Bann, D

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UCL Discovery

The European Journal of Public Health, Vol. 31, No. 3, 458–459 The Author(s) 2021. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved..........................................................................................................................................Viewpoints.........................................................................................................................................The scope of health injusticeRecent commentaries in this journal have reignited discussion aboutthe causal claims and policy implications of health inequalities re-search—particularly strikingly, whether socioeconomic differencesin health are confounded by cognitive or genetic factors (‘incon-venient truth 1’).1 An alternative way to frame this issue is to re-consider the role of these and other controversial factors. Even if thisclaim were entirely true—the totality of empirical evidence does notsuggest this in my view—what would it mean for the field of socialepidemiology?Health differences according to socioeconomic position (SEP) arewidely framed as being health inequities; monitoring and reducingthese health differences are major focuses of national and trans-national organisations, with seminal policy-directed reviews focus-sing on SEP differences in health. Awareness of the injustice of SEPdifferences in health is an important motivator for research, thefocus of epidemiological investigation, funding and policy action.2For example, the UK’s then Prime Minister Theresa May’s firstspeech noted as motivation for policy action ‘the burning injusticethat, if you’re born poor, you will die on average 9 years earlier thanothers’ (https://www.gov.uk/government/speeches/statement-from-the-new-prime-minister-theresa-may). It seems intuitive that SEPdifferences in health are unjust, and are thus health ‘inequities’ ra-ther than simply health ‘differences’. Considering whether otherhealth differences are inequities is important, give the implicationsfor research and policy. To explore whether the same definitioncould or indeed should also be applied to cognition and geneticfactors, consider the below:Individuals in the population are exposed to ‘X’ at birth—theytherefore do not choose their exposure, yet it has lasting (probabil-istic) causal effects on multiple health and social outcomes, whichextend across life. It is thus arguably unfair. It is also avoidable, sincesociety can enact policies to prevent these health consequences fromoccurring, despite exposure to X. It is thus arguably unjust.Is ‘X’(1) Socioeconomic status/position(2) General cognitive capability—‘intelligence’ or(3) Genetic propensity to ill health?As implied, there are several similarities in the above risk factors;each in fact meets multiple commonly utilized definitions of healthinequity (see table 1). The most widely used definition of healthinequity, seemingly adopted by the World Health Organization, isWhitehead’s 1991 definition that inequities are differences in healththat are ‘unnecessary, avoidable, unfair and unjust’. The authors ofthis seminal paper noted that it was intended to stimulate debate onthese issues rather than forming a canonical definition of healthinequity. Whitehead noted that ‘natural, biological variation’ as acause of health differences is probably not health inequities. Yet, thiswas before insights from genetically informed studies, and shouldperhaps now be re-addressed given there is nothing particularly‘natural’ about how common genetic propensities affect health.The relative importance of genetic factors is likely specific to con-text—time, place and the health outcome considered—and thussubject to modification by the environment which we (hope to)modify. As such, examination of factors, such as genetic propen-sities, is still within the remit of health inequalities research.A key component of a health inequity is the notion that somedifferences in health are unjust. According to multiple commonlyutilized definitions of justice—e.g. Rawls’ theory of distributivejustice and luck egalitarianism—differences in health according tosocioeconomic, cognition and genetic predictors of ill health can allbe considered unjust. Indeed, a detailed application of luck egalitar-ianism to health noted that healthcare is ‘society’s obligation toreverse individuals’ disadvantaging biological conditions for whichthey are not responsible’.3 The social science literature is increasinglyconsidering the role of genetic propensities on important social out-comes, and in doing so helping to dispel widely held myths: con-sideration of genetic factors can in fact help us to better understandsocial injustice, and does not imply genetic determinism.4 Strongcausal links between (partly) genetically determined traits, such ascognition and socioeconomic outcomes, may both exist and con-tribute to social injustice—a ‘meritocracy’ was first coined to de-scribe a hypothetical social dystopia. There are clearly many routesto inequity including and beyond SEP, which likely apply to bothsocial and health outcomes.In an extreme example, genetic variants, which cause increasedalcoholism risk will not have an observed effect in the absence ofalcohol, or arguably smaller effects in societies in which alcohol is aless predominant part of culture. In another, where the environmentis more obesogenic, obesity-related genes appear to have largereffects.5 As such, the suggestion that ‘genetic effects’ are inevitableand not modifiable by society may be largely misguided; estimates ofgenetic effect show what has been the case in the observed sample,not what could be the case in future in a different context. Theheritability value for a given health outcome is simply a value, whichranges from 0% to 100% depending on the environment (both itsvariability and its relevance for the genetic propensity).6Gaps in current evidenceA framework to represent the different strands of health equity re-search is suggested below. Researchers interested in better under-standing (and ultimately using evidence to reduce) health inequitywill typically investigate:(1) The presence and causal nature of health inequity(2) Modification across time (i.e. is the problem worsening?)