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Justice is Good for Our Health

How greater economic equality would promote public health.

Norman Daniels, Bruce Kennedy, Ichiro Kawachi

We have long known that the more affluent and better-educated members of a society tend to live longer and healthier lives: René Louis Villermé made this point as early as 1840, and it has been shown to hold for just about every human society. Recent research suggests that the correlations between income and health do not end there. We now know, for example, that countries with a greater degree of socioeconomic inequality show greater inequality in health status; also, that middle-income groups in relatively unequal societies have worse health than comparable, or even poorer, groups in more equal societies. Inequality, in short, seems to be bad for our health.

Moreover, and perhaps more surprisingly, universal access to health care does not necessarily break the link between social status and health. Our health is affected not simply by the ease with which we can see a doctor--though that surely matters--but also by our social position and the underlying inequality of our society. We cannot, of course, infer causation from these correlations between social inequality and health inequality (though we will explore some ideas about how the one might lead to the other). Suffice to say that, while the exact processes are not fully understood, the evidence suggests that there are social determinants of health.

These social determinants offer a distinctive angle on how to think about justice, public health, and reform of the health care system. If social factors play a large role in determining our health, then efforts to ensure greater justice in health care should not focus simply on the traditional health sector. Health is produced not merely by having access to medical prevention and treatment, but also, to a measurably greater extent, by the cumulative experience of social conditions over the course of one’s life. By the time a sixty-year-old heart attack victim arrives at the emergency room, bodily insults have accumulated over a lifetime. For such a person, medical care is, figuratively speaking, "the ambulance waiting at the bottom of the cliff." Much contemporary discussion about reducing health inequalities by increasing access to medical care misses this point. We should be looking as well to improve social conditions--such as access to basic education, levels of material deprivation, a healthy workplace environment, and equality of political participation--that help to determine the health of societies.

These conditions have unfortunately been virtually ignored within the academic field of bioethics, and in public discussions about health care reform. Academic bioethics is quick to focus on exotic new technologies and the vexing questions they raise for doctors and health administrators, who must make decisions about patient care and the allocation of scarce medical resources. And we all worry about the doctor-patient relationship under managed care, as insurance companies have taken a newly aggressive role in making medical decisions. But with some significant exceptions neither academic nor popular discussion has looked "upstream," past the new technologies, managed care, and the organization of health insurance, to the social arrangements that determine the health achievement of societies.

We hope to fill this gap by exploring some broader issues about health and social justice. To avoid vague generalities about justice, we shall advance a line of argument inspired principally by the theory of "justice as fairness" put forth by the philosopher John Rawls.1 We find Rawls’s theory compelling as an account of justice quite apart from its usefulness as an approach to the health care issue. But even those who do not share our ideas about justice may find our argument a helpful first step in thinking about social justice and public health.

Rawls’s theory of justice as fairness was not designed to address issues of health care. He assumed a completely healthy population, and argued that a just society must assure people equal basic liberties, guarantee that the right of political participation has roughly equal value for all, provide a robust form of equal opportunity, and limit inequalities to those that benefit the least advantaged. When these requirements of justice are met, Rawls argued, we can have reasonable confidence that others are showing us the respect that is essential to our sense of self-worth.

Recent empirical literature about the social determinants of health suggests that the failure to meet Rawlsian criteria for a just society is closely related to health inequality. The conjecture we propose to explore, then, is that by establishing equal liberties, robustly equal opportunity, a fair distribution of resources, and support for our self-respect--the basics of Rawlsian justice--we would go a long way to eliminating the most important injustices in health outcomes. To be sure, social justice is valuable for reasons other than its effects on health. And social reform in the direction of greater justice would not eliminate the need to think hard about fair allocation of resources within the health care system. Still, acting to promote social justice may a key step toward improving our health.


Social Determinants of Health
Let’s take a closer look at some of the central findings in the recent literature on the social determinants of health, each of which has implications for an account of justice and health inequalities.

