American Journal of Epidemiology 2005 161(4):399-400;
 Lawrence, R. S.

BOOK REVIEWS

Health and Social Justice: Politics, Ideology, and Inequity in the
Distribution of Disease
Robert S. Lawrence
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205

Edited by Richard Hofrichter

ISBN 0-7879-6733-5, Jossey-Bass, San Francisco, California (Telephone:
877-762-2974, Website: http://www.josseybass.com/WileyCDA/), 2003, 688 pp.,
$55 (Paperback)

Health and Social Justice is a useful compendium of new and previously
published chapters and papers describing different components of the social
determinants of health. The contributors represent many disciplines, each
providing an important perspective on the complex interplay of social,
economic, cultural, political, demographic, and ethnic factors in
influencing health status. Seven of the 27 chapters are new contributions
for this volume. Most of the previously published chapters first appeared
in the last several years with the exception of Beauchamp’s classic paper,
"Public Health as Social Justice: Ideology of Market Imperatives," that
first appeared in Inquiry in 1976. The contributors build very effectively
on three important movements of the past several decades: the epidemiologic
studies illuminating the social gradient in health, the descriptive and
analytical studies of health inequalities, and the development of a
rights-based approach to analysis of health and human rights problems.

The opening chapter, "The Politics of Health Inequities," is a new
contribution by the editor. He provides a comprehensive review of a rich
literature that sets the stage very effectively for the rest of the book.
Weaving together information about the role of class, race, and gender,
Hofrichter develops a compelling case for applying a social justice
perspective to health. Most of the great improvements in reducing premature
morbidity and mortality in the industrialized world in the past century
came about by improvements in the safety and availability of food, potable
water and sanitation, reform of child labor, protection of workers, and the
introduction of vaccines. However, in the decades since World War II, the
United States has emerged as the industrialized society with the greatest
income and wealth inequality and a consequent increase in health
disparities. The top quintile of Americans now command a greater share of
wealth than at any time in 60 years, and almost one fourth of US children
live in poverty. Asymmetries of power, ideology, persistent racism and
sexism, and problems of environmental justice are exacerbated by growing
inequalities of income and wealth. Ironically, our scientific understanding
of the social determinants of health has deepened just as the negative
influences have worsened. Working people are losing power, and the advances
in wage security and workplace safety achieved by strong trade unions are
eroding rapidly. The power of large corporations and wealthy individuals
has increased to the detriment of health status among the poor.
Disinvestment in poor communities, weakening of regulatory structures, tax
subsidies for large businesses, constriction of social services, and other
assaults on the safety net contribute to growing health disparities. The
chapter concludes with a menu of policy options to help develop strategies
for achieving health equity. Most are ambitious and would require a sea
change of political will before being implemented. They do provide an
inspiring vision of what could be done to "shift resources and power toward
disadvantaged social populations" (p. 35).

The main body of the book is organized in three sections representing the
three general themes that illuminate the links between social justice and
health. The first section, "Social Forces Exacerbating Health Inequities,"
includes chapters describing the ways that health inequities linked to
gender, race, and economic status emerge from social, political, and
economic influences. Globalization of markets and the expansion of
multinational corporations are linked to poverty and health inequity in the
United States and around the world. Other chapters focus on zoning and land
use as they influence health and the central role that income plays in
creating the conditions in which people can be healthy.

The second section, "Theory, Ideology, and Politics: Critical
Perspectives," examines the way in which the analysis of health
inequalities has itself become a victim of the biomedical model, thus
obscuring the underlying hegemonic influences of wealth and power. The
contributors to this section examine the ideologies and theories that tend
to restrict our ability to think critically about the root causes of health
inequalities. Social justice provides a perspective that leads to
consideration of the links among asymmetries of power, organization of
work, and health inequalities and opens up the possibilities of more
fundamental and wide-sweeping social change.

The final section, "Strategies: Perspectives on Social Policy and
Practice," includes chapters proposing solutions to the problem of growing
health inequalities. The emphasis is on confronting root causes and key
determinants that are best understood by applying the principles of social
justice. The authors make a compelling argument that structural and
institutional changes have to occur to improve the health of vulnerable
populations, to dismantle policies that create structural violence, and to
reduce health inequalities. Strategies such as income redistribution,
welfare services, and better employment opportunities target the root
causes of the social determinants of health but often beg the question of
how to generate the political will necessary for policy change. Lacking in
this section is a detailed analysis of the adoption of a rights agenda to
address health inequalities. Even though the United States has failed to
ratify the International Covenant on Social, Economic, and Cultural Rights
(ICSECR) (and several related covenants on the rights of women and
children), many of the Covenant’s premises have taken on the power of
customary law for the United States. Moreover, for the 149 nations that
have ratified the ICSECR, it has become a centerpiece of international
human rights law. The right to health cannot be fulfilled without a
government’s commitment to respect and protect basic social and economic
rights. The addition of a chapter dealing explicitly with the right to
health would have strengthened an already-excellent book.

This book will be a valuable resource for students, teachers, and
researchers in social epidemiology and for public health professionals
engaged in developing strategies to reduce health inequalities.