Understanding Health Inequalities and Justice: New Conversations Across the Disciplines by M Buchbinder, M Rivkin-Fish and RL Walker (eds). Chapel Hill, NC: University of North Carolina Press, 2016, 320 pages, £37.50.
Reviewed by Professor John Harrington, Cardiff University
Inequality has returned to the political agenda in Europe and North America in the aftermath of the financial collapse of 2008 and the austerity programmes which followed it. The paradoxical success in failure of Bernie Sanders and Jeremy Corbyn in US and British elections respectively marks this shift. The long decades of neo-liberal hegemony, which privileged supply-side ethics and economics over the redistribution of resources, have come to an end. Instructed by scholars such as Thomas Piketty and challenged by the Occupy movement, parties of the right and the so-called centre left now accept that a direct concern with remedying inequality is essential to sustaining the legitimacy of the capitalist order. Contemporary health policy and politics are no exception. Persistent inequality in access to care and in health outcomes, exacerbated it is claimed by austerity regimes, track patterns of social exclusion and historic disadvantage associated with gender, race, geographic location and citizenship-status. While policymaking and research on health inequalities and injustice is of longstanding, they have gained urgency in the present conjuncture.
This collection is timely therefore, containing engaging and fresh interventions on the connections between health inequality and justice from scholars working in ethics, anthropology, history of science and health policy studies. Its aim is not only to provoke reflection on how we define and address health inequalities and inequities, but also to contribute at the level of methodology, highlighting the analytical strengths, but also the blindspots of the different disciplines in their engagement with these questions. But it does much more than simply line up perspectives one alongside the other. Lively interdisciplinary dialogues are ‘staged’ within individual chapters themselves. Paul Brodwin’s essay on mental health, for example, showcases the possibility for a productive interaction between the first-person testimony of survivors and abstract work on the ethics of recognition. In a respectful reading he shows how each approach can complement the other. Personal accounts indicate the dynamic nature of the quest for respect and intersubjective recognition by former patients, while theory can clarify the values which are often simply assumed by personal accounts. His hopeful conjugation of two different genres stands in contrast to the hermeneutics of suspicion which suffuses the encounter between disciplines evident in other chapters. Thus, Eva Feder Kittay uses ethnographic accounts to challenge the assumption in law and policy that all patients exercise their autonomy to the same extent and in the same way. Her use of personal narrative here allows the reader to go deep and wide: identifying the influence of historic discrimination and location within networks of support on the ability of different individuals to behave ‘autonomously’ in accessing and benefitting from health care.
It is a notable strength of the book that the interdisciplinary conversation signalled in its subtitle is also carried on across chapters, as well as within them. Thus, Kittay’s review is augmented by the theoretical platform developed by Janet Shim and colleagues in their own critique of the ‘Patient-Centred Care’ model which has underpinned recent US health reforms. Building on the work of Pierre Bourdieu, they argue that clinical encounters are shaped by the specific ‘cultural health capital’ available to each party. This repertoire of communication skills, educational attainment, deportment and etiquette is itself unequally distributed among patients, leading to correspondingly varied attitudes and interventions on the part of their doctors.
The salience of such pre-conscious attributes (or ‘habitus’) is taken up in relation to the oral health of Mexican migrants to the US by Sarah Horton and Judith C. Barker. Drawing on extensive ethnographic work they show the enduring influence of limited access to dental work on the health and broader social prospects of the children of undocumented workers. Detailed stories of women prevented from breastfeeding by their employment conditions and the efforts made by children and young adults to hide or remedy defects make vivid the insight which several contributors borrow from Nancy Krieger, writing elsewhere, that inequality is embodied. The critique of formal autonomy is extended by Janet De Bruin and colleagues in their chapter on conceptions of risk in pregnancy, which shows how legal measures and media discourses about maternal responsibility, claimed to be based on neutral empirical studies, are in fact deeply shaped by culture and prejudice. This provides empirical substance for a critical ethical review of policy with reference to the six essential heads of well-being set out by Madison Powers and Ruth Faden in their theory of social justice and health.