Cross-national inequalities
A country’s prosperity is related to its health, as measured, for example, by life expectancy: in richer countries people tend to live longer. This well-established finding suggests a natural ordering of societies along some fixed path of economic development: as a country or region develops economically average healthimproves.

But the evidence suggests that things are more complicated. Figure 1 shows the relationship between the wealth of nations, as measured by per capita gross domestic product (GDPpc), and the health of nations, as measured by life expectancy. Clearly, GDPpc and life-expectancy are closely associated, but only up to a point. The relationship levels off when GDPpc reaches $8,000 to $10,000; beyond this threshold, further economic advance buys virtually no further gains in life expectancy. This leveling effect is most apparent among the advanced industrial economies (see Figure 2), which largely account for the upper tail of the curve in Figure 1.

Closer inspection of these two figures shows some startling discrepancies. Though Cuba and Iraq are equally poor (each has a GDPpc of about $3,100), life-expectancy in Cuba exceeds that in Iraq by 17.2 years. The difference between the GDPpc for Costa Rica and the United States is enormous (about $21,000), yet Costa Rica’s life-expectancy exceeds that of the United States (76.6 to 76.4). In fact, despite being the richest nation on the globe, the United States performs rather poorly on major health indicators.

Taken together, these observations show that the health of nations may depend, in part, on factors other than wealth. Culture, social organization, and government policies also help determine population health, and variations in these factors may explain many of the differences in health outcomes among nations.

Relative income
One especially important factor in explaining the health of a society is the distribution of income: the health of a population depends not just on the size of the economic pie, but on how the pie is shared. Differences in health outcomes among developed nations cannot be explained simply by the absolute deprivation associated with low economic development--lack of access to the basic material conditions necessary for health such as clean water, adequate nutrition and housing, and general sanitary living conditions. The degree of relative deprivation within a society also matters.

Numerous studies have provided support for this relative-income hypothesis, which states, more precisely, that inequality is strongly associated with population mortality and life-expectancy across nations. To be sure, wealthier countries generally have higher average life expectancy. But rich countries, too, vary in life-expectancy (see the tail of Figure 1), and that variation dovetails with income distribution. Wealthy countries with more equal income distributions, such as Sweden and Japan, have higher life-expectancies than does the United States, despite their having lower per capita GDP. Likewise, countries with low GDPpc but remarkably high life-expectancy, such as Costa Rica, tend to have a more equitable distribution of income.2

We find a similar pattern when we compare states within the United States. Wealthier states typically have lower mortality rates. But if we control for differences in state wealth, income inequality accounts for about 25 percent of the between-state variation in age-adjusted mortality rates. Furthermore, a recent study across US metropolitan areas found that areas with high income inequality had an excess of death compared to areas with low inequality. This excess was very large, equivalent in magnitude to all deaths due to heart disease.3

Most of the evidence for this pattern comes from cross-sectional studies, which compare different places (countries, states, metropolitan areas) at a single point in time. But longitudinal studies, which look at a single place over time, support similar conclusions. Widening income differentials in both the United States and the United Kingdom have coincided with a slowing down of improvements in life-expectancy. In many of the poorest areas of the United Kingdom, the mortality rate for several cohorts of relatively young people has increased as income inequality widened. In the United States between 1980 and 1990, states with the highest income inequality showed slower rates of improvement in average life-expectancy than did states with more equitable income distributions.4

Individual SES
Finally, when we move from comparing whole societies to comparing their individual members, we find, once more, that inequality is important. At the individual level, numerous studies have documented what has come to be known as the socioeconomic gradient: at each step along the socioeconomic ladder, we see improved health outcomes over the rung below. This suggests that differences in health outcomes are not confined to the extremes of rich and poor, but are observed across all levels of socioeconomic status.5

Moreover, the SES gradient does not appear to be explained by differences in access to health care. 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.6

