Epidemiology and social justice in light of social determinants of health research

Are individual risky behaviours relevant to healthcare allocation decisions? An exploratory study

Purpose

The problematic surrounding patients' prioritization decisions are currently at the centre of political leaders' concerns. How to define whom to treat when there are not enough resources to treat everybody is the key question. This exploratory study aims to investigate the views of Bulgarian citizens regarding the relevance of the information concerning eight individual health-related behaviours in priority setting decisions: smoking, excess of alcohol, illegal drug use, overweight/obesity, speed driving, extreme sports practice, unsafe sex and overuse of internet and/or mobile devices.

Design/methodology/approach

Data were collected through a questionnaire where 322 respondents faced hypothetical rationing dilemmas comprising option pairs of the eight risky behaviours. Descriptive statistics and non-parametric tests were performed to define the penalization of each of the risky behaviours and to test for the association between this penalization and the respondent's health habits and sociodemographic characteristics.

Findings

Most respondents would refuse to grant access to healthcare based on patients' personal responsibility for the disease. Nevertheless, respondents were more willing to consider illegal drug use, excessive alcohol consumption, engagement in unsafe sex behaviours and smoking. Respondent's own interest or advantage seems to be somehow relevant in explaining the penalization of risk behaviours in priority setting.

Practical implications

This study shows that most respondents support the lottery criterion and thus do not want to see lifestyle prioritization in action.

Originality/value

This study is the first attempt to awaken attention to the impact that personal responsibility for health may have on intergenerational access to healthcare in Bulgaria.

Implementing expanded COVID-19 testing in Massachusetts community health centers through community partnerships: Protocol for an interrupted time series and stepped wedge study design

BACKGROUND

Community Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing.

METHODS

To directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs.

CONCLUSIONS

Here, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.

Principles and methods of global legal epidemiology

Although the theory and methods of legal epidemiology-the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population-have been well developed in the context of domestic law, the challenges posed by shifting the frame of analysis to the global legal space have not yet been fully explored. While legal epidemiology rests on the foundational principles that law acts as an intervention, that law can be an object of scientific study and that law has impacts that should be evaluated, its application to the global level requires the recognition that international laws, policies and norms can cause effects independently from their legal implementation within countries. The global legal space blurs distinctions between 'hard' and 'soft' law, often operating through pathways of global agenda setting, legal language, political pressures, social mobilisation and trade pressures to have direct impacts on people, places and products. Despite these complexities, international law has been overwhelmingly studied as operating solely through national policy change, with only one global quasi-experimental evaluation of an international law's impact on health published to date. To promote greater adoption of global legal epidemiology, we expand on an existing typology of public health law studies with examples of policymaking, mapping, implementation, intervention and mechanism studies. Global legal epidemiology holds great promise as a way to produce rigorous and impactful research on the international laws, policies and norms that shape our collective health, equity and well-being.

Health equity and health system strengthening - Time for a WHO re-think

The pursuit of health equity is foundational to the global health enterprise. But while moral concerns over health inequities can galvanise political commitment, how such concerns can or should translate into practice remains less clear. This paper reviews evolving ways that equity goals have featured in key World Health Organization (WHO)-related policy documents, before discussing the heuristic value and empirical traction that the concept of equity can bring to the health system strengthening (HSS) agenda. We argue that while health equity is often presented as the overarching goal of HSS, in practice this is typically circumscribed to the provision of healthcare services. Although healthcare equity is important, we suggest that this narrow focus risks losing sight of the structural political, social and economic drivers of health and health inequities, as well as the broader contexts of care and complex socio-political mechanisms through which health systems are strengthened. Drawing on new lines of empirical inquiry, we propose that broadening the equity lens for HSS -offers exciting opportunities to put health systems at the heart of a more ambitious equity agenda in global health.

Towards an Understanding of Population Health Data in a Single NHS Trust during COVID-19

The objective of this study was to determine the further care needs of people discharged from the hospital following a COVID-19 illness from April–September 2020. Methods: In partnership with an NHS trust in the UK, data analysis was undertaken by linking data from the Trust, to facilitated a triage process. The intention was to provide information in a format that enabled an examination of the population data and highlight any inequality in provision. Data were mapped onto the indices of multiple deprivation, and a range of text and graphical methods were used to represent the population data to the hospital leadership. The visual representation of the demographics and deprivation of people discharged during a critical period of the pandemic was intended to support planning for community services. The results demonstrated that just under half of those discharged were from the poorest fifth of the English population and that just under half were aged 75 or older. This reflected the disproportional effect of COVID-19 on those who were poorer, older or had pre-existing multiple morbidities. Referral to community or outpatient services was informed by the analysis, and further understanding of the diversity of the population health was established in the Trust. Conclusion: By identifying the population and mapping to the IMD, it was possible to show that over half of discharged patients were from deprived communities, and there was significant organisational learning bout using data to identify inequalities.. The challenge of planning services that target underserved communities remains an important issue following the pandemic, and lessons learnt from one health system are being shared.

