“We should think about health inequity not as differences in outcomes across categories of individuals but as structural injustice that harms the health of everyone.”
The broad contours of America’s poor health are widely known. Once among the world leaders in life expectancy, we now trail all countries with comparable economies, erasing decades of progress and instead ranking highly in measures of chronic disease burden. This poor health, plus the dysfunctional way we finance and produce healthcare, feeds a massive amount of reactionary spending on personal healthcare, the highest amount in the world. But all this spending seemingly provides little value, and it does not even guarantee healthcare access for everyone.
Amid these problems, efforts to improve population health and health equity have focused primarily on healthcare systems, as well as on measuring health (in)equity primarily as social disparities—differences in health outcomes between socially better-off and worse-off categories of individuals. Although well intentioned, these efforts have had little measurable effect in improving outcomes.
It is in this setting that my new book, Equal Care: Health Equity, Social Democracy, and the Egalitarian State, argues for a different way to approach these fundamental problems. In my work as a primary care doctor and health researcher over the last 15 years, it has become clear to me that social conditions are the real drivers of population health, and that health inequity stems from institutions, policies, and programs that undermine everyone’s fundamental moral equality. Ultimately, we should recognize, as I write in my book, that “health inequity is social failure embodied, and the only true cures are political.”
Equal Care’s Argument
The current “disparitarian” approach to health equity warrants critique. Although research on health disparities has usefully pointed out many situations in need of remediation, the approach has important limitations. Alternative ways of thinking about health equity are needed. One key problem with disparitarianism is a tendency to focus on description over explanation: identifying situations where health outcomes differ but not necessarily uncovering concrete, addressable causes for the disparities found. A second problem, which may seem paradoxical, is the implied affirmation of existing social structures. By comparing a worse-off category of individuals to a better-off category, the implication of much disparitarian work is that social conditions are working well for the better-off category, and what we need is simply to extend those conditions to more individuals.
This approach overlooks (and indeed can intentionally hide) the fact that the better-off category may not be doing so well after all: Existing social structures may be negatively impacting both categories of individuals. An example of this is work on health equity in the United States from early in the Coronavirus (COVID-19) pandemic. The work focused on clear racial disparities in COVID-19 mortality, which were the result of unjust social conditions. But, at the same time, non-Hispanic White individuals in the United States, the reference category used, still had COVID-19 mortality about twice as great as the overall COVID-19 mortality rate in Canada at the same time. Thus, health equity work that focused simply on differences between categories of individuals in the United States ignored the larger social structures that harmed the health of everyone in the United States. Thus, the disparitarian approach can have the effect of distracting from more fundamental structural problems even while calling attention to important issues.
If focusing on differences in health outcomes between categories of individuals is not the correct approach to health equity, then, what is? We should think about health inequity not as differences in outcomes across categories of individuals but as structural injustice that harms the health of everyone. Health equity work, then, consists in trying to address the health-harming injustices that everyone faces.
This focus raises the question of how we should think of justice. As part of a school of relational egalitarian thought that includes the work of John Rawls, Amartya Sen, and Elizabeth S. Anderson, I argue that we should think of justice as occurring when we put in place institutions that work to materialize everyone’s fundamental moral equality. The goal of our public policy should be ensuring that people have the capabilities needed to stand as equal members of a democratic society. Drawing on work from Sen, I call the set of capabilities needed to do this the “essential capabilities.” These include civil and political rights, capabilities relating to economic life such as participating in the labor market on fair terms, and the capability to meet basic needs such as those for food and housing. By establishing the correct institutions, policies, and programs that guarantee the essential capabilities for everyone, the state shows equal care for the life of all individuals.
This may all seem far afield from health. But as I review in depth in the book, over a century of medical, epidemiological, and public health research makes clear that social conditions are the key explanation for variations in health outcomes within and across societies. The fundamental scientific fact is that health is an integral of lifetime social conditions: all the conditions one is exposed to, throughout one’s life, sum up to one’s current health state—what epidemiologist Nancy Krieger calls an “emergent embodied phenotype.” This means then that the major concerns of social policy—how individuals are recognized as full members of society and how property rights (and thus the distribution of society’s resources) should be configured—are also major concerns for population health. Thus, just like a population health program that failed to attend to clean water, uncontaminated food, sanitation, and immunizations would be seriously incomplete, so would a population health program that did not focus on social status and income distribution.
Given all that, what then is the population health agenda we should be pursuing? First, basic liberties such as freedom of speech, freedom of conscience, the franchise, the ability to hold office, and due process under the rule of law are the bedrock of a democratic society. We must work against democratic backsliding that seeks to take away these freedoms hard won in prior generations by egalitarian social movements. Next, we need public provision of the goods and services that markets do not supply well (such as education, healthcare, and personal care). Further, we need income support programs for the times in life people cannot and should not engage in paid labor—childhood, older age, sickness and disability, spells of unemployment, pursuing advanced education, and providing socially necessary, but unpaid, caregiving. And when people are engaging in paid labor, we need to facilitate collective bargaining arrangements that balance power between employers and employees. Finally, we need a fair system of public finance, centered on a progressive income tax, and supplemented by consumption taxes, wealth taxes, and a social wealth fund. A fair system of public finance not only bankrolls the necessary public programs but also works against the unjust power that extreme concentration of wealth brings, which ultimately undermines democratic government.
Although I am under no illusions about the ease of accomplishing this agenda, it is not utopian. Policies and programs like the ones discussed exist and function throughout the world, and the book details how to finance, implement, and publicly administer the efforts needed.
Conclusions
Neither health equity nor population health is principally about healthcare. Improvements in the ways we finance and deliver healthcare are certainly needed, but they are only one part of an overall agenda to improve population health. Because social conditions and institutions that place people in different social locations so strongly affect the incidence of disease and its treatment, addressing these issues is where our focus needs to lie.
We are living in a dangerous moment. Threats long believed to be vanquished have returned with a vengeance. At the same time, much more is up in the air than at any point in my lifetime. Institutional upheaval can dissolve not only the structures that served as safeguards but also the ones that held back progress. Now is the time to push for major reforms that meaningfully reverse declining population health. But to do so, we have to know what to aim for. I hope that my book synthesizes the normative grounding, empirical knowledge, and pragmatic know-how needed to design, finance, and implement public policies that will improve everyone’s health.
Seth A. Berkowitz is a primary care doctor and health researcher. He is an Associate Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine.
