1. Editorial
institutional affiliations were with
Who, and what, causes health universities, hospitals, and government
and international agencies. Common to all
inequities? Reflections on participants, each of whom contributed to
the range of ideas expressed in this edito-
emerging debates from an rial, were: 1. a concern with how social
injustice harms health, 2. recognition that
social inequalities in health have long been
exploratory Latin American/North documented and debated, 3. appreciation
of the importance of theory in shaping
American workshop analysis of health inequities, that is, group
differences in health outcomes (within
and between nations) due to injustice, and
Nancy Krieger,1 Margarita Alegrı 2
´a, 4. awareness of the context of the
discussion, including the gross and
Naomar Almeida-Filho, Jarbas Barbosa da Silva,4
3 growing inequities in income and wealth
that exist within and between countries
Maurı L Barreto,5 Jason Beckfield,6 Lisa Berkman,7
´cio (box 1).
The rationale for our emphasis on
Anne-Emanuelle Birn,8 Bruce B Duncan,9 Saul Franco,10 frameworks and our limited geographical
Dolores Acevedo Garcia,11 Sofia Gruskin,12 focus was twofold. First, we prioritised
theory because theoretical frameworks
Sherman A James,13 Asa Christina Laurell,14 critically shape the questions asked (or not
asked), the determinants and outcomes
Maria Ines Schmidt,15 Karina L Walters16
ˆ considered (or not considered), the data
collected (or not collected), the methods
1
used (or not used) and the approaches
Department of Society, Human, Development and taken (or not taken) to interpreting the
Rapidly rising interestdfrom national and
Health, Harvard School of Public Health, Boston,
Massachusetts, USA; 2Department of Psychiatry, international health organisations, govern- resulting data.3 Second, attention to
Harvard Medical, School, Boston, Massachusetts, USA; ments, civil society, the private sector theory in relation to conceptualising and
3
Universidade Federal Da, Bahia (UFBA) and Professor of and myriad academic disciplinesdin analysing societal determinants of health
Epidemiology and Director, Instituto De Saude, Coletiva, what has become known as the ‘social inequities has typically been stronger,
UFBA, Bahia, Brazil; 4Health Surveillance and Disease
Management, Pan American Health Organization, determinants of health’1 2 is welcome to more politically forthright and more
Washington, DC, USA; 5Department of Epidemiology, the many, in and outside of public perceived as essential in the Latin Amer-
Universidade, Federal da Bahia Instituto de Saude health, who have long held that issues of ican literature as compared to the more
Coletiva, Salvador, Brazil; 6Department of Sociology, social justice and the public’s health are voluminous but largely empirical and
Harvard, University, Cambridge, Massachusetts, USA;
7 inextricably linked (box 1).2 3 As inevi- often more methodologically oriented
Harvard Center for Population Studies and
Development, Harvard University, Cambridge, MA, and tably happens, however, when an issue North American (and other regional) work
Department of Society, Human Development and Health, gets ‘mainstreamed’, a multiplicity of on this topic, even as the latter has
Harvard School of Public Health, Boston, MA; disparate voices enter the discussion, generated important theoretically
8
Department of International Development, Studies and informed by not only different disci- informed analyses.3e8
Canada Research Chair in International Health, University
of Toronto, Toronto, Canada; 9Department of Social plinary vantages, but also divergent However, several points raised in our
Medicine, Graduate, Studies Program in Epidemiology, values, priorities and politics. exploratory discussion are, we believe, of
School of Medicine, Federal University of Rio, Grande do In the spirit of provoking constructive global applicability. Below we offer them
Sul, Porto Alegre, RS, Brazil; 10Doctorado Interfacultades debate, we share highlights of a small as a first step towards encouraging wider
´
en Salud Publica, Universidad Nacional de Colombia,
meeting, held in October 2009, on debate and discussion.
