Public Health II

1. Inequality in Health Care

2. Does Poverty and Inequality Go Hand-in-Hand? The following text is the transcript from the video: In this lesson, we will move to the second part of Public Health. We will focus on the topic of inequality. Norman Daniels asks an important question: When is an inequality in health status between different socioeconomic groups unjust? We may think the distribution of health resources is inherently unjust—richer nations have more resources while poorer nations have less, the people in these countries therefore can access more or less health care resources relative to the level of wealth of their countries. We may also think, any inequality is unjust. However, it is not that simple. Richer countries do not always have better and more accessible health care, and people who live in richer areas do not necessarily have a longer life span. This paper by Daniels will lead us to explore the complexity surrounding inequalities in health care. The question we now explore is whether poverty and inequality to health care go handin-hand, in other words, does a poor country always have more inequal health care? Do people in a wealthier country always have more equal access to health care?

Daniels points out, with support of empirical studies, that is not so. He also gives his reason here. First, no matter which areas or countries we are talking about, a persistent pattern is that social class and the social economic status of individuals correlate with their health condition and life span. We have known this for more than 150 years, individual’s chances of life and death are patterned by social class: The more affluent and better educated people are, the longer and healthier their lives (Villerme 1840, cited in Lynch et al. 1998). Daniel argues that, one, poorer countries with certain policies produce excellent aggregate health outcomes, and two, the effects of socioeconomic status are present in rich developed countries. Poverty and deprivation are not the reason. For example, Costa Rica and United States differ vastly in wealth, but their citizens have almost similar life expectancy. Here is a list of correlating factors of inequality to health care: Socioeconomic status, racial and ethnic disparities, and gender inequality in health. We will explore further the complexity surrounding inequality in health care in the following components.

3. Unjust in Healthcare (Part 1 of 2)

Daniels thinks that we are facing issues of distributive justice when we talk about health inequality, and that the way socioeconomic inequalities correlates with inequalities in health care is the root of the problem. The puzzling phenomenon is that many who are not troubled by significant inequalities in income, wealth, or opportunities for a higher equality of life are particularly troubled by health inequality.

4. Unjust in Healthcare (Part 2 of 2)

Some believe that a socioeconomic inequality that otherwise seems just becomes unjust if it contributes to health inequalities. A lot of times, Daniels thinks, we think of the basic idea as “everyone deserves a basic right” when it comes to health care. Rather, we should think about the upstream distribution of social goods that determine the health of societies, take a top-down approach. One phenomenon Daniels observes is that research done in the United States on health disparities tend to focus on issues such as race, but rarely on class. He further thinks that in order to understand the unjust in health care distribution, we need the help from a famous American philosopher, John Rawls. Rawls is most famous for his theory of justice as fairness, or justice as fair opportunities. Going forward, we will see how Rawls’s theory of justice helps us understand health inequality. 3 © May not be copied or duplicated without the permission of the owner.

5. Basic Findings

The first fact we observe from the figure is that the relationship between economic development and health is not fixed. The national income/health are influenced by social policy choices, instead of determined by economic development. There are not some fixed or determinate laws of economic development. The wealth of nations matters up to a relatively modest point, but policies always matter and arguably more in poor countries. If we look at the figure, we will notice that there is a clear association between per capita gross domestic product (GDPpc) and life expectancy, but only to a point. Once above $8000 GDPpc, there is virtually no further gains in life expectancy. We can also compare Cuba and Iraq, being equally poor, life expectancy in Cuba exceeds that in Iraq by 17.2 years in 1995. Costa Rica and the United states differs vastly in wealth, but have almost similar life expectancy. 6. Basic Findings in Canada You may wonder where does Canada stand, Daniels doesn’t talk about Canada but here is a map showing differences in expected life spans across Canada. As you can see, the life expectancy does not correlate strictly with the level of wealth. Some factors, such as urbanization make a difference in people’s life expectancy.

