Market or Social Justice: Which Path for Health Promotion/Education?

Thomas W. O’Rourke, PhD CHES

Professor Emeritus

University of Illinois

Champaign, Illinois

Nicholas K Iammarino, PhD CHES

Professor of Health Sciences

Rice University

Houston, Texas

Purpose

To contrast market and social justice and describe how each influences health education practice.

To provide insights and specific skills to enhance health education leaders, practitioners, and those involved in professional preparation.

Introduction

America is often ambivalent in terms of its attitudes about the concepts of Market Justice and Social Justice.

Both Market Justice and Social Justice are based on deeply held values in American culture.

Both have significant implications for health educators and other health professionals.

Market Justice

Based on principles of:

Individualism Personal responsibility Self-determination You “get what you work for” You “get what you deserve” With hard work anyone can achieve what they wish “Winners & Losers” Minimal collective action

Market Justice

Most societies contain elements of both market justice and social justice, although they can vary significantly.

Dominant ideology in the United States.

Personified by a libertarian philosophy and exemplified by many newly-founded Tea Party supporters.

Consistent with market justice, health and health care are viewed as the outcome of individual resources and choices, with less concern directed to collective obligation or government involvement.

Market Justice

Minimalist government involvement.

Jeffersonian – “Government (at any level) that governs best governs least.”

Classic market justice is consistent with a social Darwinism approach of “survival of the fittest”.

Oppose any role of government in health care, other than, at best, as a safety net for the indigent.

Carries over to opposing health policies such as: Implementing “smoke free” laws in workplaces. Outlawing trans fats as in New York City. Mandating seat belts in cars.

Market Justice

Supported by:

Definitions of health education – voluntary adoption of healthy behaviors conducive to health.

National documents:

1979 publication of Healthy People: The Surgeon General’s Report On Health Promotion and Disease Prevention.

Promoting Health/Preventing Disease: Objectives for the Nation.

Reinforce the notion of importance of lifestyle behavior and individual responsibility.

Market Justice

Self-help movement.

Made for “victim blaming”.

Vehicle for maintenance status quo.

Social Justice - In Contrast

Based on principles of shared responsibility and concern for the community well-being.

Societal support for those with limited opportunities or resources is encouraged. (e.g. School lunch programs, School based health clinics).

Maintains that all persons are entitled equally to basic services such as health promotion and protection, health care, minimum standards of income, housing, environmental quality, education and personal safety and security.

Social Justice

Social justice advocates maintain that each of us has a responsibility to care for each other, not simply out of charity, but because community solidarity is an essential element of a just and caring society based on humanitarian principles.

To that end, burdens and benefits of society should be fairly and equitably distributed.

Social Justice

Policy initiatives supporting social justice would increase the importance and demand for health education and public health programs and services.

Could help to reduce the rate of escalating health care costs, while increasing access to health promoting services and,

Most importantly, improving the health and quality of life of our citizenry.

Under Market Justice

In “Health Olympics” U.S. does not fare well. 1970 15th in longevity 1990 20th in longevity Now about 25th

Similar trend for infant mortality.

Despite highest level of“health care” expenditures by far.

Social Inequality and Health

Bezrucha “Is Our Society Making You Sick?”

Health not as substantially affected by individual behaviors, genetics or use of health care.

Life span depends on hierarchical structure of their society.

“Gap between rich and poor.”

Feelings That Predominate in a Hierarchical Situation

Power

Domination &

Coercion (If you are on top)

Resignation

Resentment &

Submission (If you are on the bottom)

Feelings that Predominate in an Egalitarian Environment

Support

Friendship

Cooperation

Solidarity

Respect

Areas of Inequality

Income

Education

Health & Health Care

Income

Income

Are you better off than your parents?

Probably not if you are in the middle class.

Incomes for 90% of Americans are stuck in neutral for a generation.

At same time richest 1% - those making $380,000 or more – incomes grew 33% over past 20 years.

It also follows that…

The more unequal societies will also tend to have:

A higher proportion of people in poverty. A steeper gradient between indicators of socio-

economic status and health.

Inequality reduces the tendency for cooperation in collective action problems.

Erosion of social cohesion and social solidarity results in a lower provision of public goods.

More like to act in a selfish manner such as resist welfare spending.

Education

Education

Increasing number of families going to often absurdly heroic efforts to enroll their children in the “best” private schools.

Entrance is typically beyond the financial reaches of most American wage-earning families.

Education

Public schools also not immune to these class distinctions.

Differences in educational quality and opportunities also prevail.

Knowledgeable parents jockey for seats for their children in the best of the “publics.”

Charter school and magnet school reflect these “within district” differences.

In 2002, UNICEF compared public education in 24 nations around the world. The U.S. ranked 18 out of the 24 nations.

Education

"All our children are of equal value in the eyes of God. ” But, there is no equality when it comes to education. In terms of expenditure per student per year, some are labeled underprivileged "$8,000 Walmart babies" while others are "$180,000 suburban babies."

Jonathon Kozol, Author Savage Inequalities

Health & Health Care

46 MillionUninsured

Oops! …Now 50 Million

Covers 38% of Employees

Walmartization

Crimes & Punishments in Massachusetts

The Crime The Fine

Violation of Child Labor Laws $50

Employers Failing to Partially Subsidize a Poor Health Plan for Workers

$295

Illegal Sale of Firearms, First Offense $500 max.

Driving Under the Influence, First Offense $500 min.

Domestic Assault $1000 max.

Cruelty to or Malicious Killing of Animals $1000 max.

Communication of a Terrorist Threat $1000 min.

Being Uninsured In Massachusetts $1068

Who is this kid?

… And what does he say about Health Care in America?

Even Justin Bieber Weighs In

The Canadian-born Justin Bieber never plans on becoming an American citizen.