Bogata, Colombia; 11Department of Health Sciences,
´
´
Bouve College of Health Sciences, Northeastern ‘Frameworks, questions, & studies: a Latin 1. Explicit theoretical frameworks are needed
University, Boston, Massachusetts, USA; 12Department American/North American exploratory that engage, intellectually and epistemo-
of Global Health and Population; Director, Program on workshop on investigating societal deter- logically, with how societies produce and
International Health and Human Rights, Harvard School minants of health inequities between & reproduce social inequity, political domi-
of Public Health, Boston, Massachusetts, USA;
13
Sanford School of Public Policy, Duke University, within countries’. Organised by Nancy nance, labour relations, modes of life and
Durham, North Carolina, USA; 14Department of Health of Krieger and sponsored by the Harvard ecological context, thereby affecting both
the Legitimate, Government of Mexico, Mexico City, Center for Population and Development levels and distributions of health and
Mexico; 15Department of Social Medicine, Graduate Studies, the workshop was attended by 17 health inequities. At issue is how people
Studies Program in Epidemiology, School of Medicine,
participants from five countries (Brazil, both shape and are shaped bydand hence
Federal, University of Rio Grande do Sul, Porto Alegre,
RS, Brazil; 16William P. and Ruth Gerberding University, Canada, Colombia, Mexico and the USA) biologically embodydtheir societal and
Professorship, University of Washington, School of Social and one international health agency (the biophysical context.
Work, and Indigenous, Wellness Research Institute, Pan American Health Organization The point is not ‘grand theory’ that
Seattle, Washington, USA (PAHO)). Disciplinary backgrounds deterministically purports to explain
Correspondence to Professor Nancy Krieger, included: epidemiology, sociology, ‘everything’, but rather critical uses of
Department of Society, Human Development, and theoretical frameworks that can coher-
psychology, medicine, history, health
Health, Harvard School of Public Health, 677 Huntington
Avenue, Kresge 717, Boston, MA 02115, USA; systems, demography, social work, human ently orient inquiry and analysis
nkrieger@hsph.harvard.edu rights and international law; participants’ within and across relevant levels and
J Epidemiol Community Health September 2010 Vol 64 No 9 747

2. Editorial
timeframes, situate different perspec- embodying societal context,3 they from parents’ preconception health
tives in relation to each other and make nevertheless acknowledge, rather status to in utero on through child-
the invisible visible. Suggesting this is than gloss over, the realities of hood and adulthood, and ii.
feasible was our review of several societal conflict and the necessity of agedperioddcohort effects, known
explicit theoretical frameworks for social movements and societal to be important but often ignored in
analysing health inequities, each with change for rectifying health ineq- analyses, and referring to how popu-
rich historical antecedents (see box 1). uities. lation patterns of health can reflect:
The selected frameworks were drawn 2. Attention to processes, history and embodi- a population’s age structure (given
from Latin American Social Medicine ment is critical: for analysing causal strong associations between age and
and Collective Health (including pathways and both planning and evalu- disease occurrence, in part due to the
Laurell’s labour process model; Breilh ating efforts to alter them, for under- time involved in the relevant patho-
and Granda’s social class model; standing the quality of and gaps in genic processes); exposures occurring
Samaja, Testa and Possas’ theory of health data, and for critiquing extant at a particular time that affect all age
mode of life and health; and Almeida- evidence and knowledge. groups (albeit in ways that might
Filho’s synthesis in an ethnoepidemio- Emphasising these points was our vary with age, eg, period effects of
logical model),7 8 and their North discussion of: historically situated traumatic
American/European counterparts A. Mounting evidence of context- events such as famine or genocide);
(including the political economy of dependent variations in the associa- and life-long health implications of
health framework developed by tions between societal determinants exposures affecting a cohort born at
Doyal, Navarro and others;3 4 Walters and health outcomes, whereby the a particular time (eg, babies born
and Simoni’s indigenist stress-coping magnitude, and even direction, of during the economic depression of
model;8 and Krieger’s ecosocial theory these associations can depend: i. on the early 1930s).
