Racial Health Disparities and Questions of Evidence

The United States Healthy People 2010 initiative, designed to focus nationally funded health research and care on achieving a set of nationwide goals, was directed toward the elimination of racial and ethnic health disparities. While racial and ethnic disparities are complex (with the health of some minority groups surpassing the national average), the health of black Americans continues to fall short of the national average. By focusing on the presumptions embedded in the design of health disparities research, this chapter addresses why Healthy People 2010 largely failed to reduce racial health inequality. Importantly, in thinking about health inequalities, researchers initially failed to consider how race is socially constructed; how data collection is never value-neutral (see King, chapter 8, this volume); and, finally, the limits of randomized control trials (deductive methods) when it comes to making sense of complex behavioral and structural data. The chapter ends by describing how ethnographic insights can help complicate the assumptions and conclusions of health disparities research.

Justice, Respect, and Recognition in Mental Health Services

This chapter raises a key question for the interdisciplinary study of health and justice: is dialogue possible between theoretical models and first-person testimony about the harms caused by injustice? To consider this question, the chapter examines the claim that disrespect—the systematic devaluation of others in a way that excludes them from reciprocal social relations—is a form of injustice. The philosopher Stephen Darwall and social theorist Axel Honneth conceptually elucidate the links between justice, respect, and recognition. Their normative arguments offer a high-order conceptual framework for recognizing people’s equal worth as human beings (and the harmful effects of denying such recognition). This chapter compares their abstract frameworks with a landmark autobiography by a founder of the psychiatric survivor movement. The search for commensurability between these texts exposes the precise difference between experience-far and experience-near genres of ethical expression. This chapter adopts a similar approach as DeBruin et al. (this volume) in examining popular cultural discourses in light of formal theory. Both chapters take seriously the lay narratives and forms of ethical argumentation that circulate outside the academy. Both envision a plural ethics of justice and health that acknowledges how ordinary people interpret and respond to institutionalized oppression in health-care services.

Embodied Inequalities

This chapter combines ethnographic and social epidemiological approaches to analyze the causes of Latino children’s high rates of oral disease as well as their cumulative effects. Social epidemiological approaches suggest the complex interplay of biology and social structure at multiple levels in creating health inequalities. How can we use ethnography to operationalize this model, illustrating the varying role of familial, clinical, and sociopolitical contexts in creating farmworker youths’ health inequalities? Moreover, how can social epidemiology heed the insights of ethnography, and what happens when we assign equal truth status to parents’ “local” knowledge and to expert knowledge of epidemiological reports? This chapter serves as a lens both for understanding the roots of farmworker children’s poor oral health and as a thought experiment for considering the provocative methodological and epistemological questions posed by an interdisciplinary dialogue on health inequalities. Using a life course perspective, we examine the way that farmworker young adults’ poor oral health feeds back into a system of social inequality. Using the lens of oral health, this chapter presents a vivid argument for why health inequalities are cause for policy intervention—that is, why they are a matter not only of fairness but also of equity and justice.

Global Health Inequalities and Justice

This chapter discusses challenges of global health inequalities in the current global health policy system. It then describes provincial globalism and a shared health governance framework as approaches to these challenges. Moral philosophers have for some time argued that global poverty and associated human suffering are universal concerns and that there is a moral obligation, beyond matters of charity, for wealthier countries to do more. Being serious about addressing the problem of global health inequalities requires developing a conception of global health justice. Moreover, addressing global health inequalities requires a reexamination of the norms and principles underlying global institutions in order to offer proposals for a better global health policy. This chapter sketches analytical components of provincial globalism, a framework that takes individuals to be the moral unit in both domestic and global contexts and that improves the prospects of alleviating global health inequalities. Provincial globalism promotes the realization of individuals’ health capabilities and supports a shared health governance that enables institutions to reexamine the objectives, policy goals, and decision-making procedures of the global health architecture. Shared health governance, in turn, provides standards for regulating global and domestic institutions and practices to create the conditions for realizing individuals’ health capabilities.

Cultural Health Capital

The 2010 Patient Protection and Affordable Care Act promulgated a number of fundamental changes to the United States health-care system. Less visible and controversial aspects included the creation of institutions and strategies to reduce health disparities and enhance the quality and patient-centeredness of health care. In this chapter, we offer the concept of cultural health capital (CHC) as a sociological intervention for analyzing these changes aimed at making health care more patient-centered, particularly for historically underserved populations. In particular, we use the notion of CHC to illustrate how patient-centered care is accomplished or undone through complex interpersonal and interactional work that is highly dependent on access to stratified cultural resources that both patients and providers bring to health-care interactions. In so doing, we aim to contest that racism in health care is the primary source of health inequalities. Instead we argue that patients’ and providers’ cultural assets and interactional styles—themselves the product of complex social, cultural, historical, political, and economic contexts—influence their abilities to communicate with and understand one another.

