Social Justice in public health

  1. Reflect on the “real-world” challenges described this week that you have already faced.
    Have they been to maintaining authenticity? Fairness? Objectivity? Have you experienced
    a tension between competing values and ambiguity?
  2. How do you know when you have compromised too far? When would you choose to quit
    a job rather than continue and accept compromises, ethically, and morally?
  3. List five skills that you learned in this course and explain how you can apply each of
    them to your leadership life in the next three months
    .
    Social Justice in public health
    Obesity has been associated with increased multiple pathophysiological disorders such as
    cardiovascular diseases, diabetes, and asthma. Obese children have also been found to be less
    successful into adults. This has spawned into a vicious cycle where poverty begets obesity;
    leading to increased poverty. Very few stakeholders seem to be bothered; and this gap must be
    filled to ensure that the timing bomb problem is circumvented before it explodes. Managing of
    organization conflict is one of the most social justice issues. These conflicts could be associated
    with institutional change resistance, and or clashing view point. Institutional conflicts are
    essential stage in change process and could serve as the progress engine when handled carefully.
    It is important for a leader to manage the differences between workmates in a manner that it
    reduces all destructive forces and harness the workforce energy constructively (Heifetz &
    Linsky, 2002).

This is challenging especially for the leader because the conflict temperature could boil over and
burn them in the process. Issues associated with cultural competences and weight issues are the
most common social justice concerns in the public health sector. This is especially so with the
increased wave of obesity in underprivileged communities. Self-awareness is one of the skills
emphasized in this course. Responding to interpersonal and group issues is associated such as
addressing inequitable representations dynamics and developing an inclusive cultural society is
also emphasized. Other skills enhanced includes skills which will ensure effective
transformation such critical analyzer, and effective leadership to spearhead implementation of
institutional norms and policies which are all inclusive and equitable. The most important skill
gained is that of collaborating with other disciplinary to foster societal changes (Gostin
&Powers, 2006).
References
Gostin, L., & Powers, M. (2006). What does social justice require for the public’s health? Public
health ethics and policy imperatives. Health Affairs, 25(4), 1053-1060
Heifetz, R. A., & Linsky, M. (2002). A survival guide for leaders. Harvard Business Review,
80(6), 65-72.

What Does Social Justice
Require For The Public’s
Health? Public Health Ethics
And Policy Imperatives
Social justice demands more than fair distribution of resources in
extreme public health emergencies.
by Lawrence O. Gostin and Madison Powers
ABSTRACT: Justice is so central to the mission of public health that it has been described
as the field’s core value. This account of justice stresses the fair disbursement of common
advantages and the sharing of common burdens. It captures the twin moral impulses that

animate public health: to advance human well-being by improving health and to do so par-
ticularly by focusing on the needs of the most disadvantaged. This Commentary explores

how social justice sheds light on major ongoing controversies in the field, and it provides ex-
amples of the kinds of policies that public health agencies, guided by a robust conception

of justice, would adopt. [Health Affairs 25, no. 4 (2006): 1053–1060; 10.1377/hlthaff
.25.4.1053]
J
ustice is viewed as so central to the mission of public health that it
has been described as the field’s core value: “The historic dream of public

health…is a dream of social justice.”1 This Commentary addresses a single ques-
tion of extraordinary social and political importance: What does social justice re-
quire for the public’s health? Our thesis is that justice can be an important organiz-
ing principle for public health.

Justice alone cannot determine the “correct” policy or supply an answer to ev-
ery question regarding the broad direction for public health; neither can any other

single organizing principle. However, there are certain core commitments that all
who embrace even a modest conception of social justice recognize as important,
and those commitments can shed light on the major ongoing controversies in the
field: the legitimate scope of public health, the balance between public health and
Social Justice

HEALTH AFFAIRS ~ Vo l u m e 2 5, N u m b e r 4 1053
DOI 10.1377/hlthaff.25.4.1053 ©2006 Project HOPE–The People-to-People Health Foundation, Inc.
Larry Gostin (gostin@law.georgetown.edu) is associate dean and a professor at the Georgetown University Law
Center in Washington, D.C.; director of the university’s Center for Law and the Public’s Health; and a professor at
the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Madison Powers is director and
senior research scholar at the Kennedy Institute of Ethics, Georgetown University, and an associate professor in its
Department of Philosophy.
This Health Affairs article reproduction is provided for your private,
noncommercial use only. Further distribution or reproduction is strictly prohibited.

