What is a National Health Policy?

Vicente Navarro, posted on Spirit of 1848 listserv, March 6, 2007

(Note - This article is modified from a speech 
delivered by Vicente Navarro to the International 
Association of Health Policy, Barcelona, Spain, 
August 21, 2006. The article has benefited from 
comments by Bo Burström and Margaret Whitehead.)


Unfortunately, most nation states have taken 
"health policy" to mean "medical care policy." 
Medical care, however, is only one variable in a 
nation's health equation. The article describes 
what the main components of a national health 
policy should be, including (1) the political, 
economic, social, and cultural determinants of 
health, the most important determinants of health 
in any country; (2) the lifestyle determinants, 
which have been the most visible types of public 
interventions; and (3) the socializing and 
empowering determinants, which link the first and 
second components of a national health policy: 
the individual interventions and the collective 
interventions. The author discusses the 
indicators that should be used for each component 
and for each intervention. The feasibility of 
this approach depends to a large degree on the 
political will of the national authorities and 
the broad understanding of the actual 
determinants of health. A good first step is the 
National Health Policy plan developed by the 
Swedish social democratic government. This 
article builds on and expands on that model.

A key objective of a national health policy 
should be to create the conditions that ensure 
good health for the entire population. Needless 
to say, all sectors and agencies in society 
should be responsible for creating those 
conditions, but the primary responsibility for 
ensuring the conditions for good health lies with 
the collective agencies that represent the 
interests of the population (freely expressed 
through democratic institutions)-that is, the 
public authorities and their public 
administration. Government (at the national, 
regional, and local levels), therefore, is the 
primary agency responsible for developing a 
national health policy. What are the major 
components of a national health policy? There are 
three main types. The first includes public 
interventions aimed at establishing, maintaining, 
and strengthening the political, economic, 
social, and cultural structural determinants of 
good health. They are called structural because 
they are part of the political, economic, and 
social structure of society and of the culture 
that informs them. Although rarely listed in most 
national health plans, these are the most 
important public policies in determining a 
population's level of health. Indeed, there is 
very robust scientific evidence that shows, for 
example, that countries with lower class, race, 
and gender inequalities in standard of living 
also have better levels of health for the whole 
population (1). Public policies aimed at reducing 
social inequalities, therefore, are components of a national health policy.

The second type of intervention includes public 
policies aimed at individuals and focused on 
changes in individual behavior and lifestyle. 
These lifestyle determinants are also very 
important and have been the most visible among 
national health policies. One reason for the 
higher visibility of interventions of this type 
is that health policy makers perceive them as 
more manageable and easy to deal with than the 
first type, the structural determinants. However, 
we cannot exclude the possibility that another 
reason for this difference in visibility and 
frequency is that the lifestyle determinants 
focus the responsibility for a population's 
health on the individual rather than on the 
public institutions that are primarily 
responsible for the structural determinants. This 
is one reason why conservative and liberal 
governments (and also, on many occasions, 
progressive governments) tend to emphasize this 
second type of intervention over the first type 
(which is actually more effective in improving a population's health).

The third type of public intervention, which I 
would call socializing and empowering 
determinants, links the second type (lifestyle 
determinants) with the first (structural 
determinants). Socializing and empowering 
interventions establish the relationship between 
the individual and the collective 
responsibilities for creating the conditions to 
ensure good health. This type of intervention 
would include the encouragement of individuals to 
become involved in collective efforts to improve 
the structural determinants of health, such as 
reducing the social inequalities in our societies 
or eliminating the conditions of oppression, 
discrimination, exploitation, or marginalization 
that produce disease. For example, encouraging 
individuals who are exploited to respond to that 
exploitation, not only individually but also 
collectively (with other persons who are 
similarly exploited), is an extremely important 
health policy intervention, linking improvement 
of the individual's health with improvement of 
the health of the exploited population.

Examples of these socializing and empowering 
determinants are many. For example, when the 
Black Panthers took over parts of the black 
neighborhoods in Baltimore (a city with a 
population that is 75% African American) in the 
1960s and early 1970s, mobilizing unemployed 
black youths, drug addiction declined 
dramatically among the young, and also among the 
entire black population of East Baltimore (2). 
Another example is what occurred among coal 
miners in Appalachia (West Virginia) in the 
1970s, when they mobilized and went on strike to 
protest unhealthy working conditions (3). They 
paralyzed mine operations for several months, 
creating a situation in which the mine owners and 
employers almost lost control and called for the 
Army to take over the mines. In that 
mobilization, each miner fought not only 
individually but collectively to improve the 
health of all coal miners and, in that struggle, 
their own health improved as well as the health 
of the entire population. As both cases show, 
facilitating the linkage of the individual's 
fight for better health with the collective 
struggle for better health is an extremely 
important public intervention for improving the population's health as a whole.

