A Framework We are the folksong army

Every one of us cares

We all hate poverty, war and injustice
Convention on Unlike the rest of you squares

Global Health: We are the folksong army

Guitars are the weapons we bring
To the fight against poverty, war and injustice

Social Justice Ready. Aim. Sing.

— Tom Lehrer, “The Folksong Army”

Lite, or a Light on I. Introduction

A decade ago, Jonathan Mann made a powerful case

Social Justice? that human rights could provide a vocabulary and

mode of analysis for understanding and advancing
health.1 He made the case well, and put the idea into
inspired practice, but the idea was neither new nor his
Scott Burris and alone. The idea that social justice — and henceforth
in this article we will use that term loosely (and with
Evan D. Anderson obvious imprecision) to embrace goods like human
rights, social equality, and distributive justice — was
intrinsically important to health resonated with the
social epidemiology already gathering force (not to
mention an enduring theme running through the his-
tory of public health work). That social structure and
relations of power explain a great deal about the level
and distribution of population health was implicit in
the work of pioneers like Geoffrey Rose,2 evident in
Marmot’s seminal Whitehall studies,3 explicit in the
writings of Mervyn Susser,4 and the main thrust of
scholars like Nancy Krieger5 and Meredeth Turshen.6
Although researchers tend to avoid using a term with
such normative weight, it is safe to say that Mann —
and Susser, and Marmot and Krieger among others
— were right: social justice is central to the proper
understanding of health.7
But Mann did not just argue that social justice was
useful to people trying to understand health; he also
argued that a social justice standpoint could help
us act more effectively to advance health. This same
premise animates the report of the Commission on
Social Determinants of Health (CSDH),8 Lawrence
Gostin’s campaign for a framework convention on
global health,9 and academic writing about global
health governance.10 If we can show that health is
inequitably distributed in populations and through-

Scott Burris, J.D., is a Professor of Law and Co-Director of the

Center for Health Law, Policy and Practice at the Temple Uni-
versity Beasley School of Law and the Director of the National
Program Office for the Robert Wood Johnson Foundation Pub-
lic Health Law Research Program. Evan D. Anderson, J.D.,
is the Senior Legal Fellow at the National Program Office for
the Robert Wood Johnson Foundation Public Health Law Re-
search Program.