civil liberties, and the appropriate roles of the federal government and the states.
More importantly, this paper shows how public health based on social justice

gives rise to important policy imperatives such as improving the public health sys-
tem, reducing socioeconomic disparities, addressing health determinants, and

planning for health emergencies with an eye on the needs of the most vulnerable.
Before examining the major controversies and making policy recommendations,
we provide our particular account of justice in public health.
What Is ‘Justice,’ And How Important Is It In Public Health?
Among the most basic and commonly understood meanings of justice is fairness
or reasonableness, especially in the way people are treated or decisions are made.2
Our account of justice stresses the fair disbursement of common advantages and
the sharing of common burdens. It captures the twin moral impulses that animate
public health: to advance human well-being by improving health and to do so by
focusing on the needs of the most disadvantaged. An integral part of bringing good

health to all is the task of identifying and ameliorating patterns of systematic dis-
advantage that undermine the well-being of people whose prospects for good

health are so limited that their life choices are not even remotely like those of oth-
ers.3 These two aspects of justice—health improvement for the population and fair

treatment of the disadvantaged—create a richer understanding of public health.

A core insight of social justice is that there are multiple causal pathways to nu-
merous dimensions of disadvantage. These include poverty, substandard housing,

poor education, unhygienic and polluted environments, and social disintegration.
These and many other causal agents lead to systematic disadvantage not only in

health, but also in nearly every aspect of social, economic, and political life. In-
equalities beget other inequalities, and existing inequalities compound, sustain,

and reproduce a multitude of deprivations.4
Our account of social justice is interventionist, not passive or market-driven,

vigorously addressing the determinants of health throughout the lifespan. It rec-
ognizes that there are multiple causes of ill and good health, that policies and

practices affecting health also affect other valued dimensions of life, and that

health is intimately connected to many of the important goods in life. Empirical in-
quiries, therefore, are critical to justice in public health. Data can help determine

who are most vulnerable and at greatest risk, how best to reduce the risk or ame-
liorate the harm, and how to fairly distribute services and benefits.

The Justice Perspective In Public Health

The field of public health is in the midst of a crisis of public confidence. Ameri-
can culture openly tolerates the expression and enjoyment of wealth and privilege

and is inclined to view health as a matter of personal responsibility. Meanwhile,
the public has become skeptical of government’s ability to ameliorate the harshest
consequences of socioeconomic disparities. At its deepest level, some believe that

1054 July/Aug ust 2006
Commentary

government’s purpose should not be to redress economic and social disadvantage,
and this may be doubly so for administrative agencies dedicated to public health
and the pursuit of science. We believe that it is time to rethink this view, and the
justice perspective offers an alternative. Values of socioeconomic fairness are just

as important to health as the prevailing values of personal license and free enter-
prise. The justice perspective offers a different way of seeing problems that have

long plagued the field of public health.
Legitimate scope of the public health enterprise. Perhaps the deepest,

most persistent critique of public health is that the field has strayed beyond its natu-
ral boundaries. Instead of focusing solely on narrow interventions for discrete inju-
ries and diseases, the field has turned its attention to broader health determinants. It

is when public health strays into the social/political sphere in matters of war, vio-
lence, poverty, and racism that critics become most upset.

The justice perspective does not provide a definitive defense against claims of

overreaching. But social justice does provide a counterweight to the prevailing po-
litical view of health as primarily a private matter. The justice perspective shows

why health is a matter of public concern, with the state having a role not only in

the traditional areas of infectious diseases and sanitation, but also in emerging ar-
eas such as chronic diseases caused by diet, lifestyle, and the environment. Public

health agencies have an obligation to address the root causes of ill health, even

while they recognize that socioeconomic determinants have many causes, and so-
lutions, that are beyond public health’s exclusive expertise.

Balancing individual and collective interests. The exercise of the state’s co-
ercive power has been highly contentious throughout U.S. history. When public

health officials act, they face troubling conflicts between the collective benefits of
population health on the one hand, and personal and economic interests on the
other. Public health powers encroach on fundamental civil liberties such as privacy,
bodily integrity, and freedom of movement and association. Sanitary regulations

similarly intrude on economic liberties such as freedom of contract, pursuit of pro-
fessional status, and use of personal property. Justice demands that government take

actions to safeguard the public’s health, but that it do so with respect for individuals
and sensitivity to the needs of the underprivileged.