Health Difference, Disparity, Inequality, or Inequity—What Difference Does It Make What We Call It?

Over the past two and a half decades, distinct approaches have been taken to defining and measuring health inequalities or disparities and health equity. Some efforts have focused on technical issues in measurement, often without addressing the implications for the concepts themselves and how that might influence action. Others have focused on the concepts, often without addressing the implications for measurement. This chapter contrasts approaches that have been proposed, examining their conceptual bases and implications for measurement and policy. It argues for an approach to defining health inequalities and health equity that centers on notions of justice and has its basis in ethical and human rights principles as well as empirical evidence. According to this approach, health inequality or disparity is used to refer to a subset of health differences that are closely linked with—but not necessarily proven caused by—social disadvantage. The term “inequity,” which means injustice, could also be used, but arguments are presented for using it somewhat more sparingly, for those inequalities or disparities in health or its determinants that we know are caused by social disadvantage.

Health-Care Justice, Health Inequalities, and U.S. Health System Reform

Changes in health system financing and delivery have the potential to save thousands of lives and billions of dollars. The overarching value system embedded in these new models for payment is a rough utilitarianism with origins in economic analysis. These models use financial incentives to change the behavior of physicians, hospitals, and patients. In addition, many of these policy approaches are also based in other normative approaches to medical care with links to liberal economic theory. While these utilitarian-based innovations in insurance and payment policy have often proven to improve access and quality of care in the aggregate, they have frequently been shown to have less benefit or even cause harm to vulnerable populations. This chapter demonstrates how improvements in quality of care frequently have the unintended consequence of widening disparities, either because the populations who had the worst outcomes to start with are more difficult to reach with improved-care models, or because the mechanisms designed to increase access and quality actually destabilize institutions that have long served the poor. As health reforms are implemented, attention to their impact on poor patients and the institutions that serve them will be essential.

Introduction

The introduction to Understanding Health Inequalities and Justice: New Conversations Across the Disciplines describes the terrain of health justice and inequalities and the multiple disciplinary perspectives that explore it. In the introduction, the editors advance the view that how we approach health inequalities and justice is a matter of great import, and argue for the positive impact multiple disciplinary perspectives may have when engaged in conversations together on these matters. The introduction offers a substantive discussion of normative paradigms informing health justice including egalitarian, libertarian, utilitiarian, rights-based, and principles-based bioethics approaches. In addition to examining each of the three sub-headings of the volume: 1. Interrogating Normative Perspectives on Health Inequality and Justice, 2. Disrupting Assumptions and Expanding Perspectives through Cases, and 3. Rethinking Evidence and the Making of Policy, each chapter is given a detailed introduction and described in relationship to other relevant chapters in the volume.

Justice, Evidence, and Interdisciplinary Health Inequalities Research

This chapter examines the interplay between normative judgments and empirical research. Using a case study of recent work on the social determinants of health, the author argues that three domains that are normally thought of as conceptually and disciplinarily independent—epistemology, scientific methodology, and normative judgment—are in fact closely intertwined. When considering issues related to health inequalities and social justice, keeping these domains separate leads to poor science, poor theorizing, and, ultimately, poor policy choices. The author identifies three problems with the claim that in order to reduce health inequalities and improve population health, we are morally compelled to address the social determinants of health, through interventions that redistribute social or economic resources in a more fair or just manner. The problems are (1) assuming that data are the neutral products of objective scientific investigations; (2) misunderstanding causality and counterfactual reasoning; and (3) blind belief in the consonance of the good.

Health Inequalities and Relational Egalitarianism

Much of the philosophical literature on health inequalities seeks to establish the superiority of one or another conception of luck egalitarianism. In recent years, however, an increasing number of self-avowed egalitarian philosophers have proposed replacing luck egalitarianism with alternatives that stress the moral relevance of distinct relationships, rather than the moral relevance of good or bad luck. After briefly explaining why the author is not attracted to luck egalitarianism, the author distinguishes and clarify three views that have been characterized in the philosophical literature as forms of relational egalitarianism. The author calls these three relational views equality of treatment, equality of concern, and social egalitarianism. The author argues that each deserves the title “egalitarianism” and (more importantly) that these three views are not competitors; rather, each brand of relational egalitarianism describes a plausible plank of distributive justice that bears on the evaluation of health inequalities and on the political institutions that create, sustain, or exacerbate them. To illustrate this pluralistic relational egalitarian approach, the author draws on a case study by Horton and Barker (this volume) to discuss how each of the three planks might be brought to bear on the evaluation of oral health disparities among the children of migrant Latino farmworkers in California.