JOAN BENACH is a professor of Public Health, Director of the Group for Research on Health Inequalities in the Department of Political and Social Science in the University of Pompeu Fabra in Barcelona, and author of numerous scientific publications and texts on the topic. These include Aprender a mirar la salud (available online at http://www.bvs.org.ve), Empleo, trabajo y desigualdades en salud: una visión global (Barcelona, Icaria, 2010), La sanidad está en venta (Barcelona, Icaria, 2012), Sin trabajo, sin derechos, sin miedo (Barcelona, Icaria, 2014), y Cómo comercian con tu salud (Barcelona, Icaria, 2014).
The concept of public health has evolved from an initial emphasis on hygiene and the isolation of the sick to concepts that are more related to prevention and a more social vision, such as collective health. What is your understanding of public health today?
Public health can be defined as the set of knowledge, technology and interventions aimed at understanding and improving the “health of all”, or collective health, for the wellbeing of all of society. This vision supposes, however, that it’s not only about improving health of the population as a whole. One also needs to emphasize the increase of equity in health, because it is very possible for the average health of the population to improve and same time for inequality to grow between groups or territories. In any case, when considering such a broad field, we can note that there are very distinct views of public health based on the causes and solutions of health that we focus on.
For example, there is a view of public health that is apparently “neutral” or asocial. It is related to risk management and based, paradoxically, on health as a group of biological individuals and on the implementation of solutions, “strategies” or technologies.
On the other hand, there is a view of public health that is social and historical. This view is very related to the profound importance that social and political determinants have on collective health and on equity.
You mentioned social determinants of health. What are the fundamental causes that determine that certain groups of the population have different levels of health?
The fundamental determinants of the health of a population — and of the specific groups (based on their social class, gender, ethnicity, etc.) and territories that constitute it — change according to the historical situation and theories of illness that dominate in each historical moment. For example, when infectious diseases prevailed as the fundamental cause of health problems, the emphasis of public health was on hygiene; as cardiovascular diseases became more relevant, the concept of “risk factors” emerged.
Starting in 1980, with the Black Report [United Kingdom] or the 2008 report of the Commission on Social Determinants of the World Health Organization, health inequalities and social factors have strongly emerged, though they are definitely not as dominant as the ideology of genetics or “lifestyle”. Today, many researchers search for answers to explain public health through genetics, or epigenetics in any case.
However, from my point of view, the health-illness binary is related to a chain of extremely complex causes that cannot be reduced to risk factors, biological factors or simplistic behaviors. Instead, these causes are generated by a network of historical-structural factors, as are political, ecological, and historical-social factors: where we live, how we produce, the type of environment we have, who has social power. These and other factors impact, in some way or another, the processes and fundamental mechanisms that lead to illness and poor health.
What are the ways in which these factors impact health?
It isn’t an easy topic to explain or summarize, but if we put it in the simplest terms possible, we could say that the determining factor at the start of the whole causal chain that produces better or worse collective health and more or less equity in social groups, is politics — that is, power relations and the social groups (whether they be governments, large corporations, unions, NGOs, lobby groups, social elites, civil society groups, etc.) that have more or less power to make decisions in a given society.
If we understand this whole process, it shouldn’t seem at all strange to understand that, with a broad view of public health, we can say not only that liver cells, hepatocytes, or cellular enzymes reflect his illness in the liver, but we could talk about a “capitalist liver”.
This whole network of relations ultimately creates a conglomeration of forces that result in distinct social, health, environmental, and labor policies that are implemented in each moment. Then, these policies produce another large chain of causes that in the mid- and long term lead to an infinite number of “intermediate” factors, such as, for example, types of employment, the health system, living conditions, or existing social services in a society, country, region, or given city. These factors themselves will impact, through very different pathways, the behaviors, the biology, and other factors that are closely related to health and illness.
Can you give a concrete example?
Let’s take the following case. A person ends up unemployed and therefore begins drinking more alcohol than usual. If this situation goes on, and he becomes chronically unemployed and continues drinking excessively, he will have a higher probability of ultimately becoming an alcoholic. If he is alcoholic, it will be more likely that his liver will be in bad condition and that he might suffer from liver disease.
If we understand this whole process, it shouldn’t seem at all strange to understand that, with a broad view of public health, we can say not only that liver cells, hepatocytes, or cellular enzymes reflect his illness in the liver, but we could talk about a “capitalist liver”.
