I'm not sure I understand our disagreement. First, I tend to think a focus on education entails a great deal more than working on mere "programs and services."
Second, who is advocating a nickel and dime approach? I indicated numerous times that I unabashedly support radical, wholescale change. But that does not preclude attention to other policy goals that have different feasibility profiles and that we have good reason to believe will improve population
health in the short-term.
Third, I thought I had addressed several times the narrative that links all of this to SDOH. There is good evidence that education "compresses the SES gradient" and improves health literacy, among other salutary goals. I am still waiting for an interlocutor to explain to me why these goals would
not improve health, reduce human suffering, and reduce health inequities.
Again, if we agree that policy change consistent with attention on the SDOH can simultaneously support both efforts for radical social change and efforts for policy goals like education policy that have demonstrable benefits on disparities and population health, why should we not work for both?
-----Original Message-----
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Richard Hofrichter
Sent: Friday, June 13, 2008 12:38 PM
To: [log in to unmask]
Subject: Re: [SDOH] Myths about health inequities...
The disagreement is not about whether you can do both at once.
"Compressing the SES gradient" is precisely a long-term political struggle, which will not be resolved by programs and services. You can't nickel and dime your way to equity without an effort to transform institutions and political power. No one says it has to happen overnight. The civil rights
movement didn't; the women's movement didn't. What's the narrative that links all of the SDOH? Is the idea to single each one out one at a time, like we do with diseases?
Richard Hofrichter, PhD
Senior Analyst, Health Equity
National Association of County & City Health Officials 1100 17th St. NW Washington, DC 20036
Tel: 202-507-4229
Fax: 202-783-1583
email: [log in to unmask]
-----Original Message-----
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Davidson, Alan
Sent: Friday, June 13, 2008 1:22 PM
To: [log in to unmask]
Subject: Re: Myths about health inequities...
Agreed.
Alan Davidson
UBC-O
________________________________
From: Social Determinants of Health on behalf of Goldberg, Daniel
Sent: Fri 13/06/2008 10:17
To: [log in to unmask]
Subject: Re: [SDOH] Myths about health inequities...
I disagree that improving SES doesn't do anything about social processes and imbalances of political power that create inequities. It's an indirect means of doing so, but those imbalances of power are in significant part a function of socioeconomic disparities. To be sure, power imbalances are not
reducible to these disparities, but what kind of social change are we looking for if it isn't intended to compress the SES gradient and reduce SES disparities?
In any case, I admit to a failure of imagination in seeing how any of this means we ought not invest substantial efforts in improving access to and investment in education. Why can't we parallel process? Work to link efforts as to SDOH to larger movements for social change, while acknowledging that
different policy goals have different feasibility profiles, and that agitating for radical redistribution of income, may not be likely to happen in the short-term, no matter how laudable and desirable a goal it is (and it is one I unreservedly support).
Accordingly, I tend to think that exclusively focusing on radical social change as a means of improving population health ignores a myriad of other policy goals with better feasibility profiles in the short-term that we have reason to believe will improve health and reduce human suffering.
I've written about this as the ethics of health policy paradox. While we cannot let what we can accomplish define what we ought to do (b/c this would be a rank instance of the naturalistic fallacy), if we let what we ought to do exhaust the set of what we try to do, we are unlikely to actually
achieve policy change. There is a profound difference between policy and advocacy, as important as the latter is to the former. I don't see it as an either/or proposition. We can both work for more radical social change and, while doing so, support social policies (like increased investment in
education) that are
evidence-based in terms of population health.
________________________________
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Richard Hofrichter
Sent: Friday, June 13, 2008 11:50 AM
To: [log in to unmask]
Subject: Re: [SDOH] Myths about health inequities...
SES is a static, descriptive category. Improving SES (education, employment, income) as a way to eliminate health inequity doesn't do anything about the social processes and imbalances of political power that created inequities in the first place. Embedded in this way of thinking not only avoids
acting on root causes, it ignores even recognizing those causes: that populations experiencing health inequity had bad luck, random events intervened, etc. Endless efforts at remediation will fail because the interests at work generating inequity will continue to do so. Emphasizing behavioral change
and fixing individuals to function better in society is a distraction. Efforts to cheapen labor around the world, dump waste in communities of color, gentrify communities through redlining by banks, moving jobs overseas, etc. is not about behavior. The question is: why is there inequality?
