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Tackling social injustices in healthcare

Understanding Health Inequalities and Justice: New Conversations Across the Disciplines

Mara Buchbinder, Michele Rivkin-Fish, and Rebecca L. Walker, Eds.
UNC Press
2016
335 pp.
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Inequality is core to virtually any Western conception of health justice. There is robust debate over which inequalities, if any, are unethical and over priority-setting among inequalities. Understanding Health Inequalities and Justice, edited by three scholars (two anthropologists and a philosopher) represents one of the latest contributions to this conversation.

The book is ambitious, aiming to “change the conversation about health inequalities and justice.” The method for doing so is to “move beyond disciplinary divides.” Based on issues explored at a 2013 conference at the University of North Carolina Institute for Arts and Humanities, the text is divided into three sections: “Interrogating Normative Perspectives on Health Inequality and Justice,” “Disrupting Assumptions and Expanding Perspectives through Cases,” and “Rethinking Evidence and the Making of Policy.” To promote the interdisciplinary perspectives the editors deem essential to the book’s aim, many of the chapters engage one or more of the other chapters in the book.

Anthologies arising from conferences typically struggle with coherence. This is unsurprising because the papers presented at a meeting typically were not conceptualized or written in dialogue with the other presented papers. The editors and authors are therefore to be commended for producing a readable, well-organized book that builds logically and sequentially from start to finish.

Insurance policies that promote early extraction may explain why Latino children tend to exhibit poorer oral health than their peers.PHOTO: CATHY YEULET/ISTOCK IMAGES

Insurance policies that promote early extraction may explain why Latino children tend to exhibit poorer oral health than their peers.

However, truly interdisciplinary scholarship is akin to a tiger—much spoken of but rarely seen in the wild. Collaborations between scholars hailing from different disciplines are not in and of themselves interdisciplinary. The criterion that distinguishes interdisciplinary scholarship from multi- or crossdisciplinary work is integration. To qualify, scholarship must successfully integrate the disciplinary perspectives into a cohesive whole that is not reducible to the sum of its disciplinary parts.

Most of the chapters in Understanding Inequalities do not achieve this kind of synthesis. Although the majority of them feature some attempt to engage work in at least one other chapter, most of these attempts feel forced and rushed, with much of the dialogue appearing only at the very end of the chapter. That said, several of the book’s strongest chapters do succeed in demonstrating interdisciplinarity.

In chapter 5, anthropologists Sarah Horton and Judith Barker set out to determine the causes and effects of the high rate of oral disease in Latino children. The authors successfully integrate ethno graphic analysis with population-level data. The analysis of individual and community narratives reveals a crucial point that population-level surveillance alone would miss: “Children’s premature extractions may, over time, permanently affect their oral cavities; they may in fact produce the malocclusions, or ‘crooked teeth,’ that some parents lamented.”

Horton and Baker elegantly demonstrate how state-level dental insurance programs in the United States promote such extractions as public policy precisely because alternative therapies are costly and time-consuming. “Parents’ complaints of ‘cracked’ baby teeth yielding ‘crooked’ permanent teeth are not whimsical ‘folk beliefs’ but are supported by the expert literature,” they conclude.

Carla Keirns’s chapter on health care reform in the United States reflects her unique training in medicine, health services research, history, and bioethics and demonstrates the moral tension between policies that improve absolute population health but at the same time intensify the disadvantages of the least well-off. Health care reform in Massachusetts decreased the number of uninsured, she notes, but at the same time it “nearly bankrupted safety-net hospitals that had long served the most vulnerable because it failed to account for the clustering of the remaining uninsured at a few facilities.” Keirns argues that the utilitarian assumptions driving economic modeling for health insurance reform produce comparatively less focus on inequitable distribution of benefits in favor of attention to aggregate benefits.

Nevertheless, much of the book is more fairly characterized as crossor multidisciplinary conversations than as integrative, interdisciplinary work. This is not an evaluative statement; there is pressing need for cross-, multi-, and interdisciplinary work addressing health inequalities and justice. And, in fact, the book does succeed in pushing “new conversations across the disciplines” on these subjects.

Ultimately, regardless of the extent to which it merits the label “interdisciplinary,” Understanding Inequalities is successful in its principal aims. Almost every chapter is interesting and provocative, and the book merits a place on the bookshelf of anyone interested in the myriad questions that attend health inequalities and justice.

About the author

The reviewer is at the Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.