The explanation of a complex problem: A content analysis of causality in cancer news

Understanding causality is a critical part of developing preventive and treatment actions against cancer. Three main causality models-necessary, sufficient-component, and probabilistic causality have been commonly used to explain the causation between causal factors and risks in health science. However, news media do not usually follow a strict protocol to report the causality of health risks. The purpose of this study was to describe and understand how the causation of cancer was articulated on news media. A content analysis of 471 newspaper articles published in the United States during two time-frames (2007-2008 and 2017-2018) was conducted. The analysis showed that probabilistic causality was most frequently used to explain the causal relationship between risk factors and cancer. The findings also uncovered other important details of news framing, including types and characteristics of risk factors, intervention measures, and sources of evidence. The results provided theoretical and practical implications for public understanding and assessment of cancer risks.

Improving Health Equity and Reducing Pediatric Cancer Disparities: The Role of the Medical Home

The advances in pediatric cancer outcomes over the last quarter century are some of the most successful in modern medicine. Improved diagnostics and novel therapies have led to continued increases in the survival rates of most patients; however, not all populations have benefitted equally. Compared to White children, Black, Indigenous, People of Color patients with cancer more often present with advanced stage illness, less frequently participate in clinical trials, and are more likely to be lost to follow-up once therapy is complete. Proposed hypotheses for these disparities include both biologic and nonbiologic factors, and a growing body of research suggests that barriers influencing care from diagnosis through survivorship are important. In this article, we consider how primary pediatricians can help reduce disparities over the cancer continuum by identifying vulnerable populations, considering potential diagnoses, referring to cancer centers, and following up with patients through survivorship in partnership with the oncology team. [Pediatr Ann. 2022;51(1):e22-e26.].

Integrative Behavioral Health (IBH) Model at the Intersections of the Philippine Mental Health Law, Education, and Policy: For COVID-19 Recovery and Beyond

The COVID-19 pandemic has impacted the mental health of Philippine citizens. The authors propose the Integrative Behavioral Health (IBH) model to help facilitate the country’s eventual recovery from a health psychology perspective. Findings were integrated from a faculty consultation from a private university’s psychology department, a literature review, and a survey of students who are learning online. The survey results revealed that living with family members negatively correlated with readiness to learn online, r = −.37, p < .05. Further research is needed. Furthermore, combining themes gathered from the consultation, literature review, and variables used from the survey served as anchor words for the IBH model: 1. Emancipatory Education; 2) Filipino Psychology; 3) Contextualization; 4.) Philippine Mental Health Law; 5). Symptom Science; and 6) Social Determinants of Health (SDH). The constructs were implemented into an online health psychology course. The proposed curriculum design provides for an effective mental health response towards post-pandemic recovery.

The two most important questions for ethical public health

Public health ethics is a distinct and established field, and it is important that its approaches and rationales are understood widely in the public health community. Such understanding includes the capacity to identify and combine principled and practical concerns in public health. In this paper, we present a background to the ideas that motivate public health ethics as a field of research and practice, and rationalize these through a critical ethico-legal approach to analysis. Two essential points of inquiry are identified and formulated to allow philosophical and practical agendas regarding public health to be combined. These come through asking the theoretical question 'what makes health public?'; and the practical question 'how do we make health public?'. We argue that these two questions require to be addressed if we are to achieve a robust and rigorous, ethical public health.

Collateral Paternalism and Liberal Critiques of Public Health Policy: Diminishing Theoretical Demandingness and Accommodating the Devil in the Detail

Critical literatures, and public discourses, on public health policies and practices often present fixated concerns with paternalism. In this paper, rather than focus on the question of whether and why intended instances of paternalistic policy might be justified, we look to the wider, real-world socio-political contexts against which normative evaluations of public health must take place. We explain how evaluative critiques of public health policy and practice must be sensitive to the nuance and complexity of policy contexts. This includes sensitivity to the 'imperfect' reach and application of policy, leading to collateral effects including collateral paternalism. We argue that theoretical critiques must temper their demandingness to real-world applicability, allowing for the detail of social and policy contexts, including harm reduction: apparent knock-down objections of paternalism cannot hold if they are limited to an abstract or artificially-isolated evaluation of the reach of a public health intervention.

