Sherrie, I have been thinking a lot about your questions.  Perhaps it was more
wishful thinking on my part, and a reflection of my own stance, to claim an implicit
social justice agenda for health promotion. Perhaps I leapt too quickly to the
conclusion that if inequalities and poverty are the major causes of ill health as
(narrowly defined, and probably as broadly defined too, only we're not as good at
measuring that kind of health), then our inescapable task as health promoters is to
seek a more just and equitable distribution of resources and power.

Runciman (1972) believes -- and I agree -- that social inequalities are not wrong in
and of themselves, but that they require to be justified.  He has identified three
criteria, or principles in light of which inequalities of reward could be claimed to be
just.  (By the way, there is a good discussion of this in Andrew Armitage's book
"Social Welfare in Canada Revisited: Facing up to the Future" (1996), from which I
have drawn freely in the discussion that follows. I found it extremely helpful in
sorting out my own views on redistributive justice, and I recommend it to anyone
interested in a fairly up to date Canadian perspective on these perplexing issues.)

Runciman's three principles are:
1) need -- e.g., a person who is sickor in crisis needs additional resources to obtain
equality with others;
2) merit, but only to the extent that it equates with the willingness of individuals to
do things that are difficult to do, and which involve demonstrable hardship and
sacrifice to the doer;
3) contribution to the common good, from which everyone stands to benefit.  The
extent of the advantage enjoyed would somehow be proportionate to the extent of
thegeneral  benefit obtained by all.  Thus the ideal world would be characterized by
those differences in wealth and income that all had were justified, rather than
wealth and income -- and by extension, power and privilege -- being privately
determined.

These criteria would undoubtedly be open to differences of interpretation, but they
at least provide a good starting point for thinking about the issue of social justice,
and how society's goods should be distributed (given that the distribution patterns
show up eventually as patterns of relative advantage and disadvantage, which in
turn show up in health status/outcomes, which in turn we are pledged to do
something about.)

What we're up against are those who argue that redistribution -- e.g., through social
welfare programs -- is a burden, an item of unproductive expense which the
economy must sustain.  Armitage notes that there is nothing in capitalism which
supports social welfare. Thus, any transfer from wealthy to less wealthy requires
both ideological and political justification.  How the transfer is justified directly
affects the form it ultimately takes.  Armitage lists five principal arguments which
have been used to justify transfers:
1) need , usually determined by means test of some sort, unless of course society
determines a need based on social-psychological (as opposed to social-economic)
criteria -- e.g., admission to a mental hospital/treatment program;
2) insurance, in which a premium is charged in exchange for protection from some
contingency, such as unemployment or retirement;
3) compensation -- e.g., Workers Compensation, victim compensation,
comprehensive settlements with First Nations people, financial settlements in the
wake of family breakdown;
4) investment -- e.g., in education, (re)training, and relocation programs. Armitage
notes that there is a renewed interest in this form of redistribution, as a result of
Canada's need to be competitive in the global economy.  (If you think about it, we
are hearing more and more about "investing in health" these days, and increasing
productivity is provided as one of a number of justifications.)  But Armitage warns
that an investment ideology can result in programs designed to concentrate
resources on those who will benefit most.  Thus, responsiveness to need is not a
paramount consideration.  We see this reflected in many of the new "employment
measures and benefits" available through Human Resources Development Canada
to get people working, and the evaluation criteria applied in these programs --
successful outcomes are a) numbers who gain employment (or self-employment),
and  b) amount of savings realized to the Employment Insurance Fund (as a result
of those people not making claims any more)  Clearly, community organizations
who are being funded to deliver these programs must target most of their
resources on those individuals with the best chances of getting back to work, to
keep the numbers up.  Those who are on social assistance (as opposed to EI), or
chronically unemployed, or who have multiple challenges in getting into the work
force, will tend to get left behind;
5) economic growth and stability -- e.g.,  the post-war Family Allowance program,
which was seen (among other things) as a way of providing for greater stability of
consumer demand.  By putting money into people's hands, the government
increases total spending power in economic downtimes, and thereby contributes to
economic stability and growth.

So, how do our beliefs about justice and fairness play out day to day? This is of
course our quest. For myself, I feel that it is important for health promoters never to
lose sight of the big picture, and to find ways of working to change things as close
to the roots (of the problem, as they see it) as possible.

Right now we are mainly being forced to work downstream, picking up the broken
pieces, as it were, because of the prevailing tendency to individualize social/health
problems. While we can't turn away from this (almost remedial, social service)
work, we must recognize it for the treadmill that a lot of it is. We can't allow the
discussion to remain centred here, because it distracts attention from the
underlying issues, cleverly shifting the spotlight onto health promotion's apparent
ineffectiveness.  As Armitage reminds us: "Evaluation of the effect of social
services on the poor has not encouraged the idea that such services offer an
effective strategy to deal with poverty." (He does note, however, that such
community supports are important for those who need and qualify for them --
especially "services based in the social movements" which have been "developed
from the mutual support and social participation functions of community". Inherent
in many of these services is "an analysis of social conditions based on a common
experience of oppression, disadvantage and disempowerment as in the feminist,
First Nations and gay and lesbian social movements. The services are thus
consumer-driven and designed so that service providers work with and for
consumers ..." More on these below.)

