World Health Organization releases report on social determinants of health

This week, the World Health Organization released a report entitled Closing the gap in a generation: health equity through action on the social determinants of health. The idea that the health of individuals and populations is determined a host of factors -- such as gender, income, social status and power, race, living conditions and workplace environments -- has to some extent entered into common sense. There are some who believe health is more a matter of genetics, luck and individual choice. But it is becoming more obvious, as more studies are done and more is known about dramatic disparities in health within and between nations, that man-made policies, social structures and cultural practices have a major impact on health. What is less acknowledged is the implication: improving health requires a commitment to social justice, i.e. healthier societies are more equitable ones.

Here is where things get murky, even for those who have seen health disparities firsthand and are strongly attracted to the integration of public health, bioethics and considerations of justice. That there are vast differences globally in infant and maternal mortality or life-expectancy has growing empirical support. And this situation is intuitively unjust. But it is hard to articulate precisely what makes it unjust, and what 'doing justice' might mean. The title of the WHO report would indicate that justice would be served by narrowing the differences, but the nature of this goal is unclear. Raising (say) the life-expectancy of Zimbabweans and lowering that of Swedes and Danes? That seems unfair to the latter. Raising all life-expectancies to that of Japan (82 years)? That would be a more positive way of doing justice, but the idea of doing so 'in a generation' seems wildly optimistic. Anyway, it seems unrealistic to expect that in the future countries would all have equal health indicators. Maybe doing justice means just improving the health of populations up to a certain (to be determined, somehow) threshold of decency, rather than trying to make them all equal.

I have only looked over the report briefly so far, but as far as I can see, there is no ethical discussion about the meaning of 'equity' as a goal or ideal (the word 'ethics' or 'bioethics' only appear a couple of times). The concept is used throughout, but not defined or submitted to any serious analysis. This seems a pity, because if you don't know where you want to go, it is hard to know where your analyses and interventions are supposed to be taking you.