Venkatapuram, S. (2010). Global justice and the social determinants of health . Ethics and International Affairs, 24(2). 1. What is the main point? What do you find...
Venkatapuram, S. (2010). Global justice and the social determinants of health . Ethics and International Affairs, 24(2).
1. What is the main point? What do you find surprising? Is there anything confusing?
The structure of this paper is actually a bit strange; rather than simply argue for his own position, Venkatapuram presents the argument as if he were summarizing or reviewing the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH). He does summarize and review that work, but he also goes considerably beyond it, presenting an ethical argument for why this new social approach to public health is vital for improving health around the world.
I will give him credit for this: Venkatapuram understands something I wish more economists did, which is that there is no such thing as a non-normative policy. ("normative" being about what we should do, as opposed to "descriptive" which is simply about what is.)
Couching your policy recommendations in supposedly "value-neutral" concepts like economic growth and national security as economists usually don't actually avoid making normative assumptions; rather they just make unfounded and unquestioned normative assumptions. The CSDH report is unique not because it makes normative arguments about what ought to be done, but because it does so openly---actually making an ethical argument instead of subsuming it into some vague presumption that we all want to maximize GDP. (All other things equal, sure; but what if all other things are not equal? A policy that reduces GDP can still be a good policy if it has sufficient benefits in other respects.) They argue, and Venkatapuram expands upon their argument, that when we can easily reduce suffering of people around the world we have an obligation to do so. They make a very good case for this; indeed I find it difficult to see how one could disagree (though people seem to manage).
Furthermore, they argue that this new paradigm of social epidemiology is the best way to improve health around the world; they note (quite rightly) that health outcomes are wildly divergent between people in First World versus Third World countries, and point out that for some reason almost everything written in conventional epidemiology ignores this, instead attributing the causes of disease and ill health always to individual factors like genetics or risky behaviors. This is obviously correct: There's simply no other way to explain why people live so much longer in South Korea than North Korea. It has to be their political and economic institutions; before the divergence of those institutions in the mid-20th century they were culturally and genetically essentially identical.
Venkatapuram points to several empirical studies on the subject, all of which clearly point to social factors being important in human health, and argues that we need to start taking these factors into consideration whenever we do policy research in general.
He goes on to hypothesize why these recommendations are not being well-received:
First, healthcare specialists may not like it because it seems to disempower them relative to broader institutional forces;
Second, the recognition that health outcomes vary substantially within countries and not just between them based on social factors might seem like it is drawing needed attention from the world's poorest people who need the most help;
Finally, the complexity of these social factors makes it difficult to assign responsibility for them, and thus difficult to say who exactly should be held to account in fixing them.
I think of these the third is the most important; attributing effects to broad social causes, even when correct, can leave people feeling helpless and confused, unsure how to proceed.
In the final section, Venkatapuram discusses the work of Amartya Sen, a world-renowned Nobel Laureate economist who has worked to fundamentally change the paradigm of global economic development, from narrowly-defined economic measures like GDP to much broader concepts of social welfare (he is the one who brought us the Human Development Index, and was a leader in establishing the Millennium Goals).
Venkatapuram reviews Sen's ethical arguments for why these matters are so important, chiefly his point that "when one has the power to reduce injustice, one has sufficient reason to consider doing so". Honestly that seems too weak; I would say something like "one has sufficient reason to contribute to doing so." Your responsibility is not necessarily to do literally everything you yourself could do, but I don't think you just need to consider; I think you need to actually do your share of the work. Yet apparently even "consider" is strong enough for many policymakers to find Sen's arguments too extreme.
As far as surprising or confusing parts, what I find most surprising is the fact that instead of presenting the paper as its own argument Venkatapuram felt a need to couch it in terms of reviewing other work; I also find it somewhat surprising that so many people disagree with the basic conclusion that human health depends on social factors and we have a moral obligation to work to improve those factors.