In the Journals

Theorising Health Inequalities — A special issue of Social Theory & Health

sthThe current issue of Social Theory & Health is a special double issue on theorizing health inequalities. Comprising eleven articles, the issue developed out developed out of a 2012 symposium held at the University of Edinburgh, entitled “Where Next for Health Inequalities?” As guest editors Katherine E. Smith and Ted Schrecker write in their introduction (the full text of which is freely available):

Lewin (1951, p. 169) famously reflected that there is ‘nothing more practical than a good theory’. Yet in health inequalities research, and public health more broadly, the number of theoretical contributions pales in comparison to the ever-growing number of empirical studies. It is certainly true that most of these empirical studies are informed by social theory in that many employ indicators of social categories that reflect theoretical ideas sketched out by Marx, Engels and Weber (see Kapilashrami et al and Scambler and Scambler, this issue) but these theoretical underpinnings are rarely acknowledged, interrogated or considered in any detail. Where theoretical frameworks have been applied to the study of health inequalities, this has often been with the purpose of trying to understand, or help analyse, pre-existing data sets or findings, rather than to inform decisions about how we study, and try to tackle, such inequalities or to develop theoretical approaches that are specifically intended to help us better understand health inequalities as a phenomenon. The collection of articles in this special issue is an attempt to begin redressing the empirical bias described here; to demonstrate some of the practical implications that social theories have to offer those seeking to better understand, and tackle, a social problem as complex and persistent as health inequalities; and to illustrate the indispensability of theory in generating new hypotheses for empirical research, both qualitative and quantitative.

An institutional theory of welfare state effects on the distribution of population health
Jason Beckfield, Clare Bambra, Terje A Eikemo, Tim Huijts, Courtney McNamara, and Claus Wendt

Social inequalities in health endure, but also vary, through space and time. Building on research that documents the durability and variability of health inequality, recent research has turned towards the welfare state as a major explanatory factor in the search for causes of health inequality. With the aims of (i) creating an organizing framework for this new scholarship, (ii) developing the fundamental-cause approach to social epidemiology and (iii) integrating insights from social stratification and health inequalities research, we propose an institutional theory of health inequalities. Our institutional theory conceptualizes the welfare state as an institutional arrangement – a set of ‘rules of the game’ – that distributes health. Drawing on the institutional turn in stratification scholarship, we identify four mechanisms that connect the welfare state to health inequalities by producing and modifying the effects of the social determinants of health. These mechanisms are: redistribution, compression, mediation and imbrication (or overlap). We describe how our framework organizes comparative research on the social determinants of health, and we identify new hypotheses our framework implies.

Power, intersectionality and the life-course: Identifying the political and economic structures of welfare states that support or threaten health
Dennis Raphael and Toba Bryant

The insights provided by Gøsta Esping-Andersen’s Three Worlds of Welfare Capitalism on the origins and characteristics of social democratic, conservative and liberal welfare states make explicit many of the political and economic structures and processes that can impact on health and create health inequalities. Broad stroke analysis of welfare state differences indicates social democratic welfare states may fare better at promoting health and limiting health inequalities in specific instances. This article builds on Esping-Andersen’s insights to theorize how differences in sectoral power across and within forms of welfare states can shape the resources and supports available to those occupying various social locations during important periods of the life-course. It also specifies the specific health outcomes of special relevance to those situated in vulnerable social locations across the life-course.

Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction (open access)
Carles Muntaner, Edwin Ng, Haejoo Chung, and Seth J. Prins

Most population health researchers conceptualize social class as a set of attributes and material conditions of life of individuals. The empiricist tradition of ‘class as an individual attribute’ equates class to an ‘observation’, precluding the investigation of unobservable social mechanisms. Another consequence of this view of social class is that it cannot be conceptualized, measured, or intervened upon at the meso- or macro levels, being reduced to a personal attribute. Thus, population health disciplines marginalize rich traditions in Marxist theory whereby ‘class’ is understood as a ‘hidden’ social mechanism such as exploitation. Yet Neo-Marxist social class has been used over the last two decades in population health research as a way of understanding how health inequalities are produced. The Neo-Marxist approach views social class in terms of class relations that give persons control over productive assets and the labour power of others (property and managerial relations). We critically appraise the contribution of the Neo-Marxist approach during the last two decades and suggest realist amendments to understand class effects on the social determinants of health and health outcomes. We argue that when social class is viewed as a social causal mechanism it can inform social change to reduce health inequalities.

