Health Promotion Practice October 2004 Vol. 5, No. 4, 372-376
Ideologies and Pathologies of Power: Two Books That Contribute to the Cause
of Innovative Public Health Theory, Practice, and Promotion Hofrichter, R.
(Ed.). (2003). Health
and Social Justice: Politics, Ideology, and Inequity in the Distribution of
Disease. San Francisco: Jossey-Bass. 688 pages. ISBN 0-7879-6733-5.
Paperback. $55.00.

Farmer, P. (2003). Pathologies of Power: Health, Human Rights, and the New
War on the Poor. Berkeley: University of California Press. 419 pages. ISBN
0-520-23550-9. Hardcover. $27.50.

If there is any doubt that the sciences of health promotion and disease
prevention are in a state of crisis, the publications of Health and Social
Justice and Pathologies of Power should dispel this uncertainty. The array
of articles included in Health and Social Justice and the relentless
examples of Paul Farmer’s work in Pathologies of Power  demonstrate that
physicians, public health practitioners, researchers, and policy makers
have not found and implemented appropriate responses to public health’s
most difficult challenges of improving the health of the poor and
eliminating ethnic, gender, and class disparities in health.

Both books, quite different in format, array of research, and design, have
as their central theme that the ideologies of those in power, and their
associated political and economic structures, contribute to and perpetuate
poor health and premature mortality for the majority of the human
population. Both volumes
clearly demonstrate that although the social, political, and economic
structures affect health, it is also imperative to include the voices,
opinions, and strategies of lay people
who experience more than their fair share of illness and premature death.
After reading these books, one may get the sense that public health experts
may be throwing up their
hands and turning to the ordinary people who could help, because they may
have the answers and experiential expertise to understand these injustices.

This review considers each book separately, yet with an  ear toward what
they can do for readers when considered together. Richard Hofrichter has
edited a reader in public health that explores the political and
ideological underpinnings of health disparities. It includes some of the
most wellknown articles on the relationship between public health and
social justice written by researchers, economists, and ethicists from the
United Kingdom, Canada, and the United States. The book stands on three
pillars of inquiry: (a) the inextricable relationship between social,
economic, and political forces that cause disease and health inequalities,
as they are mediated by class, gender, and ethnicity; (b) how political and
social ideologies compound health problems among the poor and perpetuate
health disparities; and (c) strategies for changing social policy and
practice to address these issues. The complexity of health and disease is
highlighted throughout the reader, as well as the inadequacy of current
methods and theories in population health.

In his introductory chapter, Hofrichter states that although the scientific
values that have driven public health research, practice, and policy need
to be brought to light,
their inadequacy is not totally at fault. He states, “The scientific world
of prediction and control cannot resolve what is ultimately a political
crisis” (p. 33). Yet, throughout
the rest of the volume, various authors assert that there is an
inextricable relationship between politics, political ideologies and
structures, and the way public health
researchers and policy makers frame public health activities. Thus,
accompanying “political crisis” (in the form of lack of participation in
civil society, disinvestment in social
programs, unregulated world market, and ultraconservative administrations)
is a scientific crisis in the world of public health. In light of this,
students of public health would do well to have this book on their shelves.
Hofrichter also suggests that the philosophical and theoretical approach of
this volume will complement a series of readings that are based on
empirical research. In addition, practitioners in public health, such as
health educators and health policy makers in departments of public health,
are well served by  this book—if not for the sheer volume of seminal
articles it draws together, then for the uncertainties of what the
structures of public health and its professionals have yet to achieve in
the effort to improve the health of the most vulnerable.