The slope of the gradient varies substantially across societies. Some societies show a relatively shallow gradient in mortality rates: being better off confers a health advantage, but not so large an advantage as elsewhere. Others, with comparable or even higher levels of economic development, show much steeper gradients. The slope of the gradient appears to be fixed by the level of income inequality in a society: the more unequal a society is in economic terms, the more unequal it is in health terms. Moreover, middle income groups in a country with high income inequality typically do worse in terms of health than comparable or even poorer groups in a society with less income inequality. We find the same pattern within the United States when we examine state and metropolitan area variations in inequality and health outcomes.7

Pathways
Earlier, we cautioned that correlations between inequality and health do not necessarily imply causation. Still, there are plausible and identifiable pathways through which social inequalities appear to produce health inequalities. In the United States, the states with the most unequal income distributions invest less in public education, have larger uninsured populations, and spend less on social safety nets. The facts on educational spending and educational outcomes are especially striking: controlling for median income, income inequality explains about 40 percent of the variation between states in the percentage of children in the fourth grade who are below the basic reading level. Similarly strong associations are seen for high school drop-out rates. It is evident from these data that educational opportunities for children in high-income-inequality states are quite different from those in states with more egalitarian distributions. These effects on education have an immediate impact on health, increasing the likelihood of premature death during childhood and adolescence (as evidenced by the much higher death rates for infants and children in the high inequality states). Later in life, they appear in the SES gradient in health.

When we compare countries, we also find that differential investment in human capital--in particular, education--is a strong predictor of health. Indeed, one of the strongest predictors of life-expectancy among developing countries is adult literacy, particularly the disparity between male and female adult literacy, which explains much of the variation in health achievement among these countries after accounting for GDPpc. For example, among the 125 developing countries with GDPpcs less than $10,000, the difference between male and female literacy accounts for 40 percent of the variation in life-expectancy after factoring out the effect of GDPpc. The fact that gender disparities in access to basic education drives the level of health achievement further emphasizes the role of broader social inequalities in patterning health inequalities. Indeed, in the United States, differences between the states in women’s status--measured in terms of their economic autonomy and political participation--are strongly correlated with higher female mortality rates.

These societal mechanisms--for example, income inequality leading to educational inequality leading to health inequality--are tightly linked to the political processes that influence government policy. For example, income inequality appears to affect health by undermining civil society. Income inequality erodes social cohesion, as measured by higher levels of social mistrust and reduced participation in civic organizations. Lack of social cohesion leads to lower participation in political activity (such as voting, serving in local government, volunteering for political campaigns). And lower participation, in turn, undermines the responsiveness of government institutions in addressing the needs of the worst-off. States with the highest income inequality, and thus lowest levels of social capital and political participation, are less likely to invest in human capital and provide far less generous social safety nets.8

In short, the case for social determinants of health is strong. What are the implications of this fact for ideas of justice?


Inequalities and Inequities
When is a health inequality between two groups "inequitable"? Margaret Whitehead and Goran Dahlgren have suggested a useful and influential answer: health inequalities count as inequities when they are avoidable, unnecessary, and unfair.9

The Whitehead/Dahlgren analysis is deliberately broad. Age, gender, race, and ethnic differences in health status exist independent of the socioeconomic differences we have been discussing, and they raise distinct questions about equity. For example, should we view the lower life expectancy of men compared to women in developed countries as an inequity? If it is rooted in biological differences that we do not know how to overcome, then it is unavoidable (and therefore not an inequity). This is not an idle controversy: taking average, rather than gender-differentiated, life expectancy in developed countries as a benchmark will yield different estimates of the degree of inequity women face in some developing countries. In any case, the analysis of inequity is only as good as our understanding of what is avoidable or unnecessary.

The same point applies to judgments about fairness. Is the poorer health status of groups whose members smoke and drink heavily unfair? We may be inclined to say it is not unfair, provided that participation in such risky behaviors is truly voluntary. But if many people in a cultural group or class behave similarly, then the behavior might acquire the qualities of a social norm--in which case we might wonder just how voluntary the behavior is (and therefore how much responsibility we should ascribe to them for it). Whitehead’s and Dahlgren’s terms leave us with an unresolved complexity of judgments about responsibility, and, as a result, with disagreements about fairness and avoidability.

