right to health care

I wrote a paper recently, the topic of which was, is there such a thing as a right to health care? I argued that yes, there is a right. Here is the paper:

HEALTH HUMAN RIGHTS

“Physical health is a site of social inequality. Unequal social relations create unequal chances of staying alive, unequal possibilities of health across lifetimes and inequalities in the experience of ill health. Profound, unjust suffering results.”[1]

– Eileen MacLeod and Paul Bywaters

Introduction
Health is said to be the great equalizer. It is of universal interest and importance; no matter who they are or where they come from, everyone thinks about health. Health is ubiquitous; because humans are embodied beings, mental and physical health are unavoidably important. When illness strikes, social privileges seem to matter less – all that matters is becoming well, or as well as possible.

This perspective is clearly a privileged one. Health is certainly not an equalizer: it has been widely acknowledged that health is to a large extent socially determined. Those who are ill but socially privileged may find their privilege matters less to them than their health, but those who are ill and socially disadvantaged are not elevated to the same social status as the privileged during the course of their illness. Social disadvantage doesn’t melt away with illness; in fact, social disadvantage prevents access to health care and contributes to the length and severity of illness.

This paper will argue that health care is a right of all citizens of all societies. First I will present evidence that health is in large part socially determined. Then I will argue that since society has a decisive hand in creating health through social conditions and structures, society has a pursuant moral obligation to provide care for citizens whose health is affected by those conditions and structures.

It is important to note that this paper focuses on population health rather than individual health. Genetics play an important part in the health of individuals, but the largest contributors to the health of populations are environmental and social factors.[2]

Social Determinants of Health
In 1980, a groundbreaking study was released in the UK on the correlation between social inequalities and health. Colloquially known as The Black Report, the study showed that such social classifications such as gender, race, ethnicity, and economic class affected health, and that poor health was directly related to social disadvantage.[3] Further, the report showed surprisingly that even though Britain has (and had at the time) a national publicly administered health care system, access to health services was reduced among the socially disadvantaged.[4] The report states, “In all cases, for an individual to seek medical care, his (or her) perception of his (or her) need for care will have to outweigh the perceived costs (financial and other) both of seeking care and of the regime which may be prescribed. These costs are class related.”[5] The Black Report began an extensive and ongoing sociological project that looked to identify and explain the social determinants of health.

The World Health Organization has comprehensively studied the links between social status and health internationally. In 2003, WHO released the second edition of the report, Social Determinants of Health: The Solid Facts.[6] This report focuses on such social conditions such as work, stress, and social exclusion due to race and economic status as factors affecting population health. The report states, “Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top.”[7] Further, “disadvantages tend to concentrate among the same people, and their effects on health accumulate during life. The longer people live in stressful economic and social circumstances… the less likely they are to enjoy a healthy old age.”[8] So, those people who fall into socially disadvantaged and marginalized groups have an increased risk of illness and death, and the ill effects on their health are cumulative. WHO has also published reports on the specific correlations between poor health and socioeconomic status,[9] and gender and health.[10]

Judith Lorber examines the links between the social construction of gender, race, and class, and population health. She writes, “Many of the risky health behaviours in adulthood, such as drinking and smoking cigarettes, seem to be a matter of individual choice. But a closer look reveals that social factors linked to gender, race and ethnicity, and economic class produce the situational circumstances that influence health-related behaviours.” [11] Studies have shown that poor uneducated black men are more likely to become heavy drinkers than black women or white men or women, and that educated black men have a significantly higher incidence of alcohol-related problems than educated white men: once per month on average as compared to three times a year for educated white men. Lorber notes that educated black men are more likely to feel pressure to maintain a standard of behaviour expected by society in relation to their social standing.[12]

Social inequalities can have both direct and indirect influences on health and health care for members of those groups.[13] Poverty precludes people from providing for themselves healthy living conditions like clean and safe housing, nutritious meals, and warm clothing. More subtly, forms of discrimination can produce psychological barriers to good health by creating stress, causing depression and despair, and preventing certain people from having their concerns listened to and met with realistic solutions.[14] Social exclusion can contribute to isolation and withdrawal from the community and social networks of support that can in turn reduce the likelihood of certain people asking for and receiving help. Poor finances can mean a person who is in poor health may not be able to afford to take time off from working for convalescence, and as a result may allow an illness to progress further before seeking medical help; additionally, such a person might have difficulty communicating across economic class and other socially determined lines, such as race and gender, to a medical professional whose social position is one of relative, yet significant, power. Women have traditionally behaved deferentially to male doctors when seeking medical help, which may adversely affect their health outcome, for example. It is easy to see how “even within relatively prosperous, ‘developed’ economies with apparently comprehensive health care systems supported by ‘scientific’ medicine, health chances are tied to economic, social and environmental factors.”[15]

Society’s Responsibility, Society’s Obligation
Because health is determined by social factors, society has a two-fold obligation: 1. to provide health care for those who become ill, and 2. to reduce social inequalities that result in poor population health. I will discuss each obligation in turn.