7. Basic Findings: Individuals and Their Socioeconomic Status (SES)

Let’s move back to the individuals and their socioeconomic status (SES). The figure shows us what is called the “socioeconomic gradient.” Though the effects of income or wealth work across the SES spectrum, the gradient is steeper at lower income levels, with considerable flattening out at the highest income levels. This steepness cannot be explained by differences in access to health care either, as studies on the British civil servants show. I won’t go into details of this study but please make sure to read it in the reading, and we will come back to discuss it shortly. Some societies show a relatively shallow gradient in mortality across SES group, while some societies with comparable or even higher levels of economic development, show steeper gradients in mortality rates across the socioeconomic hierarchy. This leads us to the idea of income relativity. There is support that income inequality, as opposed to absolute levels of income, helps to determine the steepness of the gradient. If that is true, it means that it is not just the size of the economic pie but how the pie is shared that matters for population health.

8. Basic Findings: Adult Literacy and Women’s Status

We can also observe a link between social inequalities and health inequalities. For example, another important factor is adult literacy. In developing countries, one of the strongest predictors of life expectancy is adult literacy, particularly the disparity between male and female adult literacy. In the US, women’s status (economic autonomy and political participation) strongly correlates with female mortality rates. This association leads to an important idea—health inequality is entangled with inequalities in many areas of the society. Some difference may not be a matter of justice: For example, there is generally a lower life expectancy of men compared to women in developed countries. Does that constitute inequity? Further, is that unjust?

1. Rawls Theory of Injustice

2. Rawls’ Theory of Justice (Part 1 of 4)

Daniels proposes to use John Rawls’ theory of justice to determine what kind of inequalities are considered unjust and what kind are allowed. Rawls believes that a social contract designed to be fair to free and equal people would not only justify the choice of those equal basic liberties but would also justify the choice of principles guaranteeing equal opportunity and limiting inequalities to those that work to make the worst-off groups fare as well as possible. Guaranteeing equal opportunity is key in his theory. In a just democratic society, it is not guaranteed that people will have equal income or wealth, but it should be guaranteed that everyone has the chance to succeed. And that chance, or opportunity is protected by institutions such as public education.

3. Rawls’ Theory of Justice (Part 2 of 4)

Why is inequality in health viewed differently than inequality in income or wealth? Daniels thinks that we can use Rawls’ theory to observe health status of individuals as a determinant of the opportunity range. Since opportunity is included in the index of what Rawls calls “the primary social goods,” the effects of health inequalities are thereby included as well. In sum, access to health care is essential to our opportunity to succeed in a society, therefore, health care inequality should be addressed before we can claim everyone has equal opportunity to succeed—or that our society is set to be a just democratic society. The equal opportunity principle requires extensive public health, medical, and social support services aimed at promoting normal functioning for all.

4. Rawls’ Theory of Justice (Part 3 of 4)

The equal opportunity principle requires extensive public health, medical, and social support services aimed at promoting normal functioning for all. You may recall we mentioned earlier that inequality in health is entangled with many factors such as the socioeconomic status (SES), wealth level, policies, education, and so on. The implication of Rawls’ theory, when applied to health care, is that we need to adjust or intervene when factors such as SES, wealth, education, etc. cause severe and unjust inequality in health.

5. Rawls’ Theory of Justice (Part 4 of 4)

For example, if income inequality causes unjust inequality in health care, we need to do something about the income disparity. This doesn’t mean an egalitarian approach where everyone gets equal income, it simply means that we need to manage the income disparity so that people have access to adequate health care and can stand a fair chance in the society.

6. Justifiable Inequality

We should also note that Rawls allows some inequalities in health care—as you can imagine, as long as it doesn’t hinder individuals’ chances to succeed in a society. An even more complex question Daniels raises at the end of the paper is, when justified health inequality is in tension with the productivity of a society, is it permissible to sacrifice inequality in health care? This is a question I will leave to you to think about.

7. Wrap-Up

In this lesson we discussed a very complex topic, inequality in health care. We tend to believe the right to health is something inherent and the only reasons for a lack of health care is poverty and a deprivation of resource. However, Daniels showed us that poverty and inequality do not necessarily go hand in hand. Policies and social equality play a role in people’s health and life expectancy. We then saw from data that relationship between economic development and health is not fixed. We further talked about the factors that correlate with inequality in health, such as SES, adult literacy rate, education and so on. 3 © May not be copied or duplicated without the permission of the owner. The second half of the paper discussed Rawls’ theory of justice and its application to health care. He believes in equal opportunity, and since health care ensures individuals’ basic opportunity to succeed in a society, he believes that we need to address inequality in health if it hinders individual’s opportunity to succeed. Any inequality that hinders individual’s opportunity to succeed, is therefore, unjust.