The Views of Health Care Professionals and Laypersons Concerning the Relevance of Health-Related Behaviors in Prioritizing Patients

This article aims to investigate to what extent health care professionals in Portugal find health-related behaviors relevant as a criterion to priority setting, to study what type of risk behavior they consider relevant in such decisions and to compare their views with those of laypersons. An online questionnaire was used to collect data from a sample of 178 health care professionals and 295 laypersons. The statistical analysis was performed through the application of generalized linear models and logistic regressions. Health professionals consider more than laypersons that information about health-related behaviors is relevant in prioritization between individuals. Both groups regard information about illegal drug abuse, excessive alcohol consumption, and smoking more important to priority setting decisions than information about overweight or lack of physical exercise. The findings are important for the definition of rationing policies as the professionals’ decisions are those that, ultimately, influence health expenditure.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

Decomposing disparity in adult individual's mental health in Tehran among lower and higher economic groups; an Oaxaca- Blinder analysis on urban HEART Survey- round 2

BACKGROUND

Mental health is one of the main aspects of social well-being. Tehran -capital of Iran- is metropolitan, where the mental health status of citizens is not prioritized effectively.

OBJECTIVES

The purpose of this study was identifying contributors of mental health inequality between lower and higher economic groups in Tehran through Oaxaca- Blinder method.

METHODS

The study was conducted by the data of Tehran's Urban Heart Survey- Round 2 (2012). Through a three- stage stratified and clustered sampling method, 34,700 were selected as samples. The mental health status was measured by the General Health Questionnaire 28- items (GHQ- 28) and the quantity of the inequality in mental health was measured by corrected concentration index. The Fairlie's decomposition approach was performed in STATA 14.

RESULTS

The corrected concentration index were: -0.0967 and -0.1004 by Erreyger's and Wagstaff 's approaches. Being of the Iranian origin, disability conditions, employment status and smoking were identified as the main contributors of inequality in mental health among lower and higher economic groups.

CONCLUSION

Thus, re-organizing strategies and plans on promoting the socio- economic status of non-Iranian residents, improving employment opportunities, developing well-designed environment for disabled individuals and supporting plans to reduce smoking is recommended to the urban policy makers.

Ethics, collective health, qualitative health research and social justice

The scientific field is characterized by the disputes about the delimitation of the field problems, methods and theories that can be considered scientific. The recognition that it is not neutral, that a researcher is a moral subject, and its practices are moral ones, entail that moral reflections, that is, ethics, should be a core process of every researcher. Therefore ethics is not a heteronomous issue, and cannot be reduced to guidelines. In the first part of this article we examine the need to develop an open approach to the construction of guidelines in a plural scientific field that must take into account diverse paradigms, which implies different values. The Brazilian process of writing guidelines on research ethics for social science and humanities in the context of the Ministry of Health will be discussed as an example. In the second part we expand the analysis of research ethics posing a perspective that integrates qualitative research, social justice and discipline trends. In the final considerations we explore the possibility that research ethics is better discussed taking into account the ontology, epistemology and political values rather than one specific methodological approach or from a dichotomic perspective between biomedicine versus social science and humanities.

Using Health Impact Assessment as an Interdisciplinary Teaching Tool

Health Impact Assessment (HIA) courses are teaching public health and urban planning students how to assess the likely health effects of proposed policies, plans, and projects. We suggest that public health and urban planning have complimentary frameworks for training practitioners to address the living conditions that affect health. Planning perspectives emphasize practical skills for impacting community change, while public health stresses professional purpose and ethics. Frameworks from both disciplines can enhance the HIA learning experience by helping students tackle questions related to community impact, engagement, social justice, and ethics. We also propose that HIA community engagement processes can be enriched through an empathetic practice that focuses on greater personal introspection.

Changing global policy to deliver safe, equitable, and affordable care for women's cancers

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Cause and context: place-based approaches to investigate how environments affect mental health

OBJECTIVES

Our surroundings affect our mood, our recovery from stress, our behavior, and, ultimately, our mental health. Understanding how our surroundings influence mental health is central to creating healthy cities. However, the traditional observational methods now dominant in the psychiatric epidemiology literature are not sufficient to advance such an understanding. In this essay we consider potential alternative strategies, such as randomizing people to places, randomizing places to change, or harnessing natural experiments that mimic randomized experiments.