580 journal of law, medicine & ethics


out the globe, and tie these inequities to unjust social
conditions, then the implicit theory goes, we are in
a position to mount a very powerful campaign for
healthy change. This move, however, deserves a little
more interrogation.
The conventional criticism of this move is that
addressing the intertwined determinants of social
injustice and health inequality is beyond public health’s
legitimate remit and its feasible grasp.11 Others point
out that, for all the importance of fundamental social
causes, there is still a powerful case to be made for
investing our resources in traditional health services
to reduce inequalities.12 And we read Paul Farmer as
expressing an ongoing worry that ambitious framing
of health as social issues not become a self-satisfying
substitute for pragmatic action.13 These objections are
not our concern here. Nor will we dwell on another
obvious objection to the idea that social justice can
provide a powerful vocabulary for advancing public
health: the bitter experience suggesting that social
justice does not even provide a very good vocabulary
for advancing social justice. Though we adopt a skep-
tical, if not a satiric, tone in this essay, we do not ques-
tion that a social justice perspective illuminates and
strengthens public health.14
As health work increasingly centers on promoting
social justice, we ask instead whether public health —
as a discourse, a discipline, a practice — has anything
of importance to add to social justice. Arguably, after
all, the pathological social conditions documented by
social epidemiology research and highlighted by the
Commission – such as racial and gender subordina-
tion, exploitative economic systems and unfair labor
practices – have been around for quite a while. Many
people thought they were bad even before their sys-
tematic health consequences were laid bare. Many oth-
ers did not seem too worried then and may not change
their minds in the face of evidence that gross depri-
vation and degradation are also unhealthy. Thinking
about health in terms of social justice has helped us in
health understand much better how health happens.
It has helped us see how important social justice is to
efforts to improve health. But if, in some important
respects, health has become social justice, it is time
to turn Mann’s question around: in this essay we will
ask not what social justice can do for health, but what
a health perspective adds to the enduring fight for a
more just world?
We focus on Gostin’s proposed framework con-
vention as the case to study. Given Gostin’s standing
and the widespread interest in the device, it is not
inconceivable — despite his own doubts15 — that the
proposed convention could be the next big thing in
global public health and its governance, falling into
global health governance • fall 2010 581
Burris and Anderson
place as an organizing device just as the Millennium
Development Goals wind down. Such a convention
would establish clear goals for national action (includ-
ing action in the way of assistance to less developed
nations), a flexible framework for locally appropriate
implementation, and a mechanism for tracking (and
encouraging) progress.15 To explore our essay’s ques-
tion, we consider three ways that this sort of health-
based intervention might advance a broader social
justice agenda: (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.
II. Health as an Analytical Framework
“Inequities are killing people on grand scale, reports
World Health Organization’s (WHO) Commission.”
This was the headline of WHO’s press release on the
occasion of the release of the final report of the CSDH.
We tried to find the New York Times headline, but the
Times did not cover the report. And, in fairness to the
gray lady, this sure looks like a case of dog biting man:
“Inequities in health,” the report’s Executive Summary
explains, “arise because of the circumstances in which
people grow, live, work, and age, and the systems put
in place to deal with illness. The conditions in which
people live and die are, in turn, shaped by political,
social, and economic forces.” Ah, so inequalities are
bad, and they care caused by politics and people and
money! That sure clears things up.
But wait. That reaction might explain why the Times
did not stop the presses the day the report came out,
and there is some substance to it, but in so many ways
it is depressingly wrong. For one thing, the Commis-
sion’s claims are true, which ought to count for some-
thing, and will count for something to the extent that
this set of truths will mobilize action. For another, the
exposé of global injustice as health inequality is not
the most important thing the Report — and social epi-
demiology — have to offer. Yes, the demonstration of
“the gradient” — the ubiquitous social patterning of
health — and its expression in dramatic health ineq-
uities within and across populations are essential
elements of the epidemiological project. But adding
yet another set of reasons for people to redress social
injustice is much less significant a contribution than
the way that public health analysis can particularize
the mechanisms of social injustice. By showing how
social injustice kills, public health can both make news
and guide change.16
SYMPO SIUM
Consider the Commission’s conceptual framework,
shown here in Figure 1. Though framed in the largely
neutral language of epidemiology, this is an anatomy
of how social injustice happens. A social environment
is posited that is characterized by mechanisms of social
control — distributions of power — that reflect past
distributions of power (and health and well-being).
Within this environment, people are sorted by social
position — education, wealth, occupation, gender,
ethnicity — which is translated into health through
differential exposures to risk, variations in social sup-
port, and differences in behavior, psychology, and biol-
ogy. The health care system is shown as a particularly
important mediator, but it stands here for a longer list
of social service interventions that can to some degree
moderate the main force of social injustice.
General as it is, the Commission’s model encap-
sulates a broad and deep body of work that not only
shows the broader links between environment and
social position and health, but takes up the challenge
to explore the black box of the sorting mechanisms.
The important thing is not the evidence that injustice
is bad for health, but the increasing illumination of
how injustice is bad for health, and therefore what we
can do about it within a more or less liberal, peace-
ful, non-revolutionary framework. Actions may be
palliative or responsive (like health care), in that they
may (often effectively) moderate the impact of social
determinants they do not alter,17 or they may take the
Figure 1
The Commission’s Model
Figure 4.1 Commission on Social Determinants of Health Conceptual Framework
Socioeconomic
& political
context
Social position
Governance
Policy Education
(Macroeconomic,
Occupation
Social, Health)
Income
Cultural and Gender
societal norms
and values Ethnicity / Race
Social Determinants of Health and Health Inequities
582 journal of law, medicine & ethics
form of “structural interventions” aimed at chang-
ing determinants or their more distal mechanisms
themselves.18
The Commission has any number of big ideas for
dealing with the pathological social conditions on the
left side of the model. Most policies have some impact
on health and could be changed to support equity.
Important public health work has been aimed in this
direction, ranging from efforts to improve health gov-
ernance to addressing stigma and fighting TRIPS.
Governments in some places have taken on equity as
a (at least temporary) guiding principle or goal for
policy.19 In the U.K., for instance, the 1998 Acheson
Report was the impetus for a “whole of government”
effort to comprehensively use the levers of policy to
address social determinants of health. This included
improving education, employment, and housing con-
ditions for the disadvantaged groups, targeting partic-
ularly important points in the life course (e.g., poverty
in childhood), and increasing access to and uptake of
health and social services for those who have not tra-
ditionally been well served. It entailed as well “a wider
government drive for new policies addressing social
justice and tackling poverty and disadvantage.”20
Disparities in health are legion, and every one is the
product not just of an unjust social structure but also
a set of vulnerabilities, exposures, and processes that
unfold across time and space — and many of which
are being documented by public health researchers.
Material circumstances Distribution of
Social cohesion health and well-
being
Psychosocial factors
Behaviors
Biological factors
Health Care System