In the realm of public health and civil liberties, then, both sides claim the man-
tle of justice. Finding an appropriate balance is not easy and is fraught with con-
troversy. What is most important to justice is abiding by the rule of law, which re-
quires modern public health statutes that designate clear authority to act and

provide fair processes. Policymakers, therefore, should modernize antiquated

public health laws to provide adequate power to reduce major risks to the popula-
tion but ensure that government power is exercised proportionately and fairly.5

Fairness requires just distributions of burdens and benefits to all, but also proce-
dural due process for people subjected to compulsory interventions.

Certainly, the justice perspective cannot answer many of the most perplexing
Social Justice

HEALTH AFFAIRS ~ Vo l u m e 2 5, N u m b e r 4 1055

problems at the intersection of public health and civil liberties such as paternalis-
tic interventions (for example, seat belt laws) or the exercise of powers in health

emergencies (for example, avian flu or bioterrorism). These and many other prob-
lems pose major dilemmas for the field that neither considerations of justice nor

traditional arguments based in beneficence can readily resolve. However, a more
serious failure of public policy would be a failure to recognize and give great
weight to the demands of social justice when faced with such challenges.
National, state, and local public health functions. The arguments for and
against the centralization of political power have remained largely the same over the
course of U.S. history and are part of entrenched political ideologies. There is no
simple resolution, and initially it might seem that the justice perspective can shed
little light on this contentious area. Considerations of social justice do not side with
either of the traditional combatants in the federalism debates, as they neither favor

federal nor state action. What justice does do is insist that governmental action ad-
dress the major causes of ill health, particularly among the disadvantaged; that com-
mitment has major implications for political and social coordination.

The justice perspective’s emphasis on the multicausal and interactive determi-
nants of health suggests that strategic opportunities for prevention and ameliora-
tion of ill health arise at every level of governmental interaction. The challenge of

combating the threat of systematic disadvantage can be met only with a system-
atic response among all levels of government. The level of government best situ-
ated for dealing with public health threats depends on the evidence identifying

the nature and origin of the specific threat, the resources available to each unit for
addressing the problem, and the probability of strategic success.
National obligations. The national government has a duty to create the capacity to
undertake essential public health services. A national commitment to capacity
building is important because public needs for health and well-being are universal
and compelling. The federal government should recognize these needs and invest
in a strong public health system. Certain problems demand national attention. A
health threat, such as epidemic disease or environmental pollution, might span
many states, regions, or the whole country. Further, the solution to problems such
as those related to foreign or interstate commerce could be beyond the jurisdiction
of individual states. Finally, states simply might lack the expertise or resources to
mount an effective response in a major public health emergency.

State/local obligations. Armed with sufficient resources and tools, states and local-
ities have an obligation to fulfill core public health functions such as diagnosing

and investigating health threats, informing and educating the public, mobilizing
community partnerships, and enforcing state health laws. States and localities are
closer to the people and to the problems causing ill health. Delivering public
health services requires local knowledge and direct political accountability. States
and localities are also often the preferable unit of government when dealing with
complex, poorly understood problems. In such cases, the idea of a “laboratory of

1056 July/Aug ust 2006
Commentary

the states” enables local officials to seek innovative solutions.
Harmonized engagement. Because justice emphasizes the multicausal, interactive
character of health threats, a system of overlapping and shared responsibility

among federal, state, and local governments will most often be required. Govern-
ments at all levels have differing degrees of responsibility. This insight was illus-
trated poignantly during the response to the Gulf Coast hurricanes. It was not

that a particular political unit should have had primacy. Rather, each should have
played a unique role in a well-coordinated effort.
The Policy Imperatives Of The Justice Perspective
The public health community has not been successful in gaining attention to or

resources for its core mission and essential services. Outside of health emergen-
cies, the public does not demonstrate any particular interest in public health as a

priority, and this lack of interest shows in chronic underfunding. From a fiscal

perspective, only a tiny fraction of health dollars goes to prevention and popula-
tion-based services.6 Even when attention and resources are ample, it is usually in

immediate response to some actual or perceived threat. This leads not to core, sta-
ble funding and attention but, rather, to a “disease du jour” mentality. This type of

response creates silos, disproportionately funds biomedical solutions, and poses a
“no-win” situation for public health agencies, which must respond to the latest

fashion but seldom gain the kind of ongoing political attention and economic re-
sources they need to improve the public’s health.

The justice perspective offers an opportunity to change this dynamic, and the
remainder of this Commentary offers concrete proposals based on the imperatives
of population improvement and just distribution of benefits.

