Welcome back. This is module three of week three, talking about health disparities.

In this module, we're going to talk about some theories of health disparities, really, theories of justice. And I want to give you a couple of concrete examples, some struggles but concrete examples, of remedies for health disparities. First, as I said at the first module, the idea of health disparity entails or incorporates some kind of theory of justice. It's not just a difference in health outcomes or opportunities. It's an unjust difference. That begs the question, what do we mean by justice? Importantly, I think it's clear, it's very important to state, that an idea of equality, everyone gets the same, is a quite reasonable and intellectually defensible baseline. Deviations from everyone gets the same, may be important, but it's important to think about those deviations. And I have some sort of consensus or critical dialogue about why deviations are better for some than for others or perhaps everybody. So, all kinds of theories of justice. The first one, well known, Utilitarian justice, this is the greatest good for the greatest number. What's important to think about here, well it seems nice to have the idea of greatest good for greatest number. This implies that some, perhaps a few can be sacrificed in some way for the good of many, not everyone matters equally. And that's a bit criticism of Utilitarian justice. Second, the old favorite so called Platonic justice. To the victor, the spoils, the strongest survive. So called Rawlsian justice, from the American philosopher, the late American philosopher, John Rawls. He talked about justice as fairness and the key idea here is that what's just is helping the disadvantaged as much as possible. We'll come back to this. But the implication for health disparities here, under a Rawlsian justice framework, is that the gap between the well-off and the not well-off

doesn't matter. What matters, is how well off the disadvantaged are. The goal of Rawlsian justice simply put, is to help the disadvantaged, gap being neither here nor there. Professor Rawls's colleague, Nozick, wrote a book just after Rawls's, with a very different idea. In Nozickian justice is about a process, here just as its a function of the rules and not the outcomes. We talked earlier about understanding disparities as outcomes or opportunities. For Nozich if the rules of the game if you will are fair, then the outcomes must be fair. Of course, there's Marxist judge, Marxist justice, here the simple idea is from each according to their ability. Everyone tries hard, to each according to their need. Meritocratic justice, here, the idea is, from each according to the effort, to each according to the effort. That is, those who try harder, those who are more interested in maintaining their health, deserve better health. Of course, there's Theist justice, God's will, It's a very interesting proposition. The simple golden rule, what's just is what we would do unto others. So called, Aristotelian justice from Aristotle, and the simple quip is, treat equals equally, and unequals unequally. Of course, the rub is who gets to decide who's equal and who's not? Critically, Egalitarian justice, here, it's the outcome that matters, and the outcome out to be equal. In my view, this is what most people think about when they're thinking about social health disparities. Equal outcomes is where we ought to be, this is an Egalitarian justice perspective. One of my favorites, so called Hippie justice, the idea is, let's all share but give me some of yours. And finally, a little bit of humor, what I'll call Oakesian justice, tall people get to decide. When we think about social health disparities, what's important is to think about what vision of justice we're entertaining. Most of us by default go to Egalitarian justice. Everything should be equal.

But its quite plausible as we can see here to hold a different vision of justice Meritocratic, Utilitarian, Rawlsian, or perhaps even Platonic. To the victor this spoils. The idea of health tisparities is based on this and in my opinion its going to get even more crucial as the world's population continues to rise. Obviously the world and its resources are scarce when there's more people at it, there's more room for conflict. So, how we solve this is a key problem for social epidemiology. Now I'd like to talk about some simple remedial models or some simple ways to think about, how health disparities can be addressed. First let's look at this slide. Here we have some measure of socioeconomic status. Maybe it's education, income advantaged world, disadvantaged world. Whatever you like. Rich, and poor persons. To the right we have some arbitrary measure of health. That's in this sort of pinkish color. In here we have two persons. To be simple, one white and one black. And what we see here is these two persons are at the same point of socioeconomic status. Same education, same income, same perhaps desire for health. And here, we see, in the example, some difference in their health outcome, of some number 3, an arbitrary number. This is a health disparity I think most people would find repugnant. There's no understandable reason, if people are equally motivated, if they come from the same background. To have differences in health outcomes outside some perhaps predisposing genetic, predispositions. So, this is a health disparity that we often want some remedy for, and the reason could be racism, something like that. This is generally how we see the world working, the rich persons have excellent health, disadvantage or poor persons have less good health. And then there's some gap between rich and poor. In this case the gap is some arbitrary value of 7. Now the questions is what can we do about this, what can be done?