Empowering vulnerable populations is thus an 
essential component of a national health policy. 
Educating people to act not only individually but 
also collectively, making them aware of the 
commonality of their problems and encouraging 
them to act both individually and collectively to 
resolve them, is an important dimension of a 
national health policy. Indeed, the linkage of 
the individual with the collectivity is an 
important function of public health 
interventions. Let's analyze each type of intervention in more detail.

STRUCTURAL DETERMINANTS: POLITICAL, ECONOMIC, 
SOCIAL, AND CULTURAL HEALTH POLICY INTERVENTIONS

The agents that carry out interventions of this 
type are collective (i.e., they are not 
individual persons), including political parties, 
trade unions, neighborhood associations, and 
others. The subjects of these interventions, too, 
are not individual persons but public and private 
institutions whose actions affect the conditions 
that ensure good health for the entire 
population. These interventions can be summarized as follows.

Public Policies Aimed at Encouraging Participation and Influence in Society

These extremely important interventions are aimed 
at facilitating the development of institutions 
and practices that create the conditions for 
persons (as members of social classes, genders, 
races, ethnic backgrounds, regions, or nations) 
to make decisions about and control their own 
lives. Interventions of this type are aimed at 
establishing institutions and practices that 
minimize popular alienation and 
powerlessness-conditions that cause a huge amount 
of pathology and ill-health (4). Of particular 
importance are interventions aimed at providing 
political and social instruments (such as 
political parties, trade unions, neighborhood 
associations, social movements, patients' groups) 
for the population and its different components. 
These instruments then facilitate and stimulate 
the population's active involvement in its 
members' political and social lives, deciding on 
the matters that affect their lives. Of special 
importance is the existence of political and 
social instruments that enable groups who feel 
marginalized, discriminated against, oppressed, 
or exploited to defend their interests, because 
breaking with such conditions is a key element 
for the full realization (including good health) 
of these populations. It is important, however, 
for these groups to establish alliances with 
other groups that experience similar conditions, 
thus broadening their social base to strengthen 
their power. In that respect, the segregation of 
the political actions of such groups-as in the 
United States, which has many "issue-oriented 
movements," such as feminists, seniors, 
minorities, and others, but no strong class-based 
movement or party such as a social democratic or 
labor party that could relate different types of 
exploitations-can result in less improvement of 
health than if there were a larger political 
party and movement that could mobilize across 
issues. Women, seniors, and African Americans and 
other minorities in the United States have fewer 
social and health rights and worse health 
indicators than their counterparts in countries 
with less powerful women's, seniors', or minority 
movements but larger class-based labor 
movements-as in Sweden, for example (5). To make 
this observation (empirically verifiable) is not 
to engage in class reductionism but rather to 
clarify that most women, seniors, and minorities 
are among the working classes, and if these 
groups combined their struggle for better health, 
working within common political and social 
instruments, they could achieve greater influence 
and power. Actually, there is robust scientific 
evidence for a direct relationship between 
duration of governance of a country by labor 
parties and the improvement of its population's 
health (6). Indicators of these determinants of health are as follows:

1. Indicators of class, gender, and race power, 
such as years of government by progressive 
political parties, strength of class-based unions 
(as opposed to business-based or corporatist unions), and others

2. Types of democratic institutions facilitating 
representativeness, such as proportional 
representation (based on the principle of one person, one vote)

3. Absence of barriers to electoral participation

4. Ideological diversity and plurality of the 
media plus accessibility to the media, for all sectors of the population

The limited existence of these elements (as in 
the United States) considerably constrains the 
possibility of a population breaking with 
alienation and achieving good health. In 
developed countries, in fact, the evidence shows 
that the more democratic a society is, the 
healthier it is (6, p. 234). The poor health 
indicators in the United States are also based on 
its very limited democracy (7). If people feel 
they have good, representative institutions and 
instruments, they feel better and more confident 
that they can control their own lives and improve 
their health. The fact that the majority of 
people in Sweden feel positive about their 
representative institutions (with high electoral 
participation) while the majority in the United 
States feel negative about their representative 
institutions (with very low electoral 
participation) explains the lower rate of 
alienation and powerlessness in Sweden than in 
the United States (8). This has enormous 
consequences for the health of the populations 
living in these countries: very good health 
indicators in Sweden; very poor indicators in the United States.