Health inequalities are not remedied by providing a comprehensive health care system to the public. Even in countries where health care is publicly funded and access is not restricted, social inequalities still produce inequalities in health: “The primacy of economic, social and environmental factors is reflected in evidence that treatment-oriented health care has relatively little impact on the health chances of populations.”[16] However, this does not excuse governments from providing health care to its citizens; just because comprehensive universal health care doesn’t solve the problem of social inequality, it does not mean governments have no obligation to provide health care to its citizens. Because society has a hand in determining health, it has an obligation to provide care to those who become ill as a result of inequality.

Furthermore, inequality is so pervasive and ubiquitous, it follows that the most just way of dealing with this obligation so that nobody who becomes ill due to social determinants falls through the cracks is to provide health care universally to everyone, not just to those who are marginalized. It is morally inappropriate to set an acceptable level of social inequality to endure before health care may be accessed. A perfect example is the Medicaid program in the United States. Medicaid is a publicly administered health care program that insures those with limited income. However, not everyone on a limited income is eligible to receive Medicaid; various requirements exist for different groups that are difficult to generalize.[17] For example, the working disabled qualify for Medicaid only if their income is 200% below the poverty line. These eligibility requirements leave 45.8 million American citizens without access to health care.[18] Additionally, a recent Harvard study found that half of all personal bankruptcies in the U. S. are due to medical bills.[19] Chances are many of those 45.8 million uninsured Americans are touched in some way by social marginalization that has an impact upon their health. By refusing to provide universal access to health care, the U.S. government ignores the ways in which it participates in and creates the social inequalities that contribute to or are responsible for the poor health of so many Americans.

Social Justice
Immanuel Kant’s Categorical Imperative, “Act only on that maxim whereby thou canst at the same time will that it should become a universal law,”[20] is seen as the basis for social justice and human rights. Kant’s insistence that all people must be treated as ends in themselves[21] is an expression of the notion of universal and inherent human equality. Modern accounts of social justice, such as the one advanced by John Rawls, declare that social inequalities are tolerable only insofar as those inequalities provide an overall benefit to the least advantaged members of society.[22] This can only be achieved through redistributing wealth from the rich to the poor. In the modern welfare state, this is done through taxation: wealth is collected in the form of taxes and redistributed to the economically disadvantaged through social programs that provide money, food stamps, and housing. On social justice, then, a person who is economically disadvantaged can claim a positive right to goods and services that he or she cannot afford to purchase. Because society supports social inequalities, it has an obligation to provide a basic level of goods and services to all members of that society. This view can be extended globally; because there are economic and social disparities between global communities, economically powerful countries have an obligation under social justice to alleviate some of the effects of those disparities. There may be pragmatic problems with achieving this goal, but that does not remove the obligation.

The current health care situation in the United States is an example of how social inequalities lead to poor health, and where social justice falls short. The wealthy may simply buy health care when they become sick, while the poor bankrupt themselves under the strain of medical bills. The U.S. government allows social inequalities to exist that have a negative impact on health, does nothing to alleviate the root causes of those inequalities, and does not even provide adequate health care to those who become sick due to the social conditions the government creates and supports. This is like putting a band-aid on a gunshot wound. A system in which social inequalities exist that affect the health of some members of the population, and in which health care is not universally accessible but is only available on the basis of ability to pay unjustly favours the wealthy. A system like this does not value each person equally. If social inequalities cause poor population health, governments have a moral obligation to contribute to the treatment of the illness caused by embedded social structures such as racism and poverty. If a government recognizes that individuals who are adversely affected by socio-economic constructs have a right to goods they cannot otherwise access through welfare, that government should also recognize that health care is one of those goods.

Health Care Is Not Enough: Health Human Rights
Providing health care is only half the solution. The other half must come from reducing and eliminating the inequalities that result in poor health. The World Health Organization declares in its constitution that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being,”[23] and goes on to say that “governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.”[24] The United Nations has linked human rights to health issues such as HIV/AIDS,[25] sexual and reproductive freedom,[26] and violence against women.[27] The UN believes that humans have a universal right to health and health care.

In its report on the social determinants of health, WHO makes policy recommendations that will have the effect of reducing social inequalities that are contributing factors to poor health. WHO consistently refers to claims of social justice, human rights, and welfare, and the responsibility of governments to reduce the disparities between social groups by increasing education opportunities, encouraging involvement in the community, raising housing standards, and alleviating unemployment.[28] Also, WHO has developed a Commission on the Social Determinants of Health to help find ways to reduce inequalities between social groups that may contribute to better access to health care.[29] Initiatives like these go to the heart of the problem of socially determined health inequalities, and will ultimately be the solution society needs. In the meantime, governments must commit to providing universal free access to health care to treat those who fall victim to the social determinants of poor health.