Because the task is daunting doesn't mean that there is no place to begin in producing social change. This defeatist attitude that we are stuck in a perpetual present of existing power arrangements ignores contingency and agency as well as history. The great advances in public health in the US in
the early part of the twentieth century were not the result of programs, or educating people about changing their behavior.
It was about major social change based on struggle: abolishing child labor, the eight hour workday, the sanitation movement, and the introduction of housing and factory codes. Even small steps in transforming institutions is a valuable advance. Without discussing ways to link health equity to larger
social movements for change and to name the interests involved and how influence works, there will be very little progress.
Richard Hofrichter, PhD
Senior Analyst, Health Equity
National Association of County & City Health Officials
1100 17th St. NW
Washington, DC 20036
Tel: 202-507-4229
Fax: 202-783-1583
email: [log in to unmask]
________________________________
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Goldberg, Daniel
Sent: Friday, June 13, 2008 12:17 PM
To: [log in to unmask]
Subject: Re: Myths about health inequities...
Really?
I think there's really good reason to believe that higher levels of education are correlated with better SES.
But what's more, when we're talking about the SDOH, we're not just talking about absolute poverty, as Marmot has definitively demonstrated.
Even if better education is not a strong determinant of higher SES -- which I believe it is -- there is evidence that education level is correlated with the SES gradient in health late in life.
And poverty is not the only social determinant of health. As important as it obviously is, I tend to think the goal of SDOH advocates is not per se to reduce poverty, but to improve health and reduce human suffering.
As I mentioned, we know that health literacy is an overwhelming determinant of the pathways of chronic disease in particular. Unless we think that education is insignificant in health literacy, it's hard for me to understand how education policy isn't a prime node for improving health literacy, and
thereby both improving health and ameliorating health inequities.
Look, I agree that improving investment in education is alone going to "cure" the U.S. health care problem. But inasmuch as education is a means, albeit indirect, of distributing resources in a more, if not ideally equitable manner, I contend that it's a crucial nexus for SDOH advocates in the U.S.
Income inequality leads to educational inequality, which leads to health inequality. It certainly would be preferable to focus on the root cause of the problem -- income inequality, but actual policy change requires understanding that what ought to be done is not always what can be done, and that
what can be done is, while not dispositive, certainly important.
More radical income redistribution in the U.S. is certainly an idea I support; but as a policy matter, it is VERY far away. For god's sake; we can't even agree in this country that having over 100 million uninsured or underinsured is morally unconscionable. How are we going to find the political
will to radically redistribute wealth?
Education is an indirect means of compressing the SES gradient, and of improving health literacy, and these two factors alone justify the belief (again, supported in the literature, as far as I'm aware) that increasing investment in education will improve population health.
________________________________
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Dennis Raphael
Sent: Friday, June 13, 2008 11:00 AM
To: [log in to unmask]
Subject: Re: [SDOH] Myths about health inequities...
I dont see it. Educate everybody and tell me how that reduces poverty?
dr
Of related interest:
Poverty and Policy in Canada: Implications for Health and Quality of Life by Dennis Raphael Foreword by Jack Layton http://tinyurl.com/2hg2df
Staying Alive: Critical Perspectives on Health, Illness, and Health Care, edited by Dennis Raphael, Toba Bryant, and Marcia Rioux Foreword by Gary Teeple http://tinyurl.com/2zqrox
Social Determinants of Health: Canadian Perspectives, edited by Dennis Raphael Foreword by Roy Romanow http://tinyurl.com/yptzae
See a lecture! The Politics of Population Health http://msl.stream.yorku.ca/mediasite/viewer/?peid=ac604170-9ccc-4268-a1a
f-9a9e04b28e1d
Also, presentation on Politics and Health at the Centre for Health Disparities in Cleveland Ohio http://video.google.com/videoplay?docid=-4129139685624192201&hl=en
Dennis Raphael, PhD
Professor, School of Health Policy and Management York University 4700 Keele Street Toronto ON M3J 1P3 416-736-2100, ext. 22134
email: [log in to unmask]
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