Integrating theories of social justice into public health intervention planning

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Integrating theories of social justice into
public health intervention planning

• Eric Breton MA, PhD, Zayed University, United
  Arab Emirates
• Evelyne De Leeuw, MSc, MPH, PhD, Deakin
  University, Australia
• 12th World Congress on Public Health, Istanbul,
  Turkey
• 29 April, 2009

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Abstract

• Public health practice is typically guided by
  epidemiological explanations of the causes the
  causes being act upon through behaviour or
  environmental change strategies. This approach
  has been repeatedly criticized on practical and
  ethical grounds. For one thing, the causes, i.e.
  risk factors, identified are often oblivious of
  enduring socio-economic determinants of health
  and entrenched inequalities.
• Consequently, there is a need to move from a
  strict bio-medical approach to public health
  problem resolution to one that would also account
  for and be integrative of dimensions of fairness
  and justice. We propose the first elements of an
  approach to public health intervention guided by
  a theory of social justice. Our claims are based
  on the seminal work of Amartya Sen whose
  capability approach has generated a growing body
  of works on welfare and public health programs.
  The approach rests on two central pillars. One
  is the acknowledgement of the differing needs,
  entitlements and capacity to convert resources
  that transcend populations. The other is that
  interventions should increase the freedom to
  achieve of individuals (their capabilities).
• Using examples from disease prevention programs,
  we demonstrate that the capability perspective to
  public health program planning calls for 1) a
  conceptualization of public health problems as
  instances of capability deprivation (i.e.
  individuals enjoying few options on what they can
  achieve), 2) a shift of the program focus on the
  achievements in health and well-being to one
  looking at the expansion of the freedom to
  achieve and, 3) a renewed participation of the
  public in the identification of the relevant
  capabilities.
• We conclude that by taking into account the
  differing capacity of individuals to convert
  resources into freedom, the approach inherently
  addresses health inequalities. However, its
  implementation raises a number of difficulties as
  it calls for complex multi-agency interventions
  and for a consensus on relevant capabilities.

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Introduction

• Rising health inequalities/inequities
• Public health interventions and policies
  contributing to inequities
• No theory of justice to guide public health
  programming and policy development
• We present some thoughts on the application of
  one such theory to chronic disease prevention
  programs

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The capability approach
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Main contributors to the capability approach

• Amartya Sen
• 1980 paper Equality of What
• Also contributions from
• Nussbaum
• Alkire
• Robeyns
• Walker

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Capability approach rests on two main pillars

• Acknowledgement of the diversity that transcends
  any groups or populations (e.g. genetics, life
  goals, sexual orientation, political preference
  and wealth)
• Well-being is a function of the degree of freedom
  to do or be what one values
• To improve well-being should be about increasing
  the options of the individuals

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What should be equalized?
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Two possible spaces of equalization

• Functionings (i.e. doings and beings?achievements)
  
• to live long life,
• to be fit/physically active,
• to have friends,
• to eat to ones content.
• Capabilities (potential functionings?potential
  achievements )
• To be able to live long life if one wants to,
• To be able to be fit/physically active if one
  wish it
• To be able to make friends if one wish to
• Etc.

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Capabilities freedom to achieve

• The question is no longer whether the population
  is achieving what it wants to do or be but rather
  do all individuals have the freedom to achieve
  (capabilities) what they have reason to value.
• Societys focus ? capabilities

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An infinite set of capabilities

• Hence the need to identify the most significant
  ones
• Two perspectives
• The relativist one (i.e. Sen)
• The universalist one (e.g. Nussbaum)

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Applying The capability approach to public health
practice
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The case of tobacco control

• Public health perspective (i.e. functioning
  centered)
• to live a smoke-free life
• to not be exposed to ETS
• Capability approach
• to be able to achieve a smoke-free life (or quit
  smoking) if one wishes to
• to be able to avoid exposure to ETS if one wishes
  that

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Locus of intervention

• Capability (freedom) to live a smoke-free life.
• Factual knowledge (on harms and cessation)
• Communicative environment (e.g. misleading
  information advertisement, smoking in movies,
  tobacco sponsorship, price of cigarettes)

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Locus of intervention (ETS)

• Capability (freedom) to live free of exposure to
  ETS
• Measures to prevent smoking in the public space
• Measures to prevent smoking in the
  private/domestic spaces (e.g. in cars)

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Beyond knowledge and legislative measures

• Applying a capability approach to public health
  programming and policy development requires to
  reflect on
• the exercise of free choice ? Critical thinking
  and autonomy
• The capabilities valued by the population
  (relativist perspective calls for a democratic
  process)

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Conclusion

• Public health problems as instances of capability
  deprivation (i.e. individuals enjoying few
  options on what they can achieve)
• Health or freedom?
• A renewed participation of the public in the
  identification of the relevant capabilities.
• The approach is largely inequity proof
• Implementation calls for complex multi-agency
  interventions.

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ÇOK TESEKKÜRLER!THANK YOU ???? ??MERCI!
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Questions?

• Please contact
• Eric Breton, PhD
• Assistant Professor
• Department of Natural Science Public Health
• College of Arts and Sciences
• Zayed University
• P.O. Box 4783
• Abu Dhabi, United Arab Emirates
• Office 971 2 407 9674
• Fax [phone]
• Email Eric.Breton_at_zu.ac.ae
• http//www.zu.ac.ae