Why? Well, because capitalism is a historical process that began in Europe in the 12th and 13th centuries that structurally produces unemployment (which gives it a reserve labor force that is exploited through labor), and this unemployment will create anxiety and depression, and these effects will translate into increased consumption of alcohol and alcoholism, which in turn lead to higher risk of cirrhosis and biological harm.
With all of that, to separate, as science routinely does: biology from that which is social, from that which is psychological can be useful but is inevitably incomplete. So then we need to advance towards a type of knowledge and understanding that is more integrated, complete, and also historical. As Marx understood it in his time; knowledge should a sort of “living organism” where health would be an ultimate expression of social and political life. Therefore, if everything I’ve just said about the causal chain is understood, we must understand health as the final result of this set of connected social phenomena.
How can all of this be reconciled with the emphasis that is often placed on modifying lifestyles, which in recent times has been the first line of defense in any treatment?
That’s right. Along with genetics and technological changes, lifestyles constitute the political actions that are most typically recommended by institutions. The recommendations of health policies of all health governments tell us things like, “don’t smoke, exercise, drink with moderation, have safe sex, etc.”
Is this incorrect? No, it isn’t, but it’s incomplete. It leads to mistakes and is also extremely limited if it does not take into account the social context where behaviors related to health are created. According to the neoliberal ideology of freedom, freedom is doing whatever one wants. But one does not do what one wants, one does what one can, or what one is allowed to do. Or we can also say that one does what one wants and what one can do within a set of rights that are socially determined. If one does not have rights, one has a more limited degree of freedom.
To separate, as science routinely does: biology from that which is social, from that which is psychological can be useful but is inevitably incomplete.
Public health must therefore insert itself in the center of social rights, of human rights. A few years ago, the English social epidemiologist Dave Gordon criticized the standard list of recommendations based on “blaming the victim” (don’t smoke, don’t drink, exercise, etc.), contrasting it with a new list of alternative recommendations based on social determinants, where he said things like, “Don’t be poor, but if you are poor, make sure you aren’t poor for much time,” or, “Don’t live in an area without services…Don’t work in a stressful, low paying, precarious job.”
Oftentimes, people attempt to present science as an objective, sterile discipline that is independent of any ideological influence. In this way, the findings produced by the academy are considered to be the only truth. What is your opinion on this?
The taxonomic separation that is typically made between science and ideology is a separation that in practice cannot be sustained. Science can have components that are almost totally objective, such as elements of metric or quantification, or of formal logic, and these can be very objective, but there are also many other things that aren’t. This goes from the choice of the topic of research that is made, to the possibility of conducting the research based on existing sources of funding, or the dominant theoretical paradigms in a given historical context, or the selection of data that must inevitably be made, or the analyses that is chosen and conducted, etc. There is an enormous quantity of decisions that have to do with ideology and assessments, which are subjective aspects that researchers must work through. Moreover, these scientists insert themselves in concrete social, institutional and group frameworks so that they almost never work in isolation. These are all social elements that make it so that one cannot see research as something separate, isolated, or neutral.
You have tried to recover the concept of social class to explain inequalities in health. What can it bring to this vision?
The study of social inequalities has generally been conducted by many social scientists. Not all social scientists, of course, but those who are concerned with understanding why distinct social groups have different possibilities to study, to be rich and poor, to have more or fewer opportunities, and also to have good or poor health, etc. This has been frequently studied from a point of view of “social stratification” according to level of education, income, wealth, occupation, the neighborhood where one lives, etc.
This focus, even if it is useful, leaves out some things that are very important, such as the fact that if one finds a link between income and health, we don’t understand why this happens. In public health we must try to understand the causes and mechanisms. That is to say: we find that at higher levels of income there is better health. This is a finding that is repeatedly found in hundreds of scientific studies. But one must also ask oneself why; what are the reasons for this difference in incomes and this relation with health. If we don’t do this we will get stuck mid-way.
In public health, it’s not enough to document social inequalities of health. We need to explain them, we need to get to the bottom of why these inequalities are generated.
