower a person's social position, the worse his health, an effect that the epidemiologist Michael Marmot has labeled the status syndrome. Marmot has argued that differences in autonomy, understood in terms of control, underlie the status syndrome. He has, therefore, recommended that the American medical profession champion policies that improve patient autonomy. In this paper, I clarify the kind of control Marmot sees as connecting differences in (...) socioeconomic status to health disparities. I then discuss his use of Amartya Sen's capabilities approach to justice, arguing that he is unsuccessful in relating autonomy as a descriptive property with a normative framework that can adequately explain why and to what extent we should reduce health disparities. (shrink)

This review essay looks at two important recent books on the empirical social science of inequality, Richard Wilkinson and Kate Pickett's The Spirit Level and John Hills et al .'s Towards a More Equal Society? , situating these books against the important work of Michael Marmot on epidemiology and health inequalities. I argue that political philosophy can gain a great deal from careful engagement with empirical research on the nature and consequences of inequality, especially in regard to empirical work (...) on the relationship between socioeconomic inequality, status, self-respect, domination, autonomy, the quality of social relations, and societal health outcomes. The essay also raises some methodological questions about the approach taken by Wilkinson and Pickett, as well as questioning the ways in which their argument is (or is not) best understood as being fundamentally egalitarian in character. It concludes with some reflections, prompted by Hills et al ., on the lessons that should be learned by egalitarians from the experience of the Blair and Brown governments in the UK. (shrink)

Social factors have a powerful influence on human health and longevity. Yet the social dimensions of health are often obscured in public discussions due to the overwhelming focus in health policy on medical care, individual-level risk factor research, and changing individual behaviours. Likewise, in philosophical approaches to health and social justice, the debates have largely focused on rationing problems in health care and on personal responsibility. However, a range of events over the past two decades such as the study of (...) modern famines, the global experience of HIV/AIDS, the international women’s health movement, and the flourishing of social epidemiological research have drawn attention to the robust relationship between health and broad social arrangements. In Health Justice, Sridhar Venkatapuram takes up the problem of identifying what claims individuals have in regard to their health in modern societies and the globalized world. Recognizing the social bases of health and longevity, Venkatapuram extends the ‘Capabilities Approach’ of Amartya Sen and Martha Nussbaum into the domain of health and health sciences. In so doing, he formulates an inter-disciplinary argument that draws on the natural and social sciences as well as debates around social justice to argue for every human being’s moral entitlement to a capability to be healthy. An ambitious integration of the health sciences and the Capabilities Approach, Health Justice aims to provide a concrete ethical grounding for the human right to health, while advancing the field of health policy and placing health at the centre of social justice theory. With a foreword by Sir Michael Marmot, chair of the WHO Commission on the Social Determinants of Health. (shrink)

The infant mortality rate in Liberia is 50 times higher than it is in Sweden, whilst a child born in Japan has a life expectancy at birth of more than double that of one born in Zambia. 1 And within countries, we see differences which are nearly as great. For example, if you were in the USA and travelled the short journey from the poorer parts of Washington to Montgomery County Maryland, you would find that ‘for each mile travelled life (...) expectancy rises about a year and a half. There is a twenty-year gap between poor blacks at one end of the journey and rich whites at the other’. (Marmot, 2004, p.2). There are two types of questions which it is important to ask about inequalities in health such as these. The first are social scientific questions about the extent of inequalities in health and the factors which are causally responsible for these inequalities. Examples of social scientific questions to ask might be: how do infant mortality rates in the UK differ according to social class? What is the difference in life expectancy between Japanese who emigrate to the US and those who remain in Japan? Why do civil servants in higher ranked jobs tend to live longer than civil servants in lower ranked jobs? The second type are normative questions about the reasons we have to care about inequalities in health. Important normative questions to answer are: which inequalities in health should we care about (all inequalities or merely some of them)? When is an inequality in health unjust? How should we weigh our concern for equality in health against other factors such as maximising the.. (shrink)

Despite the progress made in pediatrics over the past decades, nearly every metric of children’s health and well-being in the United States has deteriorated relative to other high-income Western democracies. This is in part due to American pediatricians’ slow response to the impact of social and environmental determinants on children’s health. It is well established that social and environmental determinants of health—the social, economic, political, environmental, and cultural conditions that influence the health and well-being of individuals and communities—are the primary (...) drivers of contemporary child and adult health and health disparities (ACE Study 2015; CDC 2015; Marmot.. (shrink)

If it is true, as suggested by Sir Michael Marmot and other researchers, that status impacts health and therefore accounts for some of the social gradient in health, then it seems to be the case that it would be possible to bring about more equality in health by equalizing status. The purpose of this article is to analyze this suggestion. First, we suggest a working definition of what status precisely is. Second, following a luck egalitarian approach to distributive justice, (...) we consider whether and to which extent individuals are responsible themselves for their position in a status hierarchy. Third, we consider the contours of a difficult question, namely which political measures are feasible in order to reduce health-affective inequalities in status and fourth, whether or to what extent such measures are legitimate. We argue that on the basis of these considerations, we have at least some prima facie reasons to counter (at least some) status inequalities in order to equalize health. (shrink)