METHODS

We discuss the strengths and weaknesses of these methodological approaches with respect to (1) defining the most relevant scale and characteristics of context, (2) disentangling the effects of context from the effects of individuals' preferences and prior health, and (3) generalizing causal effects beyond the study setting.

RESULTS

Promising alternative strategies include creating many small-scale randomized place-based trials, using the deployment of place-based changes over time as natural experiments, and using fluctuations in the changes in our surroundings in combination with emerging data collection technologies to better understand how surroundings influence mood, behavior, and mental health.

CONCLUSIONS

Improving existing research strategies will require interdisciplinary partnerships between those specialized in mental health, those advancing new methods for place effects on health, and those who seek to optimize the design of local environments.

Lifestyle Vaccines and Public Health: Exploring Policy Options for a Vaccine to Stop Smoking

Experimental vaccines are being developed for the treatment of 'unhealthy lifestyles' and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of 'lifestyle vaccines' for public health. Based on findings from a qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The 'vaccinization' of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future.

Public health nurse educators' conceptualisation of public health as a strategy to reduce health inequalities: a qualitative study

BACKGROUND

Nurses have long been identified as key contributors to strategies to reduce health inequalities. However, health inequalities are increasing in the UK despite policy measures put in place to reduce them. This raises questions about: convergence between policy makers' and nurses' understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities.

AIM

The aim of this qualitative research project is to determine public health nurse educators' understanding of public health as a strategy to reduce health inequalities.

METHOD

26 semi-structured interviews were conducted with higher education institution-based public health nurse educators.

FINDINGS

Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health.

CONCLUSION

Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than take population approaches.

The social determinants of health: why should we care?

A growing body of empirical research examines the effects of the so-called "social determinants of health" (SDH) on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the (un)fairness of particular health inequalities; and second, the policy recommendations issued on this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended-such as improving people's living conditions and reducing inequalities in wealth and power-are justified in their own right, the way these recommendations are tied to health is problematic.

Fairness and wellness incentives: what is the relevance of the process-outcome distinction?

OBJECTIVE

To determine whether the commonly drawn distinction between the fairness of incentives targeting behavioral processes (or effort) and those targeting outcomes (or achievement) provide suitable grounds for favoring either approach in healthcare research, policy and practice.

METHODS

Conceptual analysis, literature review.

RESULTS

A categorical distinction between process- and outcome-based incentives is less crisp than it seems. Both processes and outcomes involve targets, and both are subject to differences - across and within socio-economic groups - in circumstance and perspective. Thus, a spectrum view is more appropriate, in which the fairness of incentive programs increases with the extent of control that people have. The effectiveness of incentives is a further relevant consideration, and some available evidence suggests that incentives closer to the outcome-end of the spectrum can be more effective.

CONCLUSIONS

Simple distinctions between processes and outcomes by themselves provide little assurance that programs are effective or fair. Effectiveness can and should be assessed empirically. Assessments of fairness should focus on the extent to which an activity or outcome might be feasible and under an individual's control, not on whether it targets a process or outcome. Rigid uniform targets for all are generally less desirable than those that reward person-specific improvement.

Research agenda for tackling inequalities related to migration and ethnicity in Europe

Reducing ethnic inequalities and inequities in health needs to become a higher priority for public health research. Active involvement of migrant and ethnic minority populations in European population health research is necessary, for data show important inequalities but evidence, particularly on effectiveness, is sparse and strategic overviews rarer still. Ethnically disaggregated health surveillance systems are developing slowly, and pragmatically, often using country of birth. The principles to adopt, given the gaps between the ideal and the current reality, need wider discussion. Ethics may provide both principles and impetus. Doing no harm, doing good, respecting the research participants' autonomy are good starting points. More emphasis is needed on justice, fairness and equality, participation and communicating effectively. Ethnic minority groups are willing participants in trials once linguistic and trust-related barriers are overcome, though recruitment costs are higher. Guidelines and strategies by European bodies with research funding or enforcement responsibilities are needed. The research community needs an infrastructure within which to collect and utilize evidence. Research can help migrant and ethnic minority groups to participate more fully in our multi-ethnic societies.

Lifeworld-led care: Is it relevant for well-being and the fifth wave of public health action?