The public health system. Justice, with its concern for human well-being, re-
quires a serious commitment to the public’s health. It is for that reason that justice

demands a tangible, long-term pledge to the public’s health and the needs of the
least well-off. Such a commitment, as countless reports have made clear, is lacking.7

Funding for prevention and population-based services is inordinately low, and cate-
gorical funding for special programs such as bioterrorism and avian flu is limited to

a single issue and is time restricted.
To assure that actions can be taken to protect, promote, and provide for the
health of the public, there must be a substantial and stable commitment to the

public’s health at the federal, state, and local levels. Given the gravity and impor-
tance of the situation, Congress and the executive branch should create a Trust

Fund for Public Health to provide generous and stable resources to rebuild the
eroded public health infrastructure and implement core public health functions.
Nongovernmental trust-fund approaches, implemented in other countries, should
also be explored. The Public Health Leadership Initiative, established by the Trust
for America’s Health (TFAH), recommends annual, sustained spending of $1.5–$2
billion increase to ensure an adequate public health infrastructure.8

Social Justice

HEALTH AFFAIRS ~ Vo l u m e 2 5, N u m b e r 4 1057

Addressing health determinants. If justice is outcome oriented, then inevita-
bly public health must deal with the underlying causes of poor and good health. The

key health determinants include the built environment (for example, transportation

and buildings); the natural environment (for example, clean air and water); the in-
formational environment (for example, health information and advertising restric-
tions); the social environment (for example, social networks and support); and the

economic environment (socioeconomic status).9 These are all public health prob-
lems, but they are not solvable solely by public health agencies. Public health re-
searchers and agencies can provide the intellectual tools for understanding the fac-
tual basis of the problems policymakers face. They can act directly and as conveners

that mobilize and coordinate government agencies, health care institutions, busi-
nesses, the media, academia, and the community.

Obesity policy offers an apt illustration of the numerous ways that public

health, together with its partners, can act on the root causes of ill health. By a com-
bination of zoning, public construction, taxation, incentives, regulation, and

health information, the state could encourage citizens to eat healthier diets and
maintain more active lifestyles. This could be accomplished by changing the inner
city, for example, to favor supermarkets over fast foods, recreational facilities and
green spaces over roads, mass transportation over automobiles, and so forth. It
could involve transformation of schools to ensure healthier snacks and lunches,
physical activity, and health education. Critics complain that diet and lifestyle are
personal choices outside the appropriate realm of government. However, there is
nothing inherently wrong with having the state make healthier choices easier for
people to make.

Fair treatment of the disadvantaged. Fair distribution of burdens and bene-
fits, as discussed, is a core attribute of justice. Allocations based on the market or

political influence favor the rich, powerful, and socially connected. Even neutral or
random allocations can be unjust because they do not benefit those with greatest
need. For example, health officials who direct a population to evacuate or shelter in
place should foresee that the poor will not have private transportation or the means

to stock up on food or supplies. For that reason, justice requires public health offi-
cials to devise plans and programs with particular attention to the disadvantaged.

Fair distributions should be integral to public health policy and practice, but they
take on particular importance when planning for health emergencies or when there
is extreme scarcity.
Health emergencies threaten the entire community, but the poor and disabled
are at heightened risk. Social justice thus demands more than fair distribution of
resources in extreme health emergencies. A failure to act expeditiously and with
equal concern for all citizens, including the poor and less powerful, predictably

harms the whole community by eroding public trust and undermining social co-
hesion. It signals to those affected and to everyone else that the basic human needs

of some matter less than those of others, and it thereby fails to show the respect

1058 July/Aug ust 2006
Commentary

due to all members of the community. Social justice thus encompasses not only a
core commitment to a fair distribution of resources, but it also calls for policies of

action that are consistent with the preservation of human dignity and the show-
ing of equal respect for the interests of all members of the community.

Planning for emergencies involving scarce life-saving resources. Health
emergencies pose the potential for mass illness and death, often resulting in extreme
scarcity of medical countermeasures, hospital beds, and other essential resources.
Rarely will there be sufficient stockpiles or surge capacity to meet mass needs. For

example, the U.S. influenza preparedness plan anticipates marked shortages of vac-
cines, antiviral medications, and medical equipment.

