I'm only making a point about health inequities, not human suffering in
general or the value of education. My point is about how social change
comes about and whether the primary focus is treating the consequences
of inequity or the source. Negative outcomes in social determinants are
the result of a broader cause, based on conflict and interests at stake,
and I believe it's necessary to mobilize and organize to address the
broader injustice.
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
Goldberg, Daniel
Sent: Friday, June 13, 2008 2:07 PM
To: [log in to unmask]
Subject: Re: Myths about health inequities...
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]
http://www.atkinson.yorku.ca/draphael -------------------
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