A recent paper has made the case for a "fifth wave" of public health action. The paper articulated the first four waves as focusing on civil engineering, the germ theory of disease, welfare reforms and lifestyle issues. This article will focus on well-being and will expand on the authors' articulation of a current need to "discover a new image of what it is to be human" to begin to address the challenges of promoting well-being. This article will consider an alternative way of viewing human beings within a "caring" context and how this alternative view may aid this potential fifth wave of public health action. This alternative view has emerged from the work of Husserl who suggested that any human view of the world without subjectivity has excluded its basic foundation. The phenomenological understanding of "lifeworld" is articulated through five elements, temporality, spaciality, intersubjectivity, embodiment and mood that are all discussed here in detail. A world of colours, sparkling stars, memories, happiness, joy, anger and sadness. It is this "lifeworld' that when health care or as argued in this article as public health becomes overly focused on decontextualized goals, and measuring quality superficially can be neglected.

[Ethics, equity and social determinants of health]

The evidence shown by studies on the social determinants of health has changed the relationship between ethics and medicine. The evidence shown by studies on the social determinants of health has changed the relationship between ethics and medicine, and between a normative and a descriptive approach. Studies on the social determinants of health have also modified the traditional concept of equity, necessary health policies and the future of bioethics. More specifically: 1) the boundary between medicine and ethics has become much fuzzier, especially in the field of epidemiology, whose objectives are now inseparable from ethical considerations; 2) the concept of health equity traditionally defined as access to healthcare should be corrected or expanded to incorporate unfair health inequalities that occur before patients reach the healthcare system; and 3) the traditional autonomy bias of bioethics should be replaced by a primary concern for social justice and its relationship with health.

Conceptual models for cumulative risk assessment

In the absence of scientific consensus on an appropriate theoretical framework, cumulative risk assessment and related research have relied on speculative conceptual models. We argue for the importance of theoretical backing for such models and discuss 3 relevant theoretical frameworks, each supporting a distinctive "family" of models. Social determinant models postulate that unequal health outcomes are caused by structural inequalities; health disparity models envision social and contextual factors acting through individual behaviors and biological mechanisms; and multiple stressor models incorporate environmental agents, emphasizing the intermediary role of these and other stressors. The conclusion is that more careful reliance on established frameworks will lead directly to improvements in characterizing cumulative risk burdens and accounting for disproportionate adverse health effects.

Feminist intersectionality: bringing social justice to health disparities research

The principles of autonomy, beneficence, non-maleficence, and justice are well established ethical principles in health research. Of these principles, justice has received less attention by health researchers. The purpose of this article is to broaden the discussion of health research ethics, particularly the ethical principle of justice, to include societal considerations--who and what are studied and why?--and to critique current applications of ethical principles within this broader view. We will use a feminist intersectional approach in the context of health disparities research to firmly establish inseparable links between health research ethics, social action, and social justice. The aim is to provide an ethical approach to health disparities research that simultaneously describes and seeks to eliminate health disparities.

A framework convention on global health: social justice lite, or a light on social justice?

With the publication of the final report of the WHO Commission on the Social Determinants of Health, it becomes clear that there is considerable convergence between a policy agenda rooted on social epidemiology and one rooted in a concern for human rights. As commentators like Jonathan Mann have argued, concern for human rights and the achievement of social justice can inform and improve public health. In this article, we ask a different question: what does a health perspective adds to the enduring fight for a more just world? We consider three possibilities: (1) that public health, in an inversion of Mann's argument, actually provides useful tools for specifying social injustice; (2) that, contrary to the usual critical stance and assumption of weakness, the institutions of public health bring powerful capacities to the practical promotion of social justice; and (3) that health as a banner mobilizes people who would not be mobilized to act in the name of social justice.

Causation and models of disease in epidemiology

Nineteenth-century medical advances were entwined with a conceptual innovation: the idea that many cases of disease which were previously thought to have diverse causes could be explained by the action of a single kind of cause, for example a certain bacterial or parasitic infestation. The focus of modern epidemiology, however, is on chronic non-communicable diseases, which frequently do not seem to be attributable to any single causal factor. This paper is an effort to resolve the resulting tension. The paper criticises the monocausal model of disease, so successful in the nineteenth century. It also argues that a multifactorial model of disease can only be satisfactory if it amounts to more than a mere rejection of the monocausal model. A third alternative, the contrastive model, is proposed and defended on the grounds that it links the notions of disease and of general explanation, while avoiding the philosophical naiveties and practical difficulties of the monocausal model.