Well, one thing that we could do is we could improve the health of the poor. Make the poor less poor in health. Notice we've not moved the poor's socioeconomic status at all, we've only improved their health. Think for a moment about what kind of situation this could be. What kind of intervention can we have to improve the health of disadvantaged persons? But not alter the socioeconomic stratification system of society. Here's another example. In this case, we actually improve or change the socioeconomic system of the poor make them less poor. As a result, their health improves. We had a big disparity of 7, now it's 2, and what happened is, we made the poor less poor, and their health improved accordingly. Here's another way, somewhat silly, about reducing health disparities. In this example, we take the health of the rich and reduce it. So, while this is intellectually plausible, reducing the health in order to reduce the health, reduce the disparity, this is really not what people are talking about. This is the worry for many advantaged persons, that when we improve the socioeconomic position of the poor, everyone's health declines. So the rich might lose 7 units of health, the poor might lose or gain 1. The disparity's reduced, but what we have is a loss of health. This is a big change in the social system that few want to entertain. Most people think something more along these lines. That will reduce the advantage of the rich, help the poor a little bit, and have the health disparity decline. This could reduce the life expectancy of the wealthy in order to help the poor. The question is, how to do that? That's a key question for social epidemiology. This final example's an important one. This goes to Rawlsian justice, the idea here is let the rich get as rich as they want, let their health be as optimal as it can be. Here, we can imagine a person living to their biological optimum health. But what happens here is we're improving the health of the poor regardless of the

gap. This is Rawlsian justice. This is saying, I don't really care about the rich, I care only about helping the poor, helping their health improve. I want to now give you three quick but concrete examples here in Minnesota. First, though I wasn't directly involved, is the important moving to opportunity study started many years ago by some economists. But the question is critical. The idea was, what happens if we move poor people into better neighborhoods, and let's do this at random in order to have a good scientific study. So, the idea is how much of an improvement in health and well being and in this case job opportunities we have by moving poor people to better neighborhoods. That's the moving to opportunity study. Well what did we see? The short answer is ambiguous, ambiguous results. A moderate proportion of families who were eligible to move to better places chose not to. In my opinion they are not stupid, they wanted to enjoy the social connections of their home neighborhood. Maybe it's babysitting, maybe it's a job, even if it's not a great job it's still a job other social connections. Many of the places that were becoming target or places to move people said no, I don't want these kind of people in my neighborhood. There was no discernible effects of the move on employment rates. When it comes to health, there's ambiguous results. Some people improved, some people didn't. This wasn't designed as a health study, per se, but an economic study, so results are a little bit hard to d, define. But the short story is, moving people out of poor areas into better areas. And having it stick, and seeing a big health improvement, didn't quite pan out, at least not for everyone. Second example, in our local Minneapolis area, we had some increasing racial residential segregation. Minorities lived in one area, were often poor, advantaged persons in another area, often white. The school differences translate directly and, opportunities for health through better jobs, through better understanding

of health and so forth. So, one school superintendent, a leader of the area, wanted to integrate, wanted to have more combined school districts. Pretty good idea following some vision of social justice. And maybe even some good economic policy. What do you think happened? The school leader, the superintendent, was effectively fired. Technically, she resigned. But the local community would have no part of this political change. This social system rebelled, did not want to be in this disequilibrium and pushed back and removed the change agent. The final example, you may have heard of mayor Bloomberg of New York's effort to reduce obesity, particularly among African-Americans, through his ban on soda pop. And here's sort of a silly picture of a Big Gulp soda. The idea here was to mitigate, or improve, the lives of many minority persons. Often African American. The result. Well, the NAACP, a group that represents many African Americans, fought back. And said no, Mayor Bloomberg. I don't want this policy, because it can affect the economic opportunities of soda sellers, if you will, in the New York City area. Eventually, as you might know by now, this ban was overturned in the courts. The bottom line here is social remedies for health disparities are very difficult to accomplish. The social system does not like to be disrupted. That's a key idea, a key conclusion, for social epidemiology.