of disease distribution3). the outcome chosen and ii. on who F. The salience of integrated biological
Common to all of these frame- is being studied, where and when. processes, as exemplified by the case
worksdand distinguishing them from Well-known examples include the of innate immunity and inflamma-
more mainstream alternativesdis their 20th century reversal of the socio- tory responses, triggered by myriad
politicised orientation to analysing and economic gradient in smoking in contemporaneous socially patterned
rectifying health inequities. The differ- countries of the global North (from biophysical and social insults (poten-
ence, broadly stated, is between: more prevalent among the affluent tially including exposures ranging
A. increasingly de-politicised approaches to more concentrated among the from microbes to social trauma to
that view ‘social determinants of impoverished), and analogous obesity), and together forming
health’ as arising from a ‘social envi- complex shifts in the social a ‘common soil’ that gives rise to
ronment,’ structured by government patterning of obesity across time many chronic diseases; and
policies and status hierarchies, with and space.4 5 G. The necessity of understanding
social inequalities in health resulting B. The instrumental use of human health policy and health politics
from diverse groups being differen- rights concepts and methods for simultaneously as: i. aspects of
tially exposed to factors that revealing and influencing govern- broader social policies and societal
influence health, whereby ‘social ment-mediated processes linking politics and ii. determinants of health
determinants’, such as poverty, act social determinants to health and health inequities. Corollaries
as the ‘causes of causes’,1 versus outcomes, especially in relation to include challenging technocratic
B. alternatives that posit ‘societal deter- the principles of participation, non- approaches that: 1. promote vertical
minants of health’ as political- discrimination, transparency and health interventions (ie, program-
economic systems, whereby health accountability as applied to both ming focused on only one disease,
inequities result from the promotion health systems and health indica- eg, HIV/AIDS, across all levels of the
of the political and economic inter- tors. health system, from local to national)
ests of those with power and privi- C. Critical analysis of the historical as opposed to integrated health
lege (within and across countries) generation of theories, methods, systems and intersectoral strategies,
against the rest, and whose wealth empirical research, evidence, institu- 2. fail to consider the relevant time-
and better health is gained at the tions and social movements that frames for evaluating the impact
expense of those whom they subject have shaped, for good and for bad, either of new policies or of taking
to adverse living and working condi- levels and distributions of health, away positive health policies
tions; ‘societal determinants’dsuch and data on them, within diverse (whereas some policy changes might
as political-economic systems that societies. be expected to have temporally rapid
prioritise highly concentrated accu- D. The expansive view of indigenous effects, eg, affecting availability and
mulation of private wealth over health frameworks, which engage access to vaccines, others would be
redistribution of power, property with the social, cultural, spiritual likely to show effects after a longer
and privilege within and across and biological transgenerational and duration of time, eg, the impact of
countriesdthereby constitute the immediate health impacts of collec- poverty reduction on pathogenesis of
‘causes of causes of causes’.2 tive historical and current trauma. chronic non-communicable diseases),
Hence, although the more politicised E. The importance of taking into and 3. act as if science had no values
frameworks vary in the attention account: i. lifecourse processes, or obligations (including the respon-
they accord to the biophysical considering the transgenerational sibility to identify societal determi-
processes involved in biologically health impact of diverse exposures nants of health).
748 J Epidemiol Community Health September 2010 Vol 64 No 9

3. Editorial
Box 1 Political, historical, intellectual and economic context of a Latin American/North American discussion about societal
determinants of between-country and within-country health inequities
Political, historical, and intellectual context
Explicit efforts to develop theories articulating the causal connections between political economy, social injustice and health inequities can
readily be traced back to the mid-19th century.2e8 Examples include the European writings of Rudolf Virchow (1821e1902) and Friedrich
Engels (1820e1895) in the 1840s, as linked to societal upheavals spurred by the rise of industrial capitalism, along with their subsequent
elaborations in the early 20th century by European, North American and Latin American analysts and politicians, such as Chilean president
Salvador Allende (1908e1973), variously concerned with the health impact of political and economic systems, and political and economic
injustice, both within and across nations and regions.2e6 More recent antecedents include: A. the rise of critical science frameworks
during the 1960s and 1970s, including within the health fields, as spurred by post-World War II national liberation and anti-imperialist
movements along with the emergence of worldwide social movements regarding racism, indigenous rights, gender, sexuality, human
rights and the environment (ecology), and B. since the mid-1990s, a renewed round of theorising linked to efforts to: i. understand and
address the adverse health impacts of neoliberal policy regimes instituted by national governments and global institutions (eg, the World
Bank, the International Monetary Fund) commencing in the early 1980s, including privatisation of public resources, tax cuts for the wealthy
and slashing of government social welfare programmes, and ii. conversely, elucidate the potentially positive health effects of diverse
welfare state strategies to reduce social inequality and health inequities as well as improve population health.2e6
Economic context
1. According to the 2005 United Nations Human Development Report,9 the ‘champagne glass of income distribution’ (first described in their
1992 report) has grown even more elongated, such that ‘(the) annual flow of income of the richest 500 people (in the world) exceeds
that of the poorest 416 million’ and that ‘(the) cost of ending extreme povertyd$300 billiondis less than 2% of the income of the richest
10% of the world’s population’.