What can health inequalities researchers learn from an intersectionality perspective? Understanding social dynamics with an inter-categorical approach?
Anuj Kapilashrami, Sarah Hill, and Nasar Meer

The concept of intersectionality was developed by social scientists seeking to analyse the multiple interacting influences of social location, identity and historical oppression. Despite broad take-up elsewhere, its application in public health remains underdeveloped. We consider how health inequalities research in the United Kingdom has predominantly taken class and later socioeconomic position as its key axis in a manner that tends to overlook other crucial dimensions. We especially focus on international research on ethnicity, gender and caste to argue that an intersectional perspective is relevant for health inequalities research because it compels researchers to move beyond (but not ignore) class and socioeconomic position in analysing the structural determinants of health. Drawing on these theoretical developments, we argue for an inter-categorical conceptualisation of social location that recognises differentiation without reifying social groupings – thus encouraging researchers to focus on social dynamics rather than social categories, recognising that experiences of advantage and disadvantage reflect the exercise of power across social institutions. Such an understanding may help address the historic tendency of health inequalities research to privilege methodological issues and consider different axes of inequality in isolation from one another, encouraging researchers to move beyond micro-level behaviours to consider the structural drivers of inequalities.

Understanding the impacts of industrial change and area-based deprivation on health inequalities, using Swidler’s concepts of cultured capacities and strategies of action
Lisa M. Garnham

This article will explore the utility of Swidler’s concepts of cultured capacities and strategies of action in mapping the pathways through which area-based, multiple deprivation and inequality impact upon resources for health, health outcomes and health inequalities. It will be argued that these concepts have the potential to bring the collective and aggregated impacts of resource distribution to the fore in unpicking the processes through which area-based inequalities become manifest in health outcomes. This has the potential to illuminate the some of the economic, social and political processes though which neoliberalism has generated widening health inequalities in the United Kingdom. To that end, these concepts will be employed in a case study of the post-industrial town of Clydebank. It will consider the implications for population health of changes in: the amount and quality of employment on offer; the quality and affordability housing; and the accessibility of social and political resources for those who live in more deprived areas. Swidler’s concepts will be used to theoretically map the relationships between the growing wealth inequalities, widening place-based inequalities and increasing health inequalities observed over the past few decades in the United Kingdom.

Theorizing health inequalities: The untapped potential of dialectical critical realism
Graham Scambler and Sasha Scambler

We here extend our previous contributions to a neo-Marxist sociology of health inequalities via an engagement with Roy Bhaskar’s dialectical critical realism (DCR). We argue that Bhaskar’s re-grounding of the philosophies of Marx and Engels has the potential to re-invigorate sociology’s input into: (a) explanations of health inequalities and (b) interventions to reduce health inequalities. We also show that DCR provides rationale and opportunity for an action sociology beyond current professional, policy, critical and public sociologies. We briefly summarize current sociological models of health inequalities before protesting their lack of theoretical ambition. We then proffer a professional-cum-critical theory that emphasizes the continuing causal efficacy of social class in general, and of Britain’s ‘governing oligarchy’ in particular, for any credible sociological account of health inequalities. Bhaskar’s basic and dialectical critical realism are then introduced and the frame supplied by the latter commended for a deepening of the neo-Marxist theories of health inequalities being developed by us among others. The article concludes by drawing on this same frame to insist on a logical and moral commitment to an action sociology beyond any institutional constraints faced by practitioners of the discipline.

Understanding responses to the political context of health inequalities in research and policy: Can post-structural theories of power help?
Katherine E. Smith

It is now widely accepted that health inequalities are directly linked to inequalities in power and material resources. Reflecting this, persuasive accounts of both the production of health inequalities and the failure of high-income countries to reduce these inequalities have been underpinned by references to structural (particularly neo-Marxist) theories of power. Such accounts highlight the importance of macro-level political and economic policies for health outcomes and, in particular, the unequally damaging impacts of policy reforms collectively referred to as ‘neo-liberal’. This article draws on interviews with researchers, civil servants, politicians, documentary makers and journalists (all of whom have undertaken work concerning health inequalities) to examine what these conversations reveal about these actors’ perceptions of, and responses to, the political context of health inequalities in the United Kingdom. In so doing, it illustrates the fluid and networked nature of political ‘power’ and ‘context’, findings that point to the potential utility of post-structural theories of power. This article argues that, if conceived of in ways that do not deny power differentials, post-structural theories can help: (i) call attention to ‘neo-liberal’ inconsistencies and (ii) explain how and why individuals who are critical of dominant policy approaches nonetheless appear to participate in their ongoing production.