The poor in many countries lack access to clean water, sanitation, adequate shelter, basic education, vaccinations, and prenatal and maternal care. As a result of some, or all, of these factors, infant mortality rates for the poor exceed those of the rich. Since social policies could supply the missing determinants of infant health, these inequalities are avoidable.

Are these inequalities also unfair? Most of us would think they are, perhaps because we believe that policies that create and sustain poverty are unjust, and perhaps also because we object to social policies that compound economic poverty with lack of access to the determinants of health. The problem of justice in health care becomes more complicated, however, when we remember one of the basic findings from the literature on social determinants: we cannot eliminate health inequalities simply by eliminating poverty. Health inequalities persist even in societies that provide the poor with access to all standard public health and medical services, as well as basic income and education health, and they persist as a gradient of health throughout the social hierarchy, not just between the very poorest groups and those above them.

What, then, are we to think of the health inequalities that would persist, even if poverty were eliminated? To eliminate health inequalities, should we eliminate all socioeconomic inequalities? We might believe that all socioeconomic inequalities, or at least all inequalities we did not freely choose, are unjust--but very few embrace such a radical egalitarian view. Indeed, we may well believe that some degree of socioeconomic inequality is unavoidable, or even necessary, and therefore not unjust. On issues of this kind, we should take guidance from a well-articulated account of social justice--the one put forth by John Rawls.


Justice as Fairness
In A Theory of Justice,Rawls sought to show 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. Though Rawls’s account was devised for the most general questions of social justice, it also provides a set of principles for the just distribution of the social determinants of health.

Rawls did not talk about disease or health in his original account. To simplify the construction of his theory, he assumed that his contractors were fully functional over a normal life span--no one becomes ill or dies prematurely. This idealization provides a clue about how to extend this theory to the real world of illness and premature death. The goal of public health and medicine is to keep people as close to the idealization of normal functioning as possible under reasonable resource constraints. Maintaining normal functioning, in turn, makes a limited but significant contribution to protecting the range of opportunities open to individuals. So one might see the distribution of health care as governed by a norm of fair equality of opportunity.

We can now say more directly why justice, as described by Rawls’s principles, is good for our health.

Let us start by considering what a just society would require with regard to the distribution of the social determinants of health. In such an ideal society, everyone is guaranteed equal basic liberties, including the right to participate in politics. In addition, there are safeguards aimed at assuring for all, whether richer or poorer, the worth or value of those rights. Since, as we argued above, there is evidence that political participation is a social determinant of health, the Rawlsian ideal assures institutional protections that counter the usual effects of socioeconomic inequalities on participation--and thus on health.

Moreover, according to Rawls, justice requires fair equality of opportunity. This principle condemns discriminatory barriers and requires robust measures aimed at mitigating the effects of socioeconomic inequalities and other contingencies on opportunity. In addition to equitable public education, such measures would include the provision of developmentally appropriate day care and early childhood interventions intended to promote the development of capabilities independently of the advantages of family background. Such measures match, or go beyond, the best models of such interventions currently in place, such as European efforts at day care and early childhood education. We also note that the strategic importance of education for protecting equal opportunity has implications for all levels of education, including access to graduate and professional education.

The equal opportunity principle also requires extensive public health, medical, and social support services aimed at promoting normal functioning for all. It even provides a rationale for the social costs of reasonable accommodation to incurable disabilities, as required by the Americans with Disabilities Act. Because the equal opportunity principle aims at promoting normal functioning for all as a way of protecting opportunity for all, it at once aims at improving population health and the reduction of health inequalities. Obviously, this focus requires provision of universal access to comprehensive health care, including public health, primary health care, and medical and social support services.

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. Suppose we learn, for example, that workplace organization induces stress and a loss of control, and that these tend, in turn, to promote health inequalities. We should then think of modifying those features of work place organization in order to mitigate their negative effects on health as a public health requirement of the equal opportunity approach.

