International Journal of Epidemiology Volume: 33, Issue: 5, October 01,
2004, pp. 1159-1160
Gruskin, Sofia

Health and Social Justice: Politics, Ideology and Inequity
in the Distribution of Disease. Richard Hofrichter (ed.):
San Francisco, CA: Jossey-Bass, John Wiley and Sons, 2003,
pp. 688, £34.50 (PB) ISBN: 0787967335.

Health and Social Justice brings together a broad range of
contributions from many of the fields of public health
concerned with addressing health inequities. The book contains
both new and reprinted material, and is organized in four parts.
It is extremely comprehensive and its 27 chapters bring together
the writings of some of the most incisive and well-known
authors in the area. This volume is unapologetic in bringing
together readings that share a similar ideological construct—
that the determinants of health are more than individual
behaviour and the delivery of services but are grounded in
larger economic, political, social and cultural factors. No one in
the field could disagree with the book’s underlying premise or
motivation—a point of view this reviewer entirely shares. There
is, nonetheless, an assumption of common knowledge and a
common perspective evident throughout the text, and no
attempt is made to convince the sceptical reader.

An introductory essay by the editor forms the basis for the
book, and lays out the arguments and concepts picked up again
by authors in subsequent sections. The first selection of readings
is intended to bring together writings on health inequities as
they are influenced by political, economic, and social forces,
while the second claims to provide an exploration of some of
the key ideologies and paradigms that obscure the underlying
causes of these inequities and limit the potential for a
co-ordinated public response. The final section asserts a focus
on actions that can help to reduce or eliminate these inequities.

While authors come from a number of different countries, the
bulk of readings are focused on the US and Canada, even
as efforts are made throughout the text to bring to light the
linkages between the realities experienced in these countries
and those experienced by the rest of the world, as well as to
draw attention to the negative impacts on health in other parts
of the world resulting from US policies. Of note in this regard
are the ways in which, taken as a whole, the text manages to
show how out of step current US health policies are with those
of other governments, including other resource-rich countries.

The book is focused on politics and power and their influence
on inequities in health as well as their ultimate import in how
these inequities are addressed. The term social justice is presented
as the framework for understanding how to think about health
inequities as well as to define the strategies best suited to address
them. The opening essay presents social justice as ‘[ ] an ongoing
series of relationships that permeate everyday life,’ and frames
the application of a social justice framework in opposition to
inequality and support for the ‘empowerment of all social
members, along with democratic and transparent structures to
promote social goals’. This approach is interesting in that it goes
beyond traditional definitions of the term and opens the way for
attention to a range of disciplines and methods with concern for
the public’s health. That being said, it is very unclear why a reader
which implicitly draws so much from the human rights
framework in terms of analysis, process, and approach has given
no explicit space to what this framework can offer to addressing
health inequities. The text names some of the foundations for
health—food, shelter, safe water—all of which are recognized
rights constituting in one way or another the legal obligations of
every government in the world in relation to health and wellbeing.

It focuses also on the components that are central to the
application of a human rights framework to health programming:
equality, participation, transparent and functioning processes, and
the accountability of the institutions and structures that impact
on health. Yet not a single essay concerns the contribution that a
human rights framework can make to these issues, and even more
perplexing is the well-intentioned statement by the editor in the
opening essay of the need for a ‘rights-based approach to public
health [ ] one that sees health as a social and not merely an
individual right’ to help address inequities in health. This
statement is unfortunately presented with insufficient
understanding of what this entails, where there are parallels with
the approaches being put out, as well as where there are potential
disagreements. This is particularly puzzling given the 15 years or
so of scholarship in this area which elaborate many of the points
raised in the opening essay and throughout the reader.

The attention in both the opening piece and the chapters that
follow to the particular impact of inequities in class, race, and
gender on inequities in health is very much of its time, and is
clearly and appropriately the mantra of the decade. Nonetheless,
a more systematic exploration of how these forms of inequity act
in synergy with each other as well as with other forms of inequity
such as on the basis of age, disability, or pre-existing health status
is long overdue. As many of the pieces named the importance
of these linkages and their conceptualization for health, it was
disappointing to see that ultimately they ended up addressing
them separately. This quibble is not merely rhetorical, I fear even
the best of intended public health strategies will end up with less
than desired results until our multiple forms of identity and the
linkages between them are adequately addressed. Systematic
attention is needed as to how the combination of factors that
shape a person’s life can impact not only on what services are
made available to them but the constraints in their being able to
access these services even when they are available. This volume
presents many of the thinkers at the forefront of progressive
public health approaches, and my plea is for more individual and
collective attention to the need to systematically grapple with this
unfortunate reality.

Despite the issues raised here, the value of this text is clear.
Hofrichter is to be congratulated for assembling a reader that will
be of use not only to better understanding inequities in health,
but to critical thinking and approaches to better address them.
SOFIA GRUSKIN