Economic and Social Determinants

These are the interventions that aim at creating 
security and facilitating accomplishment. They include the following.

Full-employment policies aimed at creating good, 
well-paid, satisfying jobs. High or full 
employment is good for everyone's health, 
including those who are not employed. Access to 
plenty of jobs gives everyone a greater sense of 
security-including those who do not currently 
have a job (because they feel they could easily 
get one if they wanted to)-than does a high 
unemployment or low employment rate. Not being 
able to work because one cannot get a job creates 
huge health problems (9). These unhealthy 
consequences of unemployment are due not only to 
lack of resources but also to the feelings of 
insecurity that unemployment entails. Indicators 
of full-employment policies include:

1. Percentage of adult population working, and 
extent of wage differentials in the labor force

2. Levels of unemployment

3. Long-term unemployment

Social security and welfare state policies 
provide a sense of security to people who are at 
risk, providing them with the instruments, 
knowledge, practice, and resources to feel secure 
and have a chance to progress. The indicators of 
these interventions are the social rights in 
existence in a society (access to medical care, 
education, home care, child care, social 
services, public housing, and pensions for 
elderly persons and people with disabilities) and 
the resources for developing these rights. 
Populations of countries with higher social 
rights and public social resources (including 
public funds and legislative power) are healthier 
than those of countries with lower social 
protections (1). Indicators of such policies are:

1. Percentage of elderly people and people with 
disabilities who get good public pensions

2. Percentage of population covered by public 
medical care, and resources for public medical care

3. Percentage of children in public child care 
and pupils/students in primary, secondary, and 
tertiary education (including vocational and 
university education), and public resources invested in these services

4. Percentage of elderly people and people with 
disabilities who receive home care services, and 
public resources invested in these services

Policies on Reduction of Inequalities

Policies that reduce social inequalities 
(including income inequalities) by class and by 
gender, race, ethnicity, and region diminish the 
distance between social classes (and 
occupational, educational, and income groups 
within each social class) as well as between 
genders and among races, ethnic groups, and 
regions. Social inequalities can generate 
pathology and reduce the opportunities for 
persons to become healthier (10). Policies on 
reducing inequalities should include measures 
aimed at diminishing the social distances among 
all classes and groups, not only between rich and 
poor. There is strong empirical evidence that the 
most effective intervention to save lives and 
decrease mortality would be one that guaranteed a 
mortality rate for all social classes that is the 
same as that of the upper class (11). In this 
sense, antipoverty programs and programs aimed at 
preventing social exclusion (which characterize 
the Blair government's approach to reducing 
inequalities in Great Britain) are very important 
components of inequality-reducing policies, but 
they are just one component, and not the most 
effective. Policies aimed at reducing 
inequalities among all sectors of the population 
(that is, universal policies rather than 
antipoverty or anti-exclusion policies), such as 
those carried out by the social democratic 
governments in Sweden, are more effective in 
reducing mortality and morbidity (including among 
the poor and/or excluded groups) than are 
poverty-oriented policies (12). Key indicators for these types of policies are:

1. The redistributive impact of public 
interventions by the welfare state (e.g., changes 
in income distribution measured by the Gini or 
Theil indicators, before and after welfare state 
interventions). These public policies, enacted to 
reduce social inequalities, should be part of a 
broader policy directed at the causes of these 
inequalities, including the reduction and 
elimination of relations of oppression, 
discrimination, exploitation, and domination.

2. Changes in the percentage of national income 
derived from salaries. Empirical evidence shows 
that countries with a greater amount of income 
derived from property and a lesser amount from 
labor have worse health indicators. In this 
respect, the United States and Sweden represent 
the two ends of the spectrum (6). Policies aimed 
at reducing the percentage of income derived from 
capital and policies aimed at increasing the 
percentage derived from labor, as well as fiscal 
and economic policies aimed at redistributing 
resources, are effective in improving the health of populations.