What does justice tell us about how to ration scarce, life-saving resources? In
the context of influenza, the United States focuses on key personnel and sectors
such as government, biomedical researchers, the pharmaceutical industry, health
care professionals, and essential workers or first responders. These apparently
neutral categories mask injustice. In each case, people gain access to life-saving
technologies based on their often high-status employment. This kind of health
planning leaves out, by design, those who are unemployed or in “nonessential”
jobs—a proxy for the displaced and devalued members of society. Consequently,
public health planning based on pure utility, although understandable, fails to
have sufficient regard for the disenfranchised in society.10

Fair distribution from a global perspective. Perhaps the most extreme injus-
tices arise in the global allocation of health resources. Developing countries suffer

the multiple, compounding burdens of destitution (lack of medical equipment,
health professionals, and hospitals), impoverished environments (drought, famine,

and contaminated drinking water), and extremely poor health (tuberculosis, ma-
laria, and HIV). They also lack a scientific infrastructure. Realistically, scarce re-
sources will go to those countries where products are owned and manufactured.

This reality can have devastating consequences for poor countries that cannot com-
pete economically for expensive health resources. Social justice views all lives as

having equal value, so there is a moral justification for fair allocation from a global
perspective. Even from a less altruistic perspective there are reasons to invest in poor

regions. Improved surveillance and response can help in early detection and con-
tainment of infectious disease outbreaks, affording universal benefits.

A Policy Landscape Informed By Social Justice

What would the policy landscape look like if it were informed by a robust con-
ception of social justice? The political community would embrace, rather than

condemn, a wide scope for the public health enterprise; value the public good as
Social Justice

HEALTH AFFAIRS ~ Vo l u m e 2 5, N u m b e r 4 1059
“The aims of public health deserve a great deal more societal
attention and resources than the political community has allowed.”

much as personal and economic liberty; view the public good as involving a com-
mitment to the health and equal worth of all members of the community; and view

federalism as a shared responsibility for health improvement rather than an ideo-
logical battleground between national power and states rights.

Social justice would spur important policy shifts. Political leaders would create
a trust fund allocating funds on a sustained basis sufficient to assure an adequate

public health infrastructure; use a variety of tools (such as zoning, taxation, incen-
tives, regulations, and information) to address the determinants of ill health, in-
cluding reduction of socioeconomic disparities; devise programs and plans to as-
sure the health and safety of the most vulnerable, particularly in public health

emergencies; and devote substantial resources to meeting global needs for essen-
tial public health services. These measures, and many more, would not ensure

equality in health but would soften some of the most egregious inequities.
The central claim of this Commentary is that a commitment to social justice lies
at the heart of public health. This commitment is to the advancement of human

well-being. It aims to lift up the systematically disadvantaged and in so doing fur-
ther advance the common good by showing equal respect to all individuals and

groups who make up the community. Justice in public health is purposeful, posi-
tivistic, and humanistic. The aims of public health deserve a great deal more soci-
etal attention and resources than the political community has allowed.

The authors thank Benjamin Berkman, Sloan Fellow at the Georgetown University Law Center, for research and
editorial assistance.
NOTES

  1. D.E. Beauchamp, “Public Health as Social Justice,” inNew Ethics for the Public’s Health, ed. D.E. Beauchamp and
    B. Steinbock (New York: Oxford University Press, 1999), 105–114.
  2. J. Rawls, A Theory of Justice(Cambridge: Harvard University Press, 1971).
  3. M. Powers and R. Faden, Social Justice: The Moral Foundations of Public Health and Health Policy (New York: Ox-
    ford University Press, 2006).
  4. Ibid.
  5. L.O. Gostin, “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common
    Goods,” Health Affairs 21, no. 6 (2002): 79–93.
  6. K.W. Eilbert et al., Measuring Expenditures for Essential Public Health Services(Washington: Public Health Foun-
    dation, 1996).
  7. See, for example, Institute of Medicine, The Future of the Public’s Health in the Twenty-first Century (Washington:
    National Academies Press, 2003).
  8. Public Health Leadership Initiative, A Blueprint for Healthy People in Healthy Communities in the Twenty-first Cen-
    tury (Washington: Trust for America’s Health, forthcoming).
  9. L.O. Gostin, J.I. Boufford, and R.M. Martinez, “The Future of the Public’s Health: Vision, Values, and Strat-
    egies,” Health Affairs 23, no. 4 (2004): 96–107.
  10. L.O. Gostin, “Medical Countermeasures for Pandemic Influenza: Ethics and the Law,”Journal of the American
    Medical Association 295, no. 5 (2006): 554–556.
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