Social theory and health inequalities: Critical realism and a transformative activist stance?
Chik Collins, Marjorie McCrory, Mhairi Mackenzie, and Gerry McCartney

The failure successfully to project evidence on health inequalities into the policy imagination is likely related to the fact that the research community is yet to provide an appropriate critical theory of health determination – integrating different social phenomena through identifiable mechanisms and pathways across different levels and scales, and opening up a realistic perspective on how unjust outcomes might be subject to change. On what social-theoretical basis might this task most usefully be addressed? This article critically explores the utility of the work of Archer which has been applied to health inequalities by Scambler, and argues that it is quite problematic in relation to the task of theorising health inequalities. It then proceeds to explore the relevance of a longer-standing tradition of work deriving from the early twentieth century Soviet school of ‘psychology’ led by Lev Vygotsky and coalescing today under the heading of Cultural-Historical Activity Theory. Within this tradition, we highlight the particular contribution of Anna Stetsenko. We argue that this tradition, and the contribution of Stetsenko in particular, merits our close attention in developing a basis for a more expansive critical theory of health.

Theorising participatory practice and alienation in health research: A materialist approach
Claire Blencowe, Julian Brigstocke, and Tehseen Noorani

Health inequalities research has shown a growing interest in participatory ways of working. However, the theoretical ideas underpinning mainstream approaches to participation remain underexplored. This article contributes to theorising participatory practice for the kind of egalitarian politics to which many of those focused on reducing health inequalities are committed. First, we argue that the ambitions of participatory practice should be concentrated on ‘overcoming alienation’, rather than ‘attaining freedom from power’. An over-emphasis on negative freedom may help to explain a worrying confluence between participatory democracy and neo-liberal marketization agendas – we look instead to traditions of participatory practice that emphasize positive freedom and capacities for collaboration. Second, we discuss some such perspectives though consideration of critical pedagogy, but highlighting the role of materialised relations of authority, spaces, objects and encounters. Third, we explore the relationship between objectivity and alienation, arguing that participatory politics, against alienation, can look to reclaim objectivity for participatory, lively, practice. We then seek to show that participatory practice can play a role in creating common knowledge and culture, and in fostering a sense of public ownership over objective knowledge and institutions concerned with health. We conclude by asking what this looks like in practice, drawing some ‘rules of thumb’ for participatory practice in health inequalities research from existing inspiring examples.

Fantasy paradigms of health inequalities: Utopian thinking?
Alex Scott-Samuel and Katherine Elizabeth Smith

This article argues that, while it can be politically expedient for governments to engage with health inequalities, they cannot, within the confines of neo-liberalism, realistically propose actions that evidence suggests will effectively reduce them – such as tackling power inequalities, social status and connections or class inequality. Indeed, a dominant ‘policy paradigm’ prioritising economic growth restricts the ability of policy actors to imagine alternative, more equitable scenarios. In this context, some policy actors and researchers have devised a parallel fantasy world in which proximal, downstream, easily tackled exposures are posited as potential solutions to health inequalities. The consequence of this is a widespread public sector culture in which well-meaning policymakers, practitioners, researchers and members of the public collude in sustaining a ‘cargo cult’ of health behaviourism. In examining this situation, we draw on accounts and critiques of utopian thinking to help explain: (i) the remarkable persistence of policy proposals to tackle health inequalities via downstream interventions, in spite of the strength of evidence challenging such approaches; and (ii) the limited extent to which more upstream proposals inform policy debates. We argue Ruth Levitas’ notion of ‘utopia as method’ offers an imaginative and potentially useful avenue for future health inequalities research.

Health justice after the social determinants of health revolution
Daniel M. Weinstock

Social Determinants of Health (SDH) theorists claim that the distribution of social goods such as income, housing and education, has as great or greater an impact on health outcome than does health care, narrowly construed. This article attempts to integrate this claim into a plausible theory of justice. I argue that such a theory must be both political, in that it focuses on goods that states can distribute or regulate effectively and appropriately, and holistic, in that it must integrate the various values that are relevant to distribution into a plausible overall theory. While SDH-based theories are appropriately political, many of their exponents tend to undertake the task of integration in an implausibly monistic manner. I argue that monists about health are caught between the horns of an unattractive dilemma: either they employ a narrow conception of health, in which case their prescriptions are grounded in an implausible conception of the human good, and give rise to an extreme form of paternalism; or they use a broader conception of health, which leads them to address the challenge of holism in a purely rhetorical manner. I argue for a pluralistic mode of integration, one that accepts that social goods are regulated by both consequentialist and non-consequentialist considerations, and that the range of consequences that are relevant do not relate merely to health.

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