What is novel in this reader is the emphasis on political ideology and
political structure, and the section devoted to solutions. Hofrichter’s
introductory article sets the stage or almost every pathway for how
population and individual health are affected by unjust political,
economic, and social structures. He addresses environmental, cultural,
and ideological issues related to these injustices and clearly delineates
ways in which health disparities can be ameliorated. Part one in the series
addresses the social determinants of disease, such as class, ethnicity,
income inequality, racism, and gender inequality, as well as zoning and
globalization and their effects on health. Articles by John Lynch and
Dennis Raphael stand out here, and these authors figure prominently
throughout the volume. In a previously unpublished article, Raphael argues
that in the United States, the concentration of wealth in the hands of the
few trickles down into poor health for the majority of the poor through the
decline in civic participation and the decline in political and economic
investment in social support systems. Ultimately, this concentration of
wealth due to neoliberal approaches is spawning high rates of child
poverty. In turn, this is leading to cumulative experiences in poor health
and inequity causing social disintegration. He claims that public health
approaches in the United States have been inadequate, as they have focused
mainly on health behavior change rather than the structural inequities that
cause people to adopt such behaviors. The picture Raphael paints is grim,
but later on in the book he offers strategies to stop such devastation by
recalling the Ottawa Charter for Health Promotion, 1986 (World Health
Organization, 1986) that calls for widespread policy change that enhances
and protects rights of children, women, and minority groups.

Part two includes a range of articles arguing for new approaches to health
promotion and to the study of population health. Articles included are the
now-classic article by Dan Beauchamp on the need for public health values
to realign with those of social justice, Krieger on her treatment of the
ecosocial model as a more comprehensive model for
understanding the distribution and determinants of disease, and Lynch and
Raphael weighing in on how to expand our view of public health. Overall,
the arguments in this segment revolve around the inadequacy of epidemiology
due to its emphasison risk factors, individual behaviors, and biomedical
models of disease. Standouts include Popay, Williams, Thomas, and Gatrell’s
critique of public health inequity suggesting that theories driving
research and public health policy should include lay perspectives. These
lay perspectives provide insight into the complexity of human illness and
provide historical context to our understanding of illness. Also calling
for more contextual approaches to the study of health inequities is a
previously  unpublished article by Paula Braveman that critically analyzes
the superficial treatment of disparities in health in the World Health
Report, 2000. Part three includes several articles that provide solutions
for the current crisis in public health. Most offer insight into
innovations of public health research, rather than  action, with the
exception of Gavin Kearney, who describes structural and political changes
in Minnesota’s public health system to address disparities,
and Wallack’s treatment of ways in which the public health community can
use and influence mass media to build social capital for the improvement of
health and to encourage more civic engagement.

Arline Geronimus (1992, 2001) briefly and elegantly defines the
relationship between racism, historical oppression, and poverty and poor
health for African American populations (expanding on her weathering
hypothesis) and offers critical analysis of ways in which these issues can
be addressed. Indeed, the message, here again, is
that public health professionals need to become more attentive to how
research and surveillance methods are affected by political ideologies.
These ideologies shape
the way in which we categorize populations, pointing the blame, for
instance, on “single mothers” rather than on structures of child care.

Health and Social Justice brings together some of the most critical
analyses from sociological, economic, political, and epidemiological
perspectives in public health to
date. The majority of the work pays tribute to other important scholars and
their influences in this field. Anyone interested in doing cuttingedge
research or developing innovative and more effective health-promotion
strategies would do well to read this book. It is not for the faint at
heart, however, as one comes away with no coherent strategy to address
these issues. As Hofrichter states, “The discipline itself requires
reorganization. Public health cannot advance without a more coherent
philosophy
and theory—one that links economics, ecology, geography, space and time,
and philosophy of science” (p. 41). Indeed, we emerge from reading this
series of articles without a coherent analysis or rationale for having
included these articles and not others. For instance, what might be the
rationale for including the outdated work of Moss,  describing an agenda
for action that addresses the inadequacy of Healthy People 2000, without
mention that Healthy People 2010, with its stated goal of eliminating
health disparities, has been on the scene for several years?

The reader is dizzied by the long list of social, political, and economic
determinants and the litany of reason epidemiology has failed, with its
emphasis on single (simplistic) risk factors. Missing from this public
health reader is the critical mass of new approaches to public health that
include the human rights framework. This book, if used in courses on social
justice and public health, can be complemented by the 1998 Health and Human
Rights reader by Mann, Gruskin, Grodin, and Annas (1999; reviewed in Health
Promotion Practice by Gambescia, 2002). Although social justice approaches
in public health offer a disparate set of responses, the human rights
framework offers a comprehensive set of responses to health injustices that
incorporates political and legal strategies. For a clear relationship
between the works of social epidemiologists
and those in human rights, see Krieger and Gruskin (2001)... SNIP