Finally, a just society restricts allowable inequalities in income and wealth to those that benefit the least advantaged. The inequalities allowed by this principle--in conjunction with the principles assuring equal opportunity and the value of political participation--are probably more constrained than those we observe in even the most industrialized societies. If so, just inequalities would produce a flatter gradient of health inequality than we currently observe in even the more extensive welfare systems of Northern Europe.

In short, Rawlsian justice--though not devised for the case of health--regulates the distribution of the key social determinants of health, including the social bases of self respect. There is nothing about the theory that should make us focus narrowly on medical services. Properly understood, justice as fairness tells us what justice requires in the distribution of all socially controllable determinants of health.

We still face a theoretical issue of some interest. Even if a just distribution of the determinants of health flattens health gradients further than what we observe in the most egalitarian, developed countries, we must still expect a residue of health inequalities: people who are less well-off in economic terms will continue to be less healthy. Should we aim to reduce further those otherwise justifiable economic inequalities because of the inequalities in health status they create?

Suppose we reduce socioeconomic inequalities, and thereby reduce health inequalities--but the result is that the health of all is worsened because productivity is reduced so much that important institutions are undermined. That is not acceptable. Our commitment to reducing health inequality should not require steps that threaten to make health worse off for those with less-than-equal health status. So the theoretical issue reduces to this: would it ever be reasonable to allow some health inequality in order to produce some non-health benefits for those with the worst health prospects?

We know that in real life people routinely trade health risks for other benefits. They do so when they commute longer distances for a better job or take a ski vacation. Trades of this kind raise questions of fairness. For example, when is hazard pay a benefit workers gain only because their opportunities are unfairly restricted? When is it an appropriate exercise of their autonomy? Some such trades are unfair; others will only be restricted by paternalists.

Rawls gave priority to the principle of protecting equal basic liberties because he believed that once people achieve some threshold level of material well being, they will not trade away the fundamental importance of liberty for other goods. Making such a trade might deny them the liberty to pursue their most cherished ideals, including their religious beliefs, whatever they turn out to be. Can we make the same argument about trading health for other goods?

There is some plausibility to the claim that rational people should refrain from trading their health for other goods. Loss of health may preclude us from pursuing what we most value in life. We do, after all, see people willing to trade almost anything to regain health once they lose it.

Nevertheless, there is also strong reason to think this priority is not clear-cut, especially where the trade is between a risk to health and other goods that people highly value. Refusing to allow any (ex ante) trades of health risks for other goods, even when the background conditions on choice are otherwise fair, may seem unjustifiably paternalistic, perhaps in a way that refusals to allow trades of basic liberties is not.

We propose a pragmatic route around this problem. Fair equality of opportunity is only approximated even in an ideally just system, because we can only mitigate, not eliminate, the effects of family and other social contingencies. For example, only if we were willing to violate widely respected parental liberties could we intrude into family life and "rescue" children from parental values that arguably interfere with equal opportunity. Similarly, though we give a general priority to equal opportunity over the Difference Principle, we cannot achieve complete equality in health any more than we can achieve completely equal opportunity. Justice is always rough around the edges.

Suppose, then, that the decision about trade-offs is made by the legislature in a democratic society where everyone has a fair chance to participate. Because those principles require effective political participation across all socioeconomic groups, we can suppose that groups most directly affected by any trade-off decision have a voice in the decision. Since there is a residual health gradient, groups affected by the trade-off include not only the worst off, but those in the middle as well. A democratic process that involved deliberation about the trade-off and its effects might be the best we could do to provide a resolution of the unanswered theoretical question.

In contrast, where the fair value of political participation is not adequately assured--and we doubt it is so assured in even our most democratic societies--we have much less confidence in the fairness of a democratic decision about how to trade health against other goods. It is much more likely under actual conditions that those who benefit most from the inequalities--that is, those who are better off--also wield disproportionate political power and will influence decisions about trade-offs to serve their interests. It may still be that the use of a democratic process in non-ideal conditions is the fairest resolution we can practically achieve, but it still falls well short of what an ideally just democratic process involves.