(3) Amelioration/prevention by intervention.Further economic and broader societal considerations are thenundertaken to appraise the cost-effectiveness of the proposed inter-ventions and their relative utility in the contexts of opportunitycosts of investing in other policy areas. Active lines of research existacross each strand exist for SEP—including e.g. high profile reportsdocumenting the presence of health disparities, studies investigatingtheir causal nature, change across time and potential ameliorationby intervention. For each plausible group by which health inequitycan be defined—such as religion, race, area of residence etc.—pro-gress across these different aspects of research can be evaluated.For genetic propensities and cognition, evidence is notably lack-ing; something which social epidemiologists may wish to consider.The consideration of these two controversial factors helps illustratethat health inequities may exist across many more possible di-mensions than typically considered. Continued epidemiologicalevidence is required to inform such considerations across the mul-tiple possible health equity stratifiers: evidence on their magnitude,causal nature, change across time and potential reduction viaintervention.Downloaded from https://academic.oup.com/eurpub/article/31/3/458/6125327 by guest on 11 November 2022AcknowledgementsThe author would like to thank the following for providing helpfulcomments on an earlier version of this manuscript: Prof. MelBartley, Dr Vanessa Moulton, Prof. Alex Bryson and Dr NeilDavies. An earlier more extended version of this manuscript wasposted on the OSF preprint server: https://osf.io/preprints/hcn7a/.FundingThe author is supported by the Economic and Social ResearchCouncil (grant number ES/M001660/1) and the Academy ofMedical Sciences/Wellcome Trust (‘Springboard Health of thePublic in 2040’ award: HOP001/1025), and Medical ResearchCouncil (MR/V002147/1).Conflicts of interest: None declared.References1 Mackenbach JP. Re-Thinking Health Inequalities. New Jersey, USA: OxfordUniversity Press, 2020. https://doi.org/10.1093/eurpub/ckaa001.2 Marmot M. Social justice, epidemiology and health inequalities. Eur J Epidemiol2017;32:537–46.3 Segall S. Health, Luck, and Justice. New Jersey, USA: Princeton University Press,2009.4 Harden KP, Koellinger PD. Using genetics for social science. Nat Hum Behav 2020;4:567–576.5 Brandkvist M, Bjørngaard JH, Ødegård RA, et al. Quantifying the impact of geneson body mass index during the obesity epidemic: longitudinal findings from theHUNT Study. BMJ 2019;366:l4067.6 Tenesa A, Haley CS. The heritability of human disease: estimation, uses andabuses. Nat Rev Genet 2013;14:139–49.7 Whitehead M. The concepts and principles of equity and health. Health Promot Int1991;6:217–28.8 Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health2003;57:254–8.9 Porta M. A Dictionary of Epidemiology. Oxford, UK: Oxford University Press, 2008.10 Norheim OF, Asada Y. The ideal of equal health revisited: definitions and meas-ures of inequity in health should be better integrated with theories of distributivejustice. Int J Equity Health 2009;8:40.David BannCentre for Longitudinal Studies, Social Research Institute, University CollegeLondon, London, UKCorrespondence: David Bann, Centre for Longitudinal Studies, SocialResearch Institute, University College London, London WC1H 0AL, UK,e-mail: david.bann@ucl.ac.ukdoi:10.1093/eurpub/ckaa230Advance Access published on 1 February 2021.........................................................................................................................................The European Journal of Public Health, Vol. 31, No. 3, 459–460 The Author(s) 2021. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved..........................................................................................................................................Is the study of genetic propensities within the remit of health inequalitiesresearch?In his viewpoint, Bann1 claims that social epidemiologists andothers working in health inequalities research should concern them-selves with cognition and genetic factors. But do differences inhealth between groups defined on the basis of cognition or genesconstitute health inequity?There are many definitions of health (in)equity, including that ofWhitehead (cited in the viewpoint1) which, based on a review of theliterature, concluded that ‘health differences determined by [bio-logical variation] would not normally be classified as inequities inhealth’.2 It is arguable whether this definition needs to be updated inview of more recent research.Based on the Braveman and Gruskin3 definition of equity inhealth as ‘the absence of systematic disparities in health (or in themajor social determinants of health) between social groups whohave different levels of underlying social advantage/disadvantage’,Bann argues that this is applicable to genetic propensity for diseasebecause the disease may lead to social disadvantage. This is an ar-gument of reverse causation: social position is determined by healthrather than the other way round. Traditionally, social epidemiologyhas been thought of as the study of the social determinants of thedistribution of health across populations,4 but it seems reasonable toextend this to improving our understanding of the social patterningof disease and, as such, would include reverse causation.The idea that genetic predisposition might influence health, andthis in turn impact on social position, differs from the suggestion byMackenbach5 that socioeconomic differences in health may beTable 1 Multiple health inequity definitions and their applicability to socioeconomic, cognition and genetic determinants of healthApplicable to the following exposures, yes/noHealth equity/inequity definition (abridged) SocioeconomicpositionCognition Genetic propensitiesWhitehead (1992)7: ‘unnecessary, avoidable, unfair and unjust’ Arguably yes Arguably yes Arguably yesBraveman and Ruskin (2003)8: ‘Health equity is the absence ofsystematic disparities in health (or its social determinants)between more and less advantaged social groups.’Arguably yes Arguably yes, assuming in acomplex society lowercognition leads to relativesocial disadvantageArguably yes, assuming that geneticpropensities may cause health andsocial differences in outcomeswhich result in social disadvantagePorta (2008)9 health equity: ‘Fairness and impartiality in anyhealth related determinant or outcome’Arguably yes Arguably yes Arguably yesNorheim and Asada (2009)10: every group should have equalhealth unless it makes others less healthy or it is not possibleto improve itArguably yes Arguably yes Arguably yesThe scope of health injustice 459Downloaded from https://academic.oup.com/eurpub/article/31/3/458/6125327 by guest on 11 November 2022

The scope of health injustice

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