2. For Latin America: within a global context of growing income inequalities, income inequality in most Latin American countries (as
measured by the Gini coefficient) remains higher than that of all regions other than sub-Saharan Africa, as driven by the countries that
implemented neoliberal reforms.9
3. For the USA: making clear that the availability of resources to address health inequities and the social determinants of health is a matter
of political priorities, not inadequate funds: A. between 1948 and 1973, the income gains in the USA of the bottom 90% were nearly
twice as large as those of the top 1%, whereas in the current ‘Gilded Age,’ from 1982 to 2007, the gains of the top 1% were 16 times,
and those of the top 0.1% 31 times, those of the bottom 90%;10 B. the cost of the past 10 years of tax cuts to the richest 1% of
Americans is estimated to exceed $1.7 trillion11; and C. during the past 7 years the USA has spent over $712 billion on one war alone.12
3. Hence: Understanding and changing Competing interests None. 4. Kunitz S. The health of populations: general theories
determinants of health inequities requires and particular realities. Oxford: Oxford University
Contributors NK conceptualised and organised the Press, 2006.
explicit attention to societies’ political, workshop and led preparation of the manuscript. All 5. Graham H. Unequal lives: health and socio-economic
economic, cultural and ecological priorities coauthors contributed to the ideas expressed in the inequalities. Maidenhead, United Kingdom: Open
in historical context and how they become manuscript, reviewed drafts, and approved submission University Press, 2007.
of the original and revised manuscript. 6. Franco S, Nunes E, Breilh J, et al. Debates en
embodied; de-politicising and de-histori-
Provenance and peer review Not commissioned; ´
medicina social. Organizacion Panamericana de la
cising health inequities will compromise
externally peer reviewed. Salud-Alames. Quito, Ecuador: Non Plus Ultra, 1991.
evidence, knowledge and action. 7. Almeida-Filho N. La ciencia tı ´mida: ensayos de
Would anyone like to argue otherwise? Published Online First 27 June 2010 ´ ´a.
deconstruccion de la epidemiologı Buenos Aires,
J Epidemiol Community Health 2010;64:747e749. Argentina: Lugar Editorial S.A, 2000.
Acknowledgements We are very happy to 8. Walters KL, Simoni JM. Reconceptualizing native
acknowledge the contributions of Jillian Oderkirk, MS, doi:10.1136/jech.2009.106906
women’s health: an “indigenist” stress-coping model.
Director, Statistics Canada, Health Analysis, Ottawa,
Ontario, Canada, who was an active participant in our
REFERENCES Am J Public Health 2002;92:520e4.
1. World Health Organization, CSDH. Closing the 9. United Nations Development Program. United
workshop, but who cannot be included as a co-author Nations Human Development Report 2005:
gap in a generation: health equity through action on
due to agency policies. Thanks also to Emily O’Donnell International Cooperation at a Crossroads: Aid, Trade,
the social determinants of health. Final report of the
for her wonderful assistance with the workshop and Security in an Unequal World. http://hdr.undp.org/
commission on social determinants of health. Geneva:
logistics, and also to our additional student notetakers en/reports/global/hdr2005/ (accessed 1 Nov 2009).
World Health Organization, 2008.
(alphabetical order): Zinzi Bailey, Joya Banerjee, David 10. Henwood D. Miscellany. Left Business Observer,
2. Birn A-E. Making it politic(al): closing the gap in
Hurtado, Sarah MacCarthy and Jamie Zwiebel. #120, August 25, 2009:8.
a generation: health equity through action on the social
Funding No funding supported preparation of this determinants of health. Soc Med 2009;5:166e82. 11. Editorial. President Obama’s health choices. New
manuscript. Funds to cover the workshop expenses 3. Krieger N. Theories for social epidemiology in the York Times, 2009:7.
were provided by the Harvard University Center for 21st century: an ecosocial perspective. Int J 12. National Priorities Project. Cost of War. http://
Population and Development. Epidemiol 2001;30:668e77. www.costofwar.com/ (accessed 12 Mar 2010).
J Epidemiol Community Health September 2010 Vol 64 No 9 749