An Inconvenient Truth: Politics, Economics and Ethics

In making health equity fundamental to its mission, public health has adopted social justice as a profoundly political theme. The very act of defining public health is a political act. Public health must acknowledge that it cannot pursue its vision of better health for all as a human right without confronting the political and economic power opposed to it. It must begin by addressing the disparity between its goals and its means. The separation of epidemiology from political engagement reflects moral blindness. I concur that “a determined desire to achieve equality in health makes obvious the need for political action to effect fundamental social change,” and “…perhaps more assuredly than for any other health field, public health can never be depoliticized without losing its very essence and effectiveness.”[i]

In its landmark 1988 report, the Institute of Medicine identified some “appreciable barriers to problem solving in public health,” including “limits on effective leadership, including poor interaction among the technical and political aspects of decisions.”[ii] It found that “public health agencies are having difficulty striking a balance between political responsiveness and professional values.”[iii]

The acknowledgement that the health status inequities of whole populations are the result of a world being remade in a neoliberal image carries with it the promise of the ability to reverse that process through designs promoting greater equity and social justice. That is a decision societies must make, but first they must understand how and why to make it. It is not the role of public health to manage the democratic political process, but it assuredly is its role to inform it.

Much good research has been conducted on the social determinants of health as agents adversely affecting the health status of populations, agents whose existence is properly seen as a challenge to public health’s mission. The problem is that public health fails to identify the people with the economic and political power behind those agents. “It is not inequalities that kill, but those who benefit from [and perpetuate] the inequalities that kill.”[iv] “Disease is a social and political category imposed on people within an enormously repressive social and economic capitalist system, one that forces disease and death on the world’s people.”[v] In public health’s failure to identify this, it implicitly operationalizes the neoliberal policy model[vi] of assignment of responsibility for health status to the individual.

It was claimed that “a major thrust” of the WHO’s Commission on the Social Determinants of Health was “turning public health knowledge into political action,”[vii] but its report never made those linkages clear. It failed to ask the question why we are burdened by those social determinants, to ask for the causes of “the causes of the causes,”[viii] a question needed to arrive at the insight that the public’s health is politically and economically as well as socially determined. Political pathology is the cause of the causes of the causes.

This is abundantly clear in an excellent Canadian report: Social Determinants of Health: The Canadian Facts.[ix]  It describes a situation in Canada that is very similar to that in the U.S., but it includes “policy implications” that are properly governmental/political. “Our key message is that the health of Canadians is much less determined by the health care system than we typically think. Much more important are public policies that influence our living conditions,” says Dennis Raphael, the report’s co-author. And Ronald Labonté, Professor and Canada Research Chair, Globalization and Health Equity, University of Ottawa is even more pointedly specific: “We have lived through three decades where the predatory greed of unregulated markets has allowed (and still allows) some to accumulate ever larger hordes of wealth and power while denying others a fair share of the resources they need to be healthy. This book is a fast-fact reference and an invitation for Canadian health workers to join with social movement activists elsewhere to reclaim for the public good some of these appropriated resources.”

Public health is entrusted with the authority to exercise the diligence necessary to protect the public’s health. To carry out that responsibility with professionalism and integrity requires that it be independent of excessive political influence that would undermine its effectiveness. Ideally, public health leaders should be seen as having the ethics and politics defined by the value of truth, together with the freedom to correct policy errors.