If  as health promoters we are seeking to remove obstacles to the improvement of
people's health (however defined, but assumed to have something to do with
fulfilment of human potential, individually and collectively), then we have to be
concerned about poverty and inequalities, because of their documented negative
impacts on health. We have to keep reminding ourselves not to lose sight of their
influence despite the political hoopla and the ever-present temptation to focus
efforts on the immediate, more obvious, and more (seemingly) manageable causes
of ill health (smoking, poor nutrition, etc)

So, if we believe poverty and inequalities can be reduced or eliminated, we have to
find ways of working toward  that goal at the same time working at other more
downstream levels. (By way of clarification, Armitage explains that the concern with
poverty directs attention to the minimum standards of living that are to be tolerated
in a given society, regardless of the individual poor person's contribution to that
society. Poverty is part of a larger problem of inequalities, which directs attention
to the relative standards of living of different groups of persons.)

Getting rid of poverty and inequalities is not a mission for the faint of heart, since
there seems to be a fairly widespread and well entrenched acceptance that the
poor will always be with us (because we need them?) For example, in a recent
article in Foreign Policy (1998) called "Life is unfair: inequality in the world", Nancy
Birdsall (executive vice-president of the Inter-American Development Bank) writes:
"Ironically, inequality is growing at a time when the triumph of democracy and open
markets was supposed to usher in a new age."  She then eloquently documents the
increase of inequalities worldwide. Her subsequent analysis of the problem is not
one that I personally can support, but it's worth looking at because it shows what
we're up against. .

"Inequality is nobody's fault", she writes, and she goes on to explain how she
thinks inequalities have arisen:
a) history and politics have "conspired to produce economic and institutional
arrangements" that have perpetuated concentration of income;
b) the behaviour and "rational" decisions of the of the poor -- marrying each other,
investing little in income-producing assets such as schooling and job skills
(because they have so little faith in a labour market that has discriminated against
them), thus "handicapping their children economically", and having more children
than the wealthy and better educated -- have helped to widen the gap between the
rich and the poor;
c) "prosperity can produce inequality -- an outcome that, within limits, may be
economically justifiable";
d) "bad" economic policies, such as high interest rates, price controls, minimum
wages, regulatory privileges, trade protection, special access to cheap credit and
foreign exchange, described as "the most avoidable and thus most disappointing
source of inequalities", hamper economic growth and fuel inflation, which affect the
poor disproportionately.(She apparently prefers IMF-style reforms which she says
are "key to ending corrupt practices that usually benefit only a few".) She also
identifies the failure to invest in education and training as bad economic policy.

Birdsall claims that trade liberalization and open markets, rather than
protectionism, weaken "the unfair advantage enjoyed by the rich and connected".
She rejects "special worker entitlements", but does concede that while property
rights are elaborately protected in the complex codes of international agreements,
labour rights remain unacknowledged. Astonishingly, she tries to justify this by
arguing that most standards -- including collective bargaining rights -- would affect
only the "usually small proportion of workers in the formal urban sector, thus
increasing the gap between them and the majority of workers in rural and informal
jobs". Further, she contends that the resulting "higher labour costs would induce
employers to invest in labour-saving technologies", hurting mostly the poor,
"whose main asset is, after all, their own labor".  She also rejects "underpricing
public services" (water, sanitation, electricity and health care), claiming that in
times of scarcity this means a reduced supply of the services in question, leaving
the poor last in line.

After having berated trade protection, worker rights and cheap public services
because they would hurt the poor, Birdsall admits that there is "a role for
government to guarantee equal opportunities that market forces will naturally
neglect, especially for those individuals who will otherwise be left on the
sidelines." Her main prescription is educating the poor -- "the single best weapon
against income inequality".  (Notably, this solution leaves existing economic
structures and arrangements essentially undisturbed.)

The title of Birdsall's final section speaks for itself: "Learning to live with
inequality".  In it, she breezily concludes that there is no quick fix and that some
inequality is "healthy" and will help speed the transition from an industrial to an
information age. The "real danger", as she sees it, is that "growing inequality may
become a lightning rod for populist rhetoric and self-defeating isolation."

Perhaps this takes us to the heart of the problem.  As Andrew Armitage points out,
the capitalist form of the market economy is devoid of any moral character. Thus, it
is a "mixture of concern at the unfairness of the capitalist economic order, human
sympathy for the unfortunate, and fear that organized opposition might disrupt the
market economy" that has led to the development of social welfare measures.  Is
there an implication here that countries will tend to the minimum they can get away
with?.