For this reason, a more sophisticated view, even if it’s still not very prevalent or developed in the field of public health, has been to develop the view of social class with a more sociological and complex vision, where instead of thinking of social class as a simple gradient, one must think in “relational” terms. In other words, terms that from a philosophical point of view are very interesting: relations and conflicts between people and social groups. The clearest example is what happens in businesses between owners and workers. These aren’t isolated groups, there is inevitably a link, a social relation between them, that reflects different levels of power.
And it is harder because for the “groups of power” that you mention, it’s not in their interest that class differences be studied and conceptualized with this perspective. The publication of a study where class determines a large difference in health is much more intolerable than one where a gradient marks a slow, gradual difference that doesn’t separate things so clearly, right?
Yes, of course, none of the views that we are describing are neutral. Everything has its consequences. One finds what one looks for. If one conducts a very reductionist and strict study, that is not very explanatory, they won’t find certain results, or they won’t understand why they are produced. And explaining and understanding phenomena is essential to having the possibility to change them, and applying the highest degree of rationality possible. And in public health, it’s not enough to document social inequalities of health. We need to explain them, we need to get to the bottom of why these inequalities are generated.
You say that it is not enough to document health inequalities in order to eliminate them. What determines the possibility of resolving these social problems?
Policies that are implemented (or not implemented) depend on the correlation of forces that exist in a given moment, and on the social ideology that motivate these forces. This has to do with the hegemonic visions that characterize a given time. Unfortunately, when we talk about public health, because of the huge weight that biomedical and individual-level perspectives have, and the vision of the high-level hospital and of treatment with high technology, a large part of the population doesn’t end up seeing that health is a fundamentally social, political problem. Engels and Virchow already said this in the 19th century, Salvador Allende also said it and many others such as Vicente Navarro in the 20th century.
We must continue repeating it one way or another in the 21st century. Public health is an eminently political problem. Equity in health is definitely the best indicator of social justice that we have in a country because it reflects how we live, how we work, what environment we have, which services and rights have been won, etc.
At the same time, health equity should not be an object of attention and interest only among doctors, public health specialists and practitioners, but of all of society. For this reason it would be necessary to change many things, from university curricula to the hegemonic view with respect to health, leading to a profound change in research, the hegemonic causes of health and the development and evaluation of comprehensive policies.
In recent years, you wrote a series of texts on the marketization of public health services. What is this phenomenon?
Healthcare, or social health services as it should be called, is not the most important determinant of public health. Let us remember that when one goes to a doctor’s visit normally it’s because one is sick and needs help. But why are they sick? What are the causes that result in this person being sick? It probably is due to life causes–social, work-related and environmental–our understanding of which is fundamental to public health. That said, it is clear that social health services are very important for the population and are also the reflection and the result of a historic process.
In Western Europe, only starting in the second half of the 20th century, did we accept something that for many years seemed obvious and fundamental: health had to be a universal right. Unfortunately, only a few countries in the world were able to achieve health as a social right and reach the point where the population had the possibility of having quality health care and necessary services independently of their social class, status, social situation and place of residence.
Healthcare, or social health services as it should be called, is not the most important determinant of public health.
What happened in recent years in those rich countries where this developed? Beginning in the end of the 1970s, neoliberal globalization and a series of pressures and policies implemented by the dominant business elites, governments and institutions created the financialization of the economy, the deregulation of the labor market, and a series of policies linked to the privatization and marketization not only of health but also of education, of labor, of social protection, etc.
An expression of all of this was the difficulty that we find ourselves in today to separate the public sphere from the private one. Contrary to neoliberal rhetoric, which criticizes the role of the State as being bureaucratic and inefficient, reality shows us how the big companies and corporations leech off of the public sector to obtain the maximum profit from it. All of this produced a slow and progressive process that is putting the Spanish universal health system at risk; a system that developed starting in the middle of the 1980s and that has been very highly valued by the population. We are regressing in such a way that unless the population and social struggles prevent it, there could be in irreversible harm to the population.
Today’s rights are the fruit of the yesterday’s struggles, just as tomorrow’s rights will be the fruit of today’s struggles. Fortunately, there a great deal of social mobilization and there are many groups that are fighting to make these processes of privatization and marketization visible and to reverse them, but the struggle is ongoing. The forces that are interested in continuing this process are very powerful. Only a significant social mobilization will be able to reverse or stop this process.
Interviewed by: Juan Cruz Ferre
Translated from Ideas de Izquierda by Emma Vignola