If we were to achieve a just distribution of resources, then, with the least well-off being as well off as possible, there would still be health inequalities. But decisions about whether to reduce those inequalities even more are matters for democratic process. Justice itself does not command their reduction.

Policy Implications
We earlier suggested that the Whitehead/Dahlgren analysis of health inequities (inequalities that are avoidable and unfair) is useful. We then suggested that the Rawlsian account of justice as fairness provides a fuller account of what is fair and unfair in the distribution of the social determinants of health. The theory provides a more systematic way to think about which health inequalities are inequities. And it delivers the conclusion that most health inequalities that we now observe world wide among socioeconomic and racial or ethnic groups are "inequities" that should be remedied. Even the countries with the shallowest health gradients, such as Sweden and England, have viewed their own health inequalities as unacceptable and initiated policy measures to mitigate them. Clearly, the broader WHO efforts in this direction are, probably without exception, also aimed at true inequities.

Before saying more about the kind of reforms outside the health care system that would improve our health, we want to head off a misconception. We are not suggesting that we should simply ignore medical services and health sector reform because other steps will have a bigger long-term health payoff. Even if we had a highly just distribution of the social determinants of health and of public health measures, people will still become ill and need medical services. The fair design of a health system arguably should give some extra weight to meeting actual medical needs.

To see the importance of meeting medical needs, let’s distinguish between "identified victims"--people who are already ill and have known needs--and "statistical victims," whose lives would be spared illness by robust public health measures and a fairer distribution of social determinants of health. We might be tempted to judge these lives impartially, judging statistical lives saved to be just as valuable or important as identified victims. But other considerations temper our inclination to such impartial reallocation from identified to statistical victims, and suggest that we give special moral weight to the urgent needs of those already ill. Medical providers may legitimately believe that the good that they can control through their delivery of medical care has a greater claim on them than the good that would be brought about by more indirect measures beyond their control. More generally, many of us will be connected as family members and friends to the identified victims and will feel that we have obligations to assist them that supersede the obligations we have to more distant, statistical victims.

We do not suggest, then, that our society should immediately reallocate resources away from medicine to schools, for example, in the hope and expectation that a better-educated population will be healthier. But the arguments here suggest that some reallocations of resources to improve the social determinants are justifiable.

Domestic Policy
What sorts of social policies should governments pursue to reduce health inequalities? The menu of options ought to include policies aimed at equalizing individual life opportunities, such as investment in basic education, affordable housing, income security, and other forms of antipoverty policy. Though the connection between these social policies and health may seem somewhat remote, and they are rarely linked to issues of health in our public policy discussions, the evidence outlined earlier suggests that they should be part of the debate. The kinds of policies suggested by a social determinants perspective encompasses a much broader range of instruments than would be ordinarily considered for improving the health of the population.

Consider, then, four examples of social policies that might improve health by reducing socioeconomic disparities: investment in early childhood development, nutrition programs, improvements in the quality of the work environment, reductions in income inequality, and greater political fairness.

1. Early Life Intervention.Growing evidence points to the importance of early childhood environment in influencing the behavior, learning, and health of individuals later in the life course. Ensuring equal opportunity requires interventions as early in life as possible. Several studies have demonstrated the benefits of early supportive environments for children. In the Perry High/Scope Project, children in poor economic circumstances were provided a high quality early childhood development program between the ages of three and five. Compared to a control group, those in the intervention group completed more schooling by age 27; were more likely to be employed, own a home, and be married with children; experienced fewer criminal problems and teenage pregnancies; and were far less likely to have mental health problems.

Compensatory education and nutrition in the early years of life seem also to yield important gains for the most disadvantaged groups. As part of the War on Poverty, the federal government introduced two small compensatory education programs: Head Start for preschoolers and Chapter 1 for elementary school children. Evaluations of these programs indicate that children who enroll in them learn more than those who do not. So the program creates more equality of opportunity. Educational achievement, meanwhile, is a powerful predictor of health in later life, partly because education provides access to employment and income, and partly because education has a direct influence on health behavior in adulthood, including diet, smoking, and physical activity. So the program also leads to more health equality.