Conclusion
This paper has shown that health is causally linked to social factors such as race, class, and gender, and that poor population health is due to inequalities between social groups. I have argued that since health is determined by society, society has a moral obligation to provide health care to those who need it, and that the most just way to do this is to provide universal health care. I have further argued that providing universal health care is not enough, and that society has a moral obligation to reduce social inequalities that lead to poor health and suffering. I have argued that health is a human right based on equality, and that societies that do not provide universal health care do not support principles of social justice and equality. I have also argued that the only way healthy populations can be achieved is through a two-pronged approach that aims to provide universal health care while simultaneously reducing and eliminating social inequalities that lead to poor health.

Good health is more than a personal matter. Good health is a matter of concern for society. Healthy populations are productive populations, and productive populations contribute to successful economies that support democratic rights and freedoms. I’ll end this paper with a quote that elucidates the political importance of health, and encapsulates nicely my belief in the ultimate international result of good population health: “The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and states.”[30]

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[1] McLeod, Eileen and Bywaters, Paul. 2000. Social Work, Health, and Equality, pp 1. London: Routledge.

[2] The Social Determinants of Health: The Solid Facts. Second Edition. Wilkinson, R., and Marmot, M., editors, pp 7. © 2003 World Health Organization. Accessed April 6, 2006 at http://www.who.dk/document/e81384.pdf

[3] Inequalities in Health: Report of a Research Working Group. 1980. DHSS. Chapter 2, Section 2.66, 2.67, 2.68.

[4] Ibid, Chapter 4, Section 4.42-4.49. Accessed April 6, 2006 at http://www.sochealth.co.uk/history/black4.htm

[5] Ibid, Section 4.48

[6] The Social Determinants of Health: The Solid Facts. Second Edition. Wilkinson, R., and Marmot, M., editors. © 2003 World Health Organization. Accessed April 6, 2006 at http://www.who.dk/document/e81384.pdf

[7] Ibid, pp 10.

[8] Ibid, pp 10.

[9] Blakely T, Hales S, Woodward A. Poverty : assessing the distribution of health risks by socioeconomic position at national and local levels. Geneva, World Health Organization, 2004. (WHO Environmental Burden of Disease Series, No. 10). Accessed April 6, 2006 at http://www.who.int/quantifying_ehimpacts/publications/en/ebd10.pdf

[10] Gender, Women and Health. WHO website. Accessed April 7, 2006 at http://www.who.int/gender/other_health/en/, http://www.who.int/gender/documents/en/

[11] Lorber, Judith. 1997. Gender and the Social Construction of Illness, pp 26. Thousand Oaks: Sage Publications, Inc.

[12] Ibid, pp 26-27.

[13] McLeod, Eileen and Bywaters, Paul. 2000. Social Work, Health, and Equality, pp15. London: Routledge.

[14] Ibid, McLeod and Bywaters, pp 15.

[15] Ibid, pp 15

[16] Ibid, McLeod and Bywaters, pp 15.

[17] Medicaid at a Glance 2005: A Medicaid Information Source. United States Department of Health and Human Services. Accessed April 7, 2006 at http://www.cms.hhs.gov/MedicaidEligibility/downloads/MedGlance05.pdf

[18] Centre on Budget and Policy Priorities website. Accessed April 7, 2006 at http://www.cbpp.org/8-30-05health.htm

[19] “Medical Bills Leading Cause of Bankruptcy, Harvard Study Finds.” Consumer Affairs website. Accessed April 7, 2006 at http://www.consumeraffairs.com/news04/2005/bankruptcy_study.html

[20] Kant, Immanuel. “The Categorical Imperative,” Contemporary Moral Issues Fifth Edition (Cragg, W. and Koggel, C., editors), pp 592. ©2005, Canada: McGraw-Hill Ryerson Ltd.

[21] Ibid, pp 595.

[22] Rawls, John. “A Theory of Justice,” in Moral Issues in Globla Perspective (Koggel, C., editor), pp 46. © 1999, Peterborough: Broadview Press.

[23] Preamble to The Constitution of the World Health Organization, pp 2. Accessed April 7, 2006 at http://w3.whosea.org/LinkFiles/About_SEARO_const.pdf

[24] Ibid. pp 2.

[25] Declaration of Commitment on HIV/AIDS, “Global Crisis, Global Action,” Section 16, pp 10 & Sections 58-61, pp 24-25. Accessed April 7, 2006 at http://data.unaids.org/publications/irc-pub03/aidsdeclaration_en.pdf

[26] Convention on the Elimination of All Forms of Discrimination Against Women, Article 16(e). Accessed April 7, 2006 at http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm#article16

[27] UNIFEM website, “Facts and Figures on VAW [Violence Against Women].” Accessed April 7, 2006 at http://www.unifem.org/gender_issues/violence_against_women/facts_figures.php

[28] Ibid, pp 10, 11, 13, 17, 21, 23

[29] Commission on the Social Determinants of Health. WHO website. Accessed April 7, 2006 at http://www.who.int/social_determinants/en/

[30] Preamble to The Constitution of the World Health Organization, pp 2. Accessed April 7, 2006 at http://w3.whosea.org/LinkFiles/About_SEARO_const.pdf

*please note: this paper may not be used in full or in part in any form without the express permission of the author*