During the past 25 years, the life expectancy of the richest quintile of 50-year-old Americans has increased, a perhaps unsurprising development. However, this improvement has not been shared by all. The life expectancy of the middle 60 percent of Americans has seen little change, and the life expectancy of the poorest 20 percent of Americans has, during this time, actually decreased.
These data are a core reflection of the underlying social divides that produce health divides. They are also a reminder of the concerns at the heart of public health’s mission. The life expectancy gap reminds us that we will fail in our efforts if we aim to improve health without grappling with the underlying maldistribution of wealth, opportunities, and privilege within a society. A social justice approach to population health challenges us to deal with these fundamental concerns. It forces us to recognize that problems like racism, socioeconomic inequality, gender disparities, and hate have negative consequences for health, and that we cannot improve the health of populations without tackling these foundational causes, a point made repeatedly in a large body of public health literature.
How does a social justice approach inform action? During his imprisonment in the Birmingham, Alabama jail in 1963, Martin Luther King Jr. had a lot of time to consider this very question. In his celebrated letter from that confinement, he said
I am in Birmingham because injustice is here…I am cognizant of the interrelatedness of all communities and states. I cannot sit idly by in Atlanta and not be concerned about what happens in Birmingham. Injustice anywhere is a threat to justice everywhere.
King’s eloquence is both inspiring and direct in its implications for public health. It speaks to the urgency that informs our work, and the work of anyone who tries to help populations that are under threat. It is important to note that King took care to ground his sense of justice in an awareness of the “interrelatedness of all communities.” He recognized, as we must, that inequalities are never the exclusive problem of the group they seem to most directly affect. Health, in particular, is interconnected; whenever a distinct group suffers from poor health, the burden will be shared across populationsin ways both subtle and overt.
Our pursuit of public health is therefore closely linked with how effectively we can reduce inequities between populations. The need for this approach is well captured by our country’s current health expenditures. The US spends far more on health care than any other country in the world, but has far worse health outcomes than any of our peer countries. We devote tremendous resources to delivering exceptional medical care, but we do so at the expense of correcting the underlying social, economic, and cultural structures that shape health inequities within our national population. Thus, we see troubling disparities like the higher risk of heart trouble run by Latinos, or the fact that black people die sooner than white people, or that, in 2015, the maternal mortality rate actually increased over the previous year. Jennifer Prah Ruger has eloquently captured our skewed priorities in her work on the subject of social justice, noting: “Theories of social justice…have typically focused on justifying health care (medicine and public health) as a special social good…In general, less attention has been paid to universal concerns of social justice with respect to health itself.”
In discussing the need for a public health that is centered around the creation of social justice, I realize I am saying out loud what many might consider to be implicit in our work, and so this chapter could perhaps be characterized as a statement of the obvious. I persist for three reasons.
First, we know that reestablishing first principles never comes amiss. Indeed, social justice is so central to public health that it becomes, paradoxically, easy to overlook.
Second, while we might consider the social justice component of public health to be self-evident, this is not necessarily the view taken by the wider world. Where we see disparities, for example, many may only see a need for better treatment, or perhaps reason that lopsided health outcomes are merely an unfortunate fact of life. Historically, this view has obstructed many justice-oriented change movements. At the time of King’s Birmingham incarceration, the problem of Jim Crow, while clear to us now as a moral travesty, was — to many — just another aspect of normal American life. Many people did not see it this way, of course, and it is in large part thanks to the success of these dissenters at framing the issue as a matter of social justice that we no longer have legalized segregation in this country. Our own efforts would benefit from a similar, concerted emphasis.
Third, the statement and restatement of core challenges stands to nudge, to move social momentum in the direction of lasting change. History has shown us how communicating the injustice of social ills can lead to progress. About 100 years ago, Upton Sinclair denounced with unprecedented fierceness the mistreatment of employees, and the inhumane conditions under which they worked, in the Chicago meatpacking industry. His book, The Jungle, was a quintessential call to social justice, leading to legislation that regulated food production in the US. It was a notable example of the resonance of social justice as a spur to action, to the ultimate improvement of the health of the public.
Where does our sense of justice come from? What is its ethical value? In his Nicomachean Ethics, Aristotle deals at length with these considerations. He observes, “[J]ustice, alone of the virtues, is thought to be ‘another’s good,’ because it is related to our neighbor; for it does what is advantageous to another.” This strikes me as fitting. As we seek to improve the health of populations through our commitment to social justice, we should remember that our efforts might be motivated, at core, by a spirit of simple neighborliness.