As Armitage notes, in a global economy each country becomes involved in a
competition aimed at minimizing the costs of welfare in order to provide a more
profitable and attractive environment for international investment -- thus our social
welfare system (our chief mechanism of redistribution, which in turn is the main
means of reducing inequalities) has to be designed, financed and managed in a
manner that supports, or at least does not harm, Canada's external economic
competititiveness.

In this context, dearly held Canadian values struggle to find a place. As Armitage
notes: the value of concern for the individual is in conflict with global economic
processes and values that see all transactions in purely financial terms; the value
of equality conflicts with the propensity to create and maintain inequality through
inheritance, private ownership and the resolution of scarcity through competitive
bidding; and the value of maintaining viable communities conflicts with the
processes of change that disrupt communities through technological change,
industrial development (or decline) and urbanization.  The values of equity and
diversity are in conflict with established positions of privilege and power and
private ownership which always favour the status quo. Furthermore, the
conservative vision (with which we are probably saddled for the foreseeable future,
given what Armitage calls the increasingly conservative nature of Liberal
government proposals) operates in a context that favours personal freedom over
social justice and financial incentives over equity or equality.

Such treatises as that by Birdsall, coupled with the manifest intractability of the
poverty problem, in Canada and globally, suggest that poverty is viewed by some
as a "necessary evil" -- i.e., wealth for some (usually, the few) requires as a
condition precedent, poverty for many.  As Barr (1995) notes: "Within British
community development ... it has been recognised that to seek to alleviate poverty
is to swim against the tide of a market value system in which poverty is functional
and inequality part of the design."  In other words, the barriers to a more even
distribution of society's goods are more than just logistical or administrative, etc --
they are political.

So, what can health promoters do? Armitage notes that in a democracy, the
accepted instruments of change are persuasion, argument, protest, publicity,
organization, interest group politics and alliances.  Many in health promotion
already work through these avenues. We also need to be sure that health-related
issues are broadly rather than narrowly framed, and that OUR understanding of
issues receives air time. As Deborah Stone (1988) points out, policy agenda-setting
usually involves constructing a 'story' of what caused the policy problem in
question (bearing in mind that the "problems" governments resolve are also
'constructed'. As Murray Edelman (1988) has argued (cited in  Howlett & Ramesh,
1995): "Problems come into discourse and therefore into existence as
reinforcements of ideologies, not simply because they are there or they are
important for well- being. They signify who are virutous and useful and who are
dangerous and inadequate, which actions will be rewarded and which penalized ...
they create beliefs about the relative importance of events and objects... They
construct areas of immunity from concern because those areas are not seen as
problems.")

There is also important work for health promotion to do at the community level,
although, as Armitage notes, major established government service programs and
related service contractors are increasingly vulnerable to reduced public
expenditure (but in his judgment not as vulnerable as the redistributive programs).
 He believes that the newer forms of community social agencies --  those rooted in
a series of autonomous social movements such as the feminist movement, First
Nations organizations, ethnic and immigrant organizations, associations for
persons with disabilities and the gay and lesbian communities --  have better
prospects for continued  growth, regardless of government funding and deficit
issues. He acknowledges that government funding has become more significant in
their affairs, but notes that the structural mode of analysis they use supports their
independence, by encouraging a distrust of government control.

Armitage sees the social movements' social service programs and community
economic development enterprises as expressions of  a much more diverse and
plural community. He notes that community economic development initiatives
provide a new response to the issues of the global economy -- one  in keeping with
the principles of social justice and economic needs. This is because community
economic development utilizes all the processes of capitalism, except that the
endeavours are owned by the community and are in a developmental and
non-exploitative relationship to the community.

Merits of  the services of these newer types of agencies include the fact that they
are usually characterized by: "a clear statement of who is being served and why;
an approach to staffing and working relationships that is egalitarian and expresses
values important to the movement; a political mission to demonstrate to the
community can and will act; a unifying ideology anchored in a structural analysis of
the origins of the movement."

I'm sorry this is so long again (I wouldn't want to contribute to any more testiness
than has already appeared in this debate, as people can lose the courage to
contribute in such an atmosphere).

In any case, hope some of it helps. It has sure helped ME trying to sort it out!

Elizabeth


References:
Armitage, Andrew. (1996). Social Welfare in Canada Revisited: Facing up to the
Future. 3rd edition. Toronto: Oxford University Press.

Birdsall, Nancy (1998) "Life is unfair: Inequality in the world."  Foreign Policy,
Summer 1998, 76-93.

Edelman, Murray J. (1988). Constructing the Political Spectacle. Chicago:
University of Chicago Press.

Howlett, Michael, and Ramesh, M. (!995) Studying Public Policy: Policy Cycles and
Policy Subsystems. Toronto: Oxford University Press

Runciman, W.G. (1972) Relative Deprivation and Social Justice. London: Pelican
Books.

Stone, Deborah A. (1988) Policy Paradox and Political Reason. Glenview: Scott,
Foresman.


Elizabeth Rajkumar
The Working Group
1-295 Ashton Avenue
Ottawa, ON K1Z 6T5
Tel: (613)729-0953
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