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
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Market or Social Justice: Which Path for Health Promotion/Education? Thomas W. O ’ Rourke, PhD CHES Professor Emeritus University of Illinois Champaign,
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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.
“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.