2. Nutrition.A similarly persuasive case can be made for nutritional supplementation in low income women and children. An analysis of the National Maternal and Infant Health Survey found that participation of low income pregnant women in the WIC program (the Special Supplemental Nutrition Program for Women, Infants, and Children) was associated with about a 40 percent reduction in the risk of subsequent infant death. A mother’s nutritional state affects her infant’s chance of death not just in the first year of life, but also throughout the life course. Thus a woman’s pre-pregnant weight is one of the strongest predictors of her child’s birth weight; in turn, low birth weight has been shown to be linked with increased risks of coronary heart disease, hypertension, and diabetes in later life. It follows that investing in policies that reduce early adverse influences may produce benefits not only in the present, but also for future generations.

3. Work Environment.We alluded earlier to the finding that the health status of workers is closely linked to the quality of their work environment, specifically to the amount of control and autonomy available to workers on their jobs. Low control work environments--such as monotonous machine-paced work (e.g., factory assembly lines) or jobs involving little opportunity for learning and utilization of new skills (e.g., supermarket cashiers)--tend to be concentrated among low-income occupations. Michael Marmot and colleagues have shown that social disparities in health partly arise as a consequence of the way labor markets sort individuals into positions of unequal authority and control. Exposure to low-control, high-demand job conditions are not only more common in lower status occupations, but they also place such workers at increased risks of hypertension, cardiovascular disease, mental illness, musculoskeletal disease, sickness absence, and physical disability.

A growing number of case studies from around the world have concluded that it is possible to improve the level of control in workplaces by several means: increasing the variety of different tasks in the production process, encouraging workforce participation in the production process, and allowing more flexible work arrangements, such as altering the patterns of shift work to make them less disruptive of workers’ lives. In some cases it may even be possible to re-design the workplace and to enhance worker autonomy without affecting productivity, since sickness absence may diminish as a consequence of a healthier work-place.

4. Income Redistribution.Many policies suggested by the social determinants perspective tend to fall under the category of anti-poverty policy. However, research on the social determinants of health warns us that anti-poverty policies do not go far enough in reducing unjust health disparities. Though priority should go to reducing the plight of the worst-off, the fact is that health inequalities occur as a gradient; the poor have worse health than the near-poor, but the near-poor fare worse than the lower middle class, the lower middle class do worse than the upper middle class, and so on up the economic ladder. Addressing the social gradient in health requires action above and beyond the elimination of poverty.

To address comprehensively the problem of health inequalities, governments must begin to address the issue of economic inequalities directly. Evidence we sketched earlier indicates that the extent of socioeconomic disparities--the size of the gap in incomes and assets between the top and bottom of society--is itself an important determinant of the health achievement of society, independent of the average standard of living. Most importantly, economic disparities seem to influence the degree of equality in measures of political participation, including voting, campaign donations, contacting elected officials, and other forms of political activity. The more unequal the distribution of incomes and assets, the more skewed the patterns of political participation, and consequently, the greater the degree of political exclusion of disadvantaged groups.

Inequalities in political participation determine the kinds of policies passed by national and local governments. For example, Kim Hill and colleagues studied the relationship between the degree of mobilization of lower-class voters at election time and the generosity of welfare benefits provided by state governments. Even after adjusting for other factors that might predict state welfare policy--the degree of public liberalism in the state, the federal government’s welfare cost-matching rate for individual states, the state unemployment rate and median income, and state taxes--robust relationships were found between the extent of political participation by lower-class voters and the degree of generosity of state welfare payments. In other words, who participates matters for political outcomes, and the resulting policies have an important impact on the opportunities for the poor to lead a healthy life.

For both the foregoing reasons--that it yields a higher level of health achievement as well as greater political participation--the reduction of income inequality ought to be a priority of governments concerned about addressing social inequalities in health. Although discussion of strategies is beyond our scope here, a number of levers do exist by which governments could address the problem of income inequality, spanning from the radical (a commitment to sustained full employment, collective wage bargaining, and progressive taxation) to the incremental (expansion of the earned income tax credit, increased child care credit, and raising the minimum wage).

