Global Justice and the Social Determinants of Health
Venkatapuram, Sridhar, Ethics & International Affairs
Public scrutiny and deliberation are central to both the sciences and ethical reasoning. In the sciences, research findings and analyses are put forward in the public arena not simply to announce new evidence but also for public examination, to be either corroborated or disputed. In ethics there is a similar process, whereby reasoned arguments are put forward about what is the good or right thing to do. In either domain, knowledge is expanded through the coherence and acceptance of the analyses and arguments, which depends on their being able to withstand public scrutiny. Therefore, when scientific and ethical arguments are brought together, the task of public deliberation is twofold, as it must encompass the empirical and the normative; and when the arguments concern an issue of such enormous scope as global health inequalities, public deliberation has to include national and global domains.
It is precisely this kind of twofold public deliberation that the World Health Organization's (WHO) Commission on the Social Determinants of Health (CSDH) anticipated when it released its final report at the end of 2008. In that report, the commission combined epidemiological analysis of health inequalities within and across countries with an essentially cosmopolitan ethical argument for motivating global social action to mitigate ill health and health inequalities. By doing so the commission brought together the consideration of scientific evidence, the centrality of global public deliberation to global health, and a view on global social justice.
The two most notable aspects of the CSDH's report are that, first, it put forward a scientific analysis of the social causes of ill health and health inequalities within and across countries, and, second, it coupled the analysis with an ethical argument for acting to advance global health and health equity. (1) The CSDH's report is the first to apply social epidemiological analysis to global health, which is distinct from the prevailing analyses of the causes of ill health, which focus on such individual-level determinants as exposures to harmful agents, behaviors, and genetics, or those analyses that overlook social-group differences in health outcomes within countries. (22) Moreover, the commission's justification for addressing ill health and health inequalities within and across countries is grounded in the ethics of justice, as opposed to such reasons as national security or interest, economic growth, charity, or a self-evident "contain and control" epidemiological imperative. The moral principle that informs the commission's work is that where one can do something to alleviate avoidable suffering through reasonable means, one should do so.
The CSDH's report appears to be a grand experiment to see whether science, linked with ethics, can motivate global action, and whether the public scrutiny and deliberation that are so central to scientific research and ethical reasoning can meaningfully be brought together in global health policy. Established in 2005 by the late J. W. Lee, then director-general of the WHO, the CSDH had three objectives: to collect and synthesize global evidence on the social determinants of health; assess their impact on health inequity; and make recommendations for action to address that inequity. The commission published its final report at the end of 2008, presenting that evidence as well as asserting that ill health and health inequalities that were preventable by reasonable means were manifest inequities that must be addressed as a matter of social justice. The work of the CSDH and the resultant final report are intended to instigate discussions--within national and international institutions and the global public sphere--as well as to help engender social action and policies to advance health and health equity within and across countries.
Since the final report was released, it has elicited reactions ranging from dismissive journalistic commentary (the Economist described its goals as "quixotic") to critically engaged scholarly reviews and various government-level conferences. …