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 Public Health, Ethics, and Equity

 Sudhir Anand, Fabienne Peter, Amartya Sen. Oxford University Press, Dec
004. Pp 400. ISBN 0-19-927636-6.


http://www.thelancet.com/journal/vol365/iss9459/full/llan.365.9459.analysis_and_interpretation.32221.1


 Public Health, Ethics, and Equity is an important step in the process of
developing a coherent approach to public health ethics and, especially, to
the ethics of equity. To date, bioethics has almost exclusively focused on
health care issues without engaging with the more fundamental, but less
visible, conundrums around the best approaches to health improvement
generally and entrenched and increasing health inequalities specifically.
Many health inequalities are caused by such social factors as poverty,
nutrition, early life conditions, gender and ethnic discrimination, access
to water, education, housing, and sense of control over one's destiny.
Concerted action on these underlying determinants of health is needed to
improve the health of the most vulnerable populations.

 There are many stimulating and important ideas presented by the various
contributors to this book that easily justify wider discussion. Three ideas
are key to the future of public health. First, it is proposed that health
inequalities are of greater importance than other inequalities, if only
because they represent serious obstacles to people's capacity to function
effectively and contribute to other socially desirable goals. No doubt some
will argue that inequalities in wealth and education are of more
fundamental importance because of their general adverse effects. Second,
the most important contribution in this book, is the case it makes for an
extension of John Rawls' concept of "justice as fairness" to building the
ethical case for reducing health inequalities. Third, a compelling case is
made for downplaying the responsibility of individuals as the main driving
force for population health improvement. This idea is at odds with much of
what goes for contemporary public health, although it is well supported by
the epidemiological theses presented more than 20 years ago by Geoffrey
Rose.

 An important next step in the evolution of this field would be
consideration of the ethical underpinning-- implicit and explicit--of the
practical policy measures that have been introduced in the past few years
to address health inequalities, notably in Sweden, the UK, the Netherlands,
and New Zealand. The evidence from the evaluation of the Netherlands
experience, as summarised by Johan Mackenbach and colleagues in this book,
is of particular importance.

 Public Health, Ethics, and Equity is an important addition to the very
small number of publications on the ethics of public health and health
inequalities. They represent tangible evidence of this new discipline that,
for convenience, might be called "public health ethics". There is still
much to be done to entrench this discipline in mainstream public health,
and from there to extend its influence into policy discourse more
generally. It remains to be seen whether building the ethical base for
public health will help those struggling with these issues on a daily
basis.

There is some cause for optimism. The locus of the normative work on
approaches to reduce health inequalities has passed to WHO. Next month, the
WHO Commission on the Social Determinants of Health will be launched in
Chile. It is a complement to the earlier Commission on Macroeconomics and
Health and is a reflection of WHO's recommitment to the idea of social
justice. The Commission, under the leadership of Michael Marmot--one of the
contributors to this book--will identify policies able to reduce health
inequalities through action on social determinants, and will also call for
the widespread implementation of such policies, with a focus on the needs
of low income and middle income countries.

 The Commission will report in 2007, and there is high hope that by then
the evidence base will be robust enough for a serious assault on reducing
health inequalities. The difficult work of implementing the Commission's
recommendations will be on a firmer basis if the central ideas in this book
are further elaborated and widely discussed, even if consensus is difficult
to achieve.

 A quarter century after my first serious engagement with issues relating
to tobacco control, it is interesting to reflect back on the ethical issues
involved. A key question is whether we would have had more success in
reducing tobacco-induced health inequalities if we had had a more explicit
ethical underpinning to our public health work. Clearly, we would have been
on firmer ground, even if I am not convinced we would have made more
progress in generating the social movement which is so critical to the
success of all public health efforts. 70;61;

Robert Beaglehole

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