Venkatapuram, S. Health Justice . Cambridge, UK/Malden, USA : Polity Press , 2011 , £16.99 (pbk ) xi + 270 pp . ISBN: 978-0-7456-5035-7

Seventeen years ago I wrote an article for Sociology of Health and Illness, the purpose of which was to link the epidemiological evidence on health inequalities to politics, rights and social justice. I feel humbled when I read Health Justice by Sridhar Venkatapuram. In twenty years the evidence has accumulated enormously, the arguments have matured and health equity has become a common policy objective nationally and internationally, for instance in the recent Rio Political Declaration on Social Determinants of Health, embraced by 187 countries.

It is very timely and very necessary that someone now examines carefully the moral underpinnings of this endeavour. Health Justice is a landmark achievement, dense, carefully argued and bold in its conclusions. According to the author, it is ‘the first instalment of a long term project to put health at the centre of the theory and the practical evaluation of social justice’. In this, Venkatapuram stands on the shoulders of others, in particular Amartya Sen and Marta Nussbaum. Health should be seen as a ‘capability to be healthy’ and the moral claim is to that capability (set of capabilities), not to a particular health outcome, according to Venkatapuram. Consequently, he rejects the biomedical and biostatistical concepts of health as too narrow. Need and biological endowments, the social and environmental conditions we live in, and our capacity to act within these, are central elements in Venkatapuram’s theory of health. If health is fundamentally shaped by our social conditions, our physical environment and our ability to act within their constraints, then these should be put at the centre of a theory of health justice, which is what Venkatapuram does.

The book draws on the latest developments in epidemiological and sociological research on health inequalities. The most recent work in social epidemiology ‘explodes outwards’ the current bio-medical model of health, he states. This is partly a reference to the large body of work on social determinants of health, and partly a reference to the more complex task of linking group properties (of societies, such as social cohesion or income distribution) to individual health.

The concept of health equity is examined. In a well-known formulation, originally from Margaret Whitehead, health inequity is defined as ‘unfair and avoidable health inequalities’. Health inequity thus has a moral load, unlike health inequalities (or health disparities, health differences). The Commission on Social Determinants of Health took this one step further and defined health inequity as ‘systematic inequalities that can be avoided by reasonable action’. Neither Whitehead nor the CSDH (of which I was a member) solved the problem in practical terms. We were left, instead, with the question of which health inequalities should be seen as avoidable. What is avoidable is very much dependent on our present state of knowledge and further, on the political context in which we consider it reasonable to take action to remove health inequalities.

This observation leads to one of the most interesting discussions in the book: that about global health justice. Mortality of under-fives in Kenya is one in ten births. In Northern Europe it is more like one in 200 births. Probably this difference cannot be avoided if ‘reasonable action’ refers to what local political and national forces in Kenya can do. Is there then a moral duty to address such inequality globally? Previous theories of health justice, such as those of Rawls and Daniels, were influenced by contract theory and the idea that any right to health (care) followed from a social contract between citizens and government. Thus, it did not extend beyond national borders. A well-known economist, Angus Deaton – who has written extensively about health in poor countries – surprisingly takes a similar view: international health inequalities cannot be seen as unjust. Venkatapuram strongly disagrees and develops a comprehensive argument for health inequalities as a matter of global concern. If global resources are sufficient to avoid global inequalities in health, then there is a moral case for their removal. This would be more realistic with a stronger system of international institutions; but, even without such a system, the moral obligation is there, resting on anyone that has the power to make a difference. This ‘cosmopolitan’ position gets increasing support from modern reality, where no country is an island and health risks, both biological and social, increasingly ignore national borders.

Venkatapuram rejects the notion that a human being’s entitlement to health, or to the capability to be healthy, is defined by what is commonly achieved in that society. On the contrary, a theory of health justice must be ‘species-wide’, applicable to all human beings across all societies. His mission calls for a much better understanding of how society – global and national – influences health on all levels. His broad view on the determinants of health should be welcome news to sociology and should engage sociologists in the study of health and its social distribution. The book is an excellent read for anyone who takes an interest in the moral and political aspects of health and health inequalities. It demonstrates the maturity of a field that many of us have seen growing for some decades now.


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