Cultural Interventions

Cultural interventions are aimed at creating a 
culture of solidarity rather than a culture of 
competition. A strong sense of competition 
creates enormous insecurity and stress, which 
produces a lot of pathology. This was shown when 
Thatcher's liberal policies were established and 
developed in Great Britain, with a consequent 
fall in the rate of mortality decline across all 
age groups (13). A culture of high competition 
that focuses on individual competitiveness 
(reflected in the slogan "everyone should fly on 
their own") is unhealthy, because this creates anxiety and frustration.

Some cultural traits can also be very unhealthy, 
such as the excessive commercialization of 
society and the preponderance of the values of 
egocentrism, narcissism, consumerism, violence, 
and hedonism, which also create stress and 
frustration. This value contamination, one of the 
worst public health problems in society, should 
be a wakeup call for public authorities to 
intervene in the value-generating systems-from 
the schools to the media-to discourage and 
eliminate unhealthy values. The definition of 
beauty as "young and sexy," for example, is very 
exploitative; it generates great frustration 
among the majority of people who are not young or 
sexy (but feel they must strive to appear so in 
order to be accepted in our society). Also, the 
ubiquitous presence, in most countries, of 
members of the upper middle class as the main 
characters in television programs creates 
frustration among viewers, most of whom are 
working class (whose lives are rarely presented 
in the media). Indicators of cultural interventions include:

1. Number of educational programs that embrace 
solidarity rather than competition

2. Degree of violence in television programs

3. Degree of reproduction of class, race, and gender stereotypes in the media

Healthier Working Life Interventions

These interventions aim at creating safe, 
satisfying, creative, and enjoyable work. There 
is strong evidence to suggest that the nature, 
type, and conditions of work are among the most 
important variables determining a population's level of health (3).

Indicators of healthier working life interventions include:

1. Self-reported work-related health status

2. Index of accumulation of risk factors

3. Index of job strain and job conditions

4. Index of workers' satisfaction with their work

5. Workers' self-perceived level of control over their working conditions

Environmental and Consumer Protection

This protection is aimed at improving the 
physical environment for workers, consumers, and 
residents, thus ensuring conditions that protect 
and promote health. Indicators of such interventions include:

1. Percentage of population exposed to unhealthy noise levels

2. Nitrogen dioxide levels in outdoor settings

3. Levels of persistent chemical substances in breast milk

4. Injury incidence (deaths, and numbers of 
injured treated in medical care institutions) per 
100,000 workers in different environments

Secure and Favorable Conditions During Childhood and Adolescence

Interventions of this type are among the most 
effective ways of reducing poverty and preventing 
social exclusion. Here, again, there is plenty of 
evidence that children and adolescents in 
families that are poor feel excluded (14). It is 
therefore of great importance to provide good 
remedial education from birth to age 18 
(including good child care services) and good 
jobs for parents (especially for single mothers) 
in order to prevent social exclusion. Indicators 
of such types of interventions include:

1. Percentage of children (ages 0 to 3 years) in 
public child care centers, by social class

2. Level of education of preschool children

3. Percentage of youngsters who finish primary 
and secondary school and enter and complete tertiary education, by social class

4. Indicators of students' and teachers' influence in the schools

Health Care Interventions That Promote Health

These policies should emphasize public health 
interventions, both outside and within medical 
care services that cover the entire population. 
The medical care services should be designed in a 
way that facilitates access, comfort, and 
satisfaction for users and the population at 
large. Also, health promotion should be a key 
element of the medical care system, and all 
health personnel (particularly physicians and 
other health professionals) should be trained in 
the political, economic, social, and cultural 
determinants of health as well as in individual 
lifestyle interventions. Indicators of 
interventions that promote health include:

1. Percentage of population covered by the public 
medical care system and by public health services

2. Percentage of adult population working in health services

3. Percentage of public expenditures in health 
care that are spent on primary care

4. Indicators of accessibility to health care services

5. Indicators of power resources held by public 
health agencies to sanction delinquent corporate or business behavior

6. Percentage of people in the population who smoke or are alcoholics

7. Percentage of unwanted pregnancies

8. Percentage of television and radio time dedicated to health promotion

9. Rates of food poisoning in the population

10. Level of citizens' satisfaction with health 
care received and information provided

11. Percentage of population vaccinated against communicable diseases

12. Rates of HIV/AIDS

LIFESTYLE INTERVENTIONS

Lifestyle interventions, as the name indicates, 
are aimed at changing the unhealthy behaviors of 
individuals. These are the most classical 
interventions and the most visible components of 
health promotion. They include the following.