"You guys are evil," he jokes. "Canada's the best country in the world." He adds, "We go to the doctor and we don't need to worry about paying him, but here, your whole life, you're broke because of medical bills.

My bodyguard's baby was premature, and now he has to pay for it. In Canada, if your baby's premature, he stays in the hospital as long as he needs to, and then you go home.

Insights from Japan

What Have We Learned from the Recent Disaster in Japan?

What Have We Learned from the Recent Disaster in Japan?

Social Solidarity particularly in times of crises.

Strength and durability of the Japanese social fabric that unites and connects.

It’s also how they come together.

“Gaman” roughly translated = Toughing it out”.

Health Gains in Japan After WWII

In 1960 Japan stood 23rd.

Now, Japan at or near the top and 3 ½ years ahead of U.S.

2x male smoking rate but deaths attributable to smoking are half of ours.

What Happened & Why?

Marmot & Davey Smith noted an impressive reduction in mortality in 1980s that was not attributed to medical care.

Potential explanations included: Low levels of income disparities. Greater security and Control in the workplace. Psychological benefits of loyalty and group

commitment aka “social solidarity”.

What Happened & Why?

Japan has low levels of inequality and equitably shared economic growth.

After WW II hierarchal structure of Japan reorganized (forced) to reestablish a more egalitarian governing and social systems.

Since 1890s Japan industrialization dominated by powerful families called zaibatsu i.e. Mitsubishi established themselves as corporate-like entities.

What Happened & Why?

Income inequality increased dramatically leading up to WW II.

General McArthur goal was to dismember the Japanese empire, promote democracy and “blast apart the concentrations of wealth, …dismantle the structures through which they worked …and encourage the growth of new constituencies.”

What Happened & Why?

Japanese constitution more liberal than U.S. Free universal education Rights of workers to organize and bargain collectively Academic freedom

Article 25 – State shall use its endeavors for the promotion and extension of social welfare and security, and of public health.

What Happened & Why?

Instituted land reform policies (90% was redistributed).

Voice given to women and labor unions.

Maximum wage was legislated.

Democratization of the political process.

Health Gains in Japan after WWII

Longevity remained stagnant (1895-1946).

But between 1946-1951 male life expectancy went from 42.8 to 60.8 years.

Women went from 51.1 to 64.8 years.

Net gain of 18 years for men and 13.7 for women even though income did not return to pre-war level.

Japanese Society

By 1979 highest life expectancy.

Crime & violence very low.

Lowest income distribution gap of any country reporting to the World Bank.

Focus on societal rather than individual gain.

Other Explanations

Country's health system

Genetic makeup of its people

Health behaviors

What Does Explain It?

Murray & Chen show that:

Equitable distribution of national income and Effective public policies directed toward reductions in

mortality. Support for public education. Population based public health programs. Access to health care especially primary care. Unemployment insurance. Retirement income.

Insights from Japan

Today, Japanese CEOs make 15-20 X what entry level workers make. (Not the 500+ fold difference in the U.S.)

In economic bad times CEOs and Managers often take pay cuts rather than lay off workers.

Higher tax rate & higher levies for high incomes than U.S.

Which Path for Health Education?

Does this have to be an “either – or” choice?

Can these competing ideologies coexist?

Which Path for Health Education?

Yes!

In Health education/promotion there is room for: Individualism Personal responsibility Voluntary behavior Promoting social solidarity Collective responsibility Caring based on humanitarian principles

Was McLuhan right?

Well… maybe yes, and maybe no.

Language is Important but…

Language is an essential expression of public health values it should never be its first and foremost consideration.

Before determining What to Say, you must determine What You Want to Change.

Needs to be specific and in concrete terms.

Framing the Issue

Typical news stories are most often framed as “Portraits” rather than “Landscapes”.

Framing the Issue

Portrait stories focus on the individual or event but it is difficult to see the the larger picture.

Landscape stories pull the lens back and takes a broader view that may connect to the larger social and economic context.

Levels of Framing the Issue

Three conceptual levels for Framing messages in the context of public health:

Level 1 = Expression of overarching values such as fairness, equality, responsibility etc.

Level 2 = General issue being addressed such as obesity, tobacco, alcohol.

Level 3 = Political detail or strategy and tactics for achieving change.

Example - Framing the Issue: Drinking & Driving

Portrait Landscape

Whoever Frames the Issue Best, “Wins”

Messages should articulate Level 1 values and not get mired down in Level 3 minutiae.

Level 3 values tend to crowd out Level 1 values and thus make the message less effective.

Components of a Health Message

Framed to emphasize Level 1 values

1) What’s wrong?

2) Why does it matter?

3) What should be done about it?

Whoever Frames the Issue Best, “Wins”

Rx for Success:

Level 1 = Expressing of overarching values trumps Level 3 minutiae.

Landscape trumps Portrait.

Conclusion

“If they can get you asking the wrong questions, they don’t have to worry about the answers.”

Thomas Pynchon

References

Beauchamp DE. Public health as social justice. Inquiry. 1976; 12: 3-14.

Bezruchka S et. al. Interplay of politics and law to promote health: Improving economic equality and health: The case for postwar Japan. Am J Pub Hlth. 2008; 98(4):589-594.

Budetti PP. Market justice and US health care. JAMA. 2008; 299(1): 92-94.

Dorfman L et. al. More than a message: Framing public health advocacy to change corporate practices. Health Educ & Beh. 2005; 32(3):320-336.

Kawachi IK et. al. The health of Japanese – What can we learn from America? J Natl Inst Public Health. 2007; 56(2):114-121.

Wallack L and Lawrence R. Talking about public health: Developing America’s “second language”. Am J Pub Hlth. 2005; 95(4):567-570.