International Development
Our discussion has implications for international development theory, as well as for economic choices confronted by industrialized countries. To the extent that income distribution matters for population health status, it is not obvious that giving strict priority to economic growth is the optimal strategy for maximizing social welfare. Raising everyone’s income will improve the health status of the poor--the trickle-down approach--but not as much as by paying attention to the distribution of the social product. Within the developing world, a comparison of Kerala, a state in India, with highly unequal countries such as Brazil and South Africa illustrates this point. Despite having only one-third to a quarter of the income of Brazil or South Africa (and thereby having a higher prevalence of poverty in the absolute sense), the citizens of Kerala nonetheless live longer, most likely as a result of the higher priority that the government of Kerala accords to a fair distribution of economic gains.

The real issue for developing countries is what kind of economic growth is salutary. Hence Jean Dreze and Amartya Sen distinguish between two types of successes in the rapid reduction of mortality, which they term "growth mediated" and "support-led" processes. The former works mainly through fast economic growth, exemplified by mortality reductions in such countries as South Korea or Hong Kong. Their successes depended on the growth process being wide-based and participatory (for example, full employment policies), and on the gains from economic growth being utilized to expand social services in the public sector, particularly health care and education. Their experiences stand in stark contrast to the example of countries such as Brazil, which have similarly achieved rapid economic growth, but lagged behind in health improvements.

In contrast to growth-mediated processes, "support-led" processes--for example, in China, Costa Rica, or Kerala--operate not through fast economic growth, but through governments giving high priority to the provision of social services that reduce mortality and enhance the quality of life.

Policies of either kind can succeed in promoting the health of the population. In either case, success depends on generating a more fair distribution of income. Once more, health is the byproduct of justice.

We noted earlier that academic bioethics and popular discussion of health care reform has generally tended to focus on medicine at the point of delivery and has inadequately attended to determinants of health "upstream" from the medical system itself. Empirical findings about the social determinants of health suggests that this is a serious mistake: upstream is precisely where we need to look. Put these findings together with a philosophical theory of justice that might apply to any society, and we get this striking result. In a just society, health inequalities will be minimized and population health status will be improved--in short, social justice is good for our health.

To read responses to this article from Ezekiel Emanuel, Michael Marmot, Marcia Angell, and others, click here.


1 John Rawls, A Theory of Justice, rev. ed. (Cambridge, Mass.: Belknap Press of Harvard University Press, 1999).

2 See Richard G. Wilkinson,Unhealthy Societies: The Afflictions of Inequality (London: Routledge, 1996).

3 John W. Lynch et al., "Income Inequality and Mortality in Metropolitan Areas of the United States," The American Journal of Public Health 88 (1998): 1074-1080.

4 Ichiro Kawachi, Bruce Kennedy, and Richard G. Wilkinson, Income Inequality and Health: A Reader (New York: New Press, 1999).

5 See Douglas Black et al., Inequalities in Health: The Black Report, The Health Divide (London: Penguin Group,1988).

6 Michael Marmot et al., "Contribution of Psychosocial Factors to Socioeconomic Differences in Health," Milbank Quarterly 76 (1998): 403-408.

7 Bruce Kennedy et al., "Income Distribution, Socioeconomic Status, and Self-rated Health: A US Multi-Level Analysis," British Medical Journal 317 (1998): 917-921.

8 For example, the correlation between social capital, as measured by low interpersonal trust, and the maximum welfare grant as a percent of state per capita income, is -.76. See Kawachi et al., "Social Capital, Income Inequality, and Mortality," American Journal of Public Health 87 (1997): 1491-1498.

9 Goran Dahlgren and Margaret Whitehead, Policies and Strategies to Promote Social Equality in Health (Stockholm: Institute of Future Studies, 1991).

Originally published in the February/March 2000 issue of Boston Review



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