Interventions on Safe Sexual Behavior and Good Reproductive Health

These interventions are aimed at developing 
sexuality as a human right, separating enjoyment 
and pleasure from reproduction. Sexuality should 
be seen as an enjoyable activity and a component 
of human caring, and positive views about sex 
should be promoted. Information about sexuality 
should be available to all age groups, starting 
with the young. People should be able to express 
their sexual identity freely, without 
discrimination, and reproductive health 
information and care should be available to all 
persons who may benefit from it. Indicators of these interventions include:

1. Number of pregnancies and abortions per 1,000 women under 20 years of age

2. Incidence of Chlamydia infections in the 15 to 29 age group

3. Percentage of population that receives information on sex and sexuality

4. Availability of methods of contraception to the population

5. Analysis of media content to evaluate 
television and radio programs and avoid 
commercialization, exploitation, and stereotyping of sexual behavior

6. Redefinition of exploitative standards of 
beauty (such as equating it with "young and sexy") that create frustration.

Increased Physical Activity

This is an important but not highly visible 
health-enhancing intervention that prevents, 
among other diseases, hypertension and type 2 
diabetes, which are increasing among obese and 
sedentary people. The public authorities should 
promote physical activity in preschools, schools, 
and centers of work and learning, and should 
encourage the use of bicycles and walking. 
Indicators of such intervention include:

1. Percentage of population physically active for at least 30 minutes per day

2. Percentage of youngsters (ages 15 to 29 years) 
who have had a physical examination

3. Percentage of physical space in an urban 
center that is dedicated to physical activity

4. Availability of physical exercise centers per 10,000 inhabitants per year

5. Availability of physical exercise centers 
adapted to elders and persons with disabilities

6. Percentage of the population walking or 
cycling in relation to total personal transportation methods

Good Eating Habits and Safe Food

This type of intervention addresses one of the 
most important aspects of improving health, 
because at least 30 percent of disease can be 
related to eating behaviors. Being overweight is 
now one of the main health problems in developed 
countries. It is imperative, therefore, that (a) 
good and healthy food should be widely available 
to the whole population, including a wide variety 
of food choices; (b) food should be safe, with 
delinquent corporate behavior, as well as 
restaurants responsible for food poisoning, 
strongly penalized; (c) the public should be 
fully informed about the caloric content and 
composition of all food products; and (d ) the 
public should be educated about the relationship 
between food and health. Indicators of these interventions include:

1. Body mass index (BMI)

2. Percentage of population eating at least 500 
grams of fruit and/or vegetables every day

3. Percentage of infants breastfed (exclusively, 
at the age of 4 months and 6 months)

4. Incidence of Campylobacter and Salmonella infections

Reductions in Tobacco and Alcohol Consumption, Drug Use, and Excessive Gambling

Tobacco addiction is a disease and should be 
cured by helping the individual control his or 
her addiction. The tobacco industry should be 
prohibited from encouraging that addiction. 
Tobacco advertising targeted to the young should 
be made illegal, and advertising should be 
restricted to certain forums, with restriction of 
ads on radio and television. Tobacco should be 
highly taxed, with the collected funds assigned 
to programs aimed at curing tobacco addiction. 
Tobacco industry contributions to political 
parties or candidates or to political and social 
causes should be outlawed. Smoking should be 
forbidden in all public spaces, restaurants, theaters, streets, and workplaces.

Alcohol consumption should also be reduced (it 
has increased in the countries of the 
Organization for Economic Cooperation and 
Development), and alcoholic beverages should be 
taxed according to their alcohol content. Alcohol 
consumption should be allowed only in restricted 
areas and not in public places, such as streets, theaters, or sports forums.

Individuals who are addicted to drugs should be 
assisted and not penalized (except when drugs are 
consumed in public places), but the distribution 
of drugs should be strongly penalized.

