"Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death."
These first words from the WHO Commission on Social Determinants of Health Final report entitled Closing the Gap in A Generation: Health Equity Through Action on the Social Determinants of Health highlight the deep connection between lived experience, social injustice, and systematic inequities in rates of mortality, morbidity and life expectancy among different groups.
Can public health influence the unequal structuring of life conditions? NACCHO thinks public health can reach the heart of the matter: the core social injustices associated with class oppression, racism, and gender inequity. Advances can occur, even if only incrementally, by thinking differently about possibilities for practice.
This course provides an online learning environment from which to explore root causes of inequity in the distribution of disease, illness, and death. Funded by the National Center for Minority Health and Health Disparities, National Institutes of Health, its audience is primarily the local public health workforce. It seeks to ground participants in the concepts and strategies that could lead to effective action.
The curriculum specifically prompts participants to reflect on how our institutions, as historian Elizabeth Fee says, "structure the possibility for healthy or unhealthy lives and how societies create the preconditions for the production and transmission of disease," (see Resources, Elizabeth Fee, p.xxxviii) and the implications for acting on those systems to eliminate inequity.
The course arose from a need expressed by public health practitioners for assistance in tackling root causes of health inequities. Repeatedly, they asked, "Where do we start? How do we address the bureaucratic and financial constraints?" Renewed interest in social medicine, social epidemiology and an outpouring of research and analysis about health inequity also influenced us. NACCHO is not an expert on the issues. Rather, as a national organization supporting local practice in the U.S., we view ourselves as colleagues engaging with our peers and raising questions, based on what we have learned from the field and from the growing knowledge base related to inequities in health throughout the industrialized world.
Why It Matters
The social and economic origins of health inequity have been well-documented since the industrial revolution in the 1840s. Recent data demonstrates a staggering and growing degree of social and economic inequality in the U.S. not seen since the Great Depression. Rates of disease and illness for people with low income are worsening across almost all categories and geographic areas in the U.S.
Racism plays a significant role. Blacks have 2.5 times the infant mortality rate of Whites, along with a decline in. life expectancy. Overall, the U.S. went from 12th in 1980 to 42nd in 2010 in life expectancy. Newly arriving immigrants will likely experience a decrease in health status the longer they live in the U.S. The restructured global economy, high unemployment, continuing wage depression and reductions in living standards, suggest that the resulting disruption to stable social life lead to a continuing inequitable gap in illness and disease.
Health inequity limits people's ability to gain access to resources and experiences required for health and well-being. As a result, people are less likely to participate effectively in social and political life. When people lack access to decision-making that affects their work life and living conditions their health suffers.
Public Health's Response
Health equity and social justice have traditionally been at the heart of public health practice. Public health played a central role pushing for reforms as an organized response to the negative consequences of industrial capitalism. Its history has also been closely associated with social justice movements, especially those related to the introduction of housing and factory codes, the abolition of child labor, support for guaranteed employment, and food safety among others.
Some Barriers Faced by Public Health
Local health departments (LHDs) face many barriers and contradictory demands, making change seem intractable. Legal mandates and regulations are two examples. Institutional culture can also generate resistance. LHDs often lack both human and financial resources. Local agencies whose policies and procedures have serious health consequences may not want to cooperate with public health. Orienting an engaged county leadership takes time and effective communication strategies.
Public health's political environment often places it on the defensive with regard to requirements for evidence, rather than those who introduce potential threats to health and safety. Addressing inequity is mainly confined to mitigation rather than tackling the source.
Finally, the general public has little knowledge of or appreciation for the work of public health. Their critical efforts remain mostly invisible, except in times of crisis, such as epidemics or hurricanes. But public health today is broadening its capacity to address the social context in which disease and illness occur.
Even with these barriers, the boundaries of public health are open. They require ongoing renegotiation, opening possibilities. Some local health departments play a role in issues such as land-use planning neighborhood safety, and living wage by forecasting the potential health effects of decisions through the use of tools such as Health Impact Assessments. As recognition of the connections between social injustice and health become more broadly understood, public health finds that preventing harm requires involvement in areas such as housing, labor, education, and transportation, to name a few. The realities of growing inequality demand a reexamination of what public health is about, who it is for, and how practice might change. We hope this course stimulates thinking in that direction and we welcome feedback from the field on its improvement as practice evolves.