The chapters discussed are animated by faith in the capacity of interdisciplinary approaches to produce new perspectives on the nature and ethical significance of health inequalities, even if their conclusions are often pessimistic in substance. Nicholas King is a notable exception to this, warning of the perils of ‘cross-disciplinary’ cherry picking which lead to easy but not wholly justifiable policy recommendations. His immediate target is the widely held view that reducing social inequalities will lead to improvements in health. That position, he argues, confuses the undeniable association of poverty and ill health, with the existence of a causal relationship between them, which has not by and large been proven. He suspects philosophers and social scientists of wilfully or carelessly paying insufficient attention to the limits of epidemiological findings and assuming their objective and value-free character in order to strengthen their own normative position. This argumentative sleight of hand will be found out, he suspects. Better to be honest and stake a direct claim for combatting social injustice, regardless of its (unproven) effect on health. This is a wise counsel, though King might have augmented it by adopting the contextualizing methods on display elsewhere in the book. A more historically-informed reading would suggest that the desire to ground interventions in ostensibly neutral studies concerning health effects is consonant with the dominance of evidence-based policymaking, and the more insidious compulsion to defer open debates on distribution and equality both typical of neo-liberalism.
The problem of causation also troubles Paula Braveman in her opening contribution to the book. She accepts that the term ‘health inequities’ gains its specific rhetorical force from the attendant notion that such disparities can be traced to unfair social structures. Like King, she accepts that this causal flow is hard to prove. Like him she wishes to avoid pinning the case for active intervention to meet health needs to this element, arguing instead that bare health inequalities are themselves of ethical significance in so far as they compound pre-existing unfairness. State responsibility to act in such cases can be based on the normative repertoire of international human rights law, and in particular its strong injunction against discrimination and its focus on remediating the position of disadvantaged groups. This is indeed a plausible reading of human rights law, though one wonders at the extent of its likely political traction in the US, which has not of course ratified the International Covenant on Economic, Social and Cultural Rights, central in this context.
State obligations are a key focus of Jennifer Prah Ruger’s chapter, which is the only one to engage directly with questions of global health justice. Based on a careful blending of governance studies and theories of justice she sees an important role for the nation state, which had previously been somewhat overlooked in the global health literature. The state is conceived of here as an indispensable lever for addressing health inequalities as between populations in different parts of the world. This is a wholly instrumental characterization. The state’s contribution is defined only in categorical and functional terms, circumscribed by universally binding standards of justice themselves based on the rights and responsibilities of individuals. No attention is paid to the historical specificity of different states, and particularly those in the global south which are the focus of most global health efforts in practice. As medical anthropologists and historians of science have shown, the work of independent states in health as in other social sectors was oriented by the aspiration for development and emancipation from the effects of colonialism widely shared among their citizens. Of course, in many cases this aspiration was bitterly disappointed. But states remain nonetheless the objects of desires and concerns which exceed the merely instrumental.
Ruger also demonstrates the power of the capabilities approach in orienting studies of health justice domestically and globally. Its emphasis on the protection and promotion of agency is a theme taken up implicitly and explicitly by many other contributors from different disciplines. Indeed, the detailed ethnographic studies and closely-read patient testimonies, as well as the critical engagement with popular discourses around pregnancy and migrant health rights, offer us wide ranging evidence of the ceaseless struggle to secure patient autonomy and health justice. Structural determinants, arising out of economic and legal constraints, as well as conscious bias and inherited disadvantage mean that health agency is almost always realized in ‘tight corners’. This crisply edited, well-constructed collection deserves our praise for directing our attention ‘up’ to the level of critical ethics, and ‘down’ to the messy world of practice and in forcing us to reflect on the often problematic, but sometimes enriching and productive relationship between the two.