Indicators of these interventions include:

1. Self-reported tobacco use

2. Self-reported exposures to environmental tobacco smoke

3. Percentage of restaurants and public places in 
violation of smoking, alcohol, and drug restrictions

4. Total consumption of alcohol

5. Mortality and injuries due to alcohol consumption

6. Percentage of drivers intoxicated by alcohol

7. Percentage of population taking drugs (self-reported and police-reported)

8. Mortality due to narcotics-related diseases and injuries

9. Prevalence of excessive gambling

EMPOWERMENT STRATEGIES

Empowerment strategies should help individuals 
link their personal struggle for improved health 
with the collective struggle to improve 
everyone's health. There is robust evidence to 
show that individuals who are aware of their 
health limitations and the causes of these 
limitations can improve their health if they link 
their own struggle for better health with the 
struggles of other persons who share their 
limitations. As noted above, young people with 
drug addictions who became members of the Black 
Panthers in the 1960s and 1970s improved their 
own health (i.e., stopped taking drugs) and the 
health of their neighborhoods. Black 
Panther-controlled areas became drug-free areas. 
And the coal miners of West Virginia who went on 
strike to improve their working conditions 
improved both their own health and the health of their community.

Individual commitment to improving other people's 
health improves one's own health-that is, 
commitment and solidarity are good for your 
health. Commitment means a desire to serve 
others; solidarity means development of networks 
of support in a joined cause to improve 
individual and collective health. Moreover, a 
collective response strengthens individual 
efforts to gain power, thus empowering the 
individual. These linkages between individual 
response and the collective, based on commitment 
and solidarity, are critical to achieving the 
structural determinants of good health. 
Collective action (political empowerment, using 
the term political in the broad sense of the 
collective expression of power) is of extreme 
importance to producing a healthy society. Its 
opposite is either acceptance or alienation 
(individual and collective). Acceptance of 
exploitation, however, would not be unhealthy if 
the person who is exploited were unaware of being 
exploited. A person may believe she lives in 
poverty, for example, because God wants her to be 
poor (what Mother Teresa called "the gift of 
poverty"). Poverty is thus seen as a welcome 
stage that helps individuals get to heaven, their 
final and most important destination (their stay 
on Earth being merely a transition). It is highly 
unlikely, however, that poverty and inequality 
are welcome to those who suffer them.

Poverty and inequality will be increasingly 
resisted because all the available information 
shows that inequality (and the social distance it 
creates) is frequently based on exploitation-that 
is, the wealthy classes are healthier because the 
poorer classes are less wealthy and less healthy. 
The perception of this social distance as 
exploitative is the basis for the widely held 
opinion in Western societies that society is not 
fair, that there is too much inequality. Indeed, 
opinion polls show that large majorities in the 
developed countries believe there is too much 
inequality in their societies (15). Needless to 
say, those at the top, the 20 to 25 percent of 
the population in the upper income brackets (who 
hold enormous power and influence in Western 
societies and are the healthiest sectors of the 
population), want the other 75 to 80 percent to 
believe that those at the top are there because 
of merit-that they deserve it; that this distance 
in status is a natural event; and that the 
current social order requires an acceptance of 
this situation so as to maintain itself. The 
problem is that increasing numbers of people do 
not believe that merit is the real criterion for 
social standing. The awareness of exploitation is 
one of the greatest threats for those at the top.

The response to an awareness of exploitation can 
be twofold. One response can be individual, which 
can create serious pathology (both individual and 
collective) as a consequence of frustration. 
Contrary to prevalent cultural ideas, such as the 
image of the solitary cowboy single-handedly 
dispatching the gang of bad guys, individual 
responses are inefficient and of limited value. 
The individual response of young black persons in 
East Baltimore to their exploitation is 
unhealthy, because it may take the form of anger, 
frustration, alcoholism, drug addiction and 
crime. This huge amount of energy, individually 
channeled, is of limited value and is unproductive for society.

The other possible response to exploitation is 
for that young person to join a group of 
youngsters to respond to and struggle together 
against that exploitation. This is the healthier 
alternative. The sense of commitment, struggle, 
solidarity, and hope for a better future are the 
healthier solutions, linking individual lifestyle 
determinants with structural determinants. This 
long tradition of linking the individual and 
collective struggles (which has characterized the 
history of the labor movement, among other 
movements) predates the faulty concept of "social 
capital," widely used by some researchers in the 
field of inequality, which trivializes the 
concept of solidarity and its purpose. The famous 
Putnam vision (16) of encouraging social 
capitalists to be even better capitalists (as one 
of his chapter titles phrases it) and to win in 
the competitive world is different from the 
concept of solidarity. It is the opposite of what 
healthy social behavior should be and the 
opposite of what is advocated here-that is, to 
link the struggle for individual liberation and 
health with the collective struggle. The 
objective should not be to enhance 
competitiveness in our societies but rather to enhance solidarity (17).

I also disagree with the widely used concept of 
"social cohesion," which I consider to be 
profoundly conservative. As a matter of fact, 
this concept was established by the conservative 
and Christian Democratic traditions as a response 
to the labor movement's struggle to change 
society (18). Social cohesion can exist 
side-by-side with enormous exploitation. There 
are many cohesive societies, where the social 
order is widely accepted, but where cohesiveness 
masks widespread exploitation and high levels of 
disease. In fact, a healthy intervention may be 
needed to facilitate a collective response, by 
those who are exploited, against that very cohesiveness.

There is a need to favor the concept and use of 
solidarity and a solidarious society as an 
alternative to a highly competitive society in 
which social capital helps individuals compete 
better. The ideas outlined in this article 
present an alternative to the dominant and 
hegemonic views in our societies. Still, we have 
recently witnessed some developments that are 
encouraging. Among them is the Swedish social 
democratic government's national health plan, 
which includes many of the structural and 
individual determinants of health and represents 
a gigantic step in the correct direction. It is 
important to expand these interventions along the 
lines outlined in this article, as well as to 
include the empowerment strategies referred to 
here. As it now stands, Sweden's national health 
plan is the most progressive such plan in 
existence. It is developing a strategy that far 
surpasses the narrow, reductionist view that 
tends to limit health policy to medical care 
interventions. Still, more needs to be done. I 
hope this article will help to define the 
pointers for a road toward better health.

REFERENCES

1. Navarro, V., and Muntaner, C. (eds.). 
Political and Economic Determinants of Population 
Health and Well-Being. Baywood, Amityville, NY, 2004.

2. Navarro, V. The Health Situation of East 
Baltimore. Department of Health Policy and 
Management, School of Hygiene and Public Health, 
Johns Hopkins University, 1978.

3. Navarro, V. Crisis, work and health. In 
Crisis, Health and Medicine: A Social Critique, 
ed. V. Navarro. Tavistock, London, 1986.

4. Marmot, M. The Status Syndrome: How Social 
Standing Affects Our Health and Longevity. Owl Books, New York, 2005.

5. Navarro, V., et al. Politics and health 
outcomes. Lancet 368:1033-1037, 2006.

6. Navarro, V. (ed.). The Political and Social 
Contexts of Health. Baywood, Amityville, NY, 2004.

7. Navarro, V. Dangerous to Your Health: 
Capitalism in Health Care. Monthly Review Press, New York, 1998.

8. Vagero, D. Do health inequalities persist in 
the new global order? A European perspective. In 
Inequalities in the World, ed. G. Therborn. Verso, London, 2006.

9. Burström, B., et al. Winners and losers in 
flexible labor markets: The fate of women with 
chronic illness in contrasting policy 
environments-Sweden and Britain. Int. J. Health Serv. 33:199-218, 2003.

10. Wilkinson, R. The Impact of Inequality: How 
to Make Sick Societies Healthier. New Press, New York, 2005.

11. Benach, J. Analysis of Mortality 
Differentials by Social Class. Papers of the 
Department of Health Policy, Pompeu Fabra University, Barcelona, 2005.

12. Whitehead, M., and Burström, B. Evaluation of 
the UK and of the Swedish Health Policies. 
Seminar on Health Inequalities, Johns Hopkins 
University Fall Institute, Barcelona, November 4, 2005.

13. Wilkinson, R. Unhealthy Societies: The 
Afflictions of Inequality. Routledge, London, 1996.

14. Esping-Andersen, G. A child centered social 
investment strategy. In Why We Need a New Welfare 
State, ed. G. Esping-Andersen. Oxford University Press, Oxford, 2002.

15. The International Value Survey, 2003 and 2005.

16. Putnam, R. Bowling Alone: The Collapse and 
Revival of American Community. Simon and Schuster, New York, 2000.

17. Navarro, V. A critique of social capital. In 
Political and Economic Determinants of Population 
Health and Well-Being, ed. V. Navarro and C. 
Muntaner. Baywood, Amityville, NY, 2004.

18. Navarro. V. Why some countries have national 
health insurance, others have national health 
services, and the United States has neither. Int. 
J. Health Serv. 19:383-404, 1989.

Direct reprint requests to: Dr. Vicente Navarro 
Department of Health Policy and Management Johns 
Hopkins University 624 North Broadway, Room 448 
Baltimore, MD 21205 e-mail: [log in to unmask]

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