One of the great benefits of health is that it particu-
larizes problems in terms of discrete phenomena (e.g.,
infant mortality, birth weight, disease incidence) that
lend themselves towards empirical measurement and
remedial action. Social epidemiology, in turn, maps
these ills in social space, and follows causal pathways
back towards the structural causes of incidence. Thus
public health, here standing in the guise of the Com-
mission, can break down our modern Malthusian
monoliths of suffering into structures we can start to
Health not only illuminates the associations and causal pathways between the
slum environment and specific health outcomes and processes; it can also indentify
pressure points for targeted interventions at all levels of social organization.
renovate a few bricks at a time. Consider these exam-
ples, and the kinds of interventions that came to mind
as a result of the research and the social determinants
framework.
Today, slums are a global emblem of social injustice.
They reflect an array of specific social injustices like
unequal access to public goods (e.g., schools, sewers,
libraries, safe parks), political disenfranchisement,
and exposure to all sorts of environmental harms (e.g.,
crime, toxic waste). Slums are — in their essence —
the most elegant reflection of how the unequal alloca-
tion of resources (e.g., wealth, political power) creates
socially unjust disparities in power (e.g., the power
to move from a slum or to improve it) that produce
long-term accumulation of the effects of disadvantage.
Yet the image of the slum also hides much that can be
revealed by the scientific inquiry of health research-
ers. Health research can tell us how living in slums is
translated into poor health outcomes. For example, it
can tell us that obesity has roots in the physical and
economic conditions of urban areas.21 Poor people’s
lower purchasing power is reflected in fewer healthy
eating options, making it a daily challenge to avoid the
fatty, high calorie fast foods that are, as a substitute for
fresh food, pervasive.22 What is proximate in the way
of food matters, because health research tells us that if
we have to go far to get healthy food, we probably will
not or cannot on a regular basis.23 Could more exer-
cise substitute for healthier food? Less affluent areas
also tend to have fewer safe outdoor places for chil-
dren, and conditions less conducive to walking and
physical activity.24 Health research can measure with
precision the impact on obesity of specific factors like
the quality of sidewalks,25 proximity to health clubs,26
or the absence of graffiti.27 The absence of comfort-
global health governance • fall 2010 583
Burris and Anderson
able communal spaces and venues for public interac-
tion undermine social cohesion, which in turn under-
mines health.28 Low cohesion and collective efficacy
undermines the ability of communities to resist and
repair unhealthy intrusions, whether they come from
exposure to toxics mediated by “neutral” zoning pro-
cesses,29 or higher rates of crime.30 Not only do crime
and disorder have obvious impacts on physical safety
and other violence-related health outcomes, but they
create stress for slum inhabitants that accumulates —
though a number of specific physiological mechanisms
now being enumerated31 — as higher rates of cardio-
vascular disease and other poor health outcomes over
a life time.
This is not mere academic exercise. Health not
only illuminates the associations and causal pathways
between the slum environment and specific health
outcomes and processes; it can also indentify pressure
points for targeted interventions at all levels of social
organization. Providing better access to healthy foods,
by, for example, redesigning food markets,32 stimulat-
ing the opening of lower-cost supermarkets in poorer
neighborhoods,33 or otherwise reducing cost or other
barriers, can improve diets and reduce obesity.34 Crime
and violence can be targeted by supporting institu-
tions — like communal meeting spaces, school-based
community efforts — that foster neighborhood col-
lective efficacy.35 Zoning processes can be refashioned
or conducted to protect weaker areas from unbridled
political competition — moving, for example, from
a paradigm in which noxious land uses are merely
passed between areas with the least collective power
to one where certain uses are totally prohibited from
residential areas (from “not-in-my-backyard” to “not-
in-anyone’s-back-yard”).36
Likewise, social epidemiology is beginning to paint
a very clear and detailed picture of how the minor
insults of daily living, seemingly an inevitable and
apparently harmless friction of existence in unequal
societies, can actually accumulate to produce dramatic
outcome inequalities. One of the best illustrations of
this dynamic is provided by stress and the concept of
allostatic load.37 Research is describing now how an
elaborate chemical reaction unfolds when humans
are faced with threats. In individual instances, this
SYMPO SIUM

is a healthy adaptation that provides energy for us to
respond. When experienced too often, however, this
process can have a corrosive impact on health, and
when exposure to stress differs across populations,
distinct inequalities in outcome will develop over
time. This mechanism explains the susceptibility of
children who suffer inordinate stress through depriva-
tion or abuse to a broad range of associated unhealthy
outcomes later in life. It supplies a mechanism to sup-
port the finding that lower status people have worse
health outcomes than their bosses. It underscores the
importance of a life-course perspective.
Of course, the research supports, and the Commis-
sion urges, comprehensive policies to ensure decent
conditions — adequate food, good education, safe
housing, access to care — which are desirable regard-
the effect of encouraging hurried and furtive injection
in public places where sanitation is poor. Paraphernalia
laws, easily circumvented by the wealthy, make clean
needles scarce for the poor, encouraging risky sharing
and reuse of needles. Greater vulnerability to crimi-
nal laws produces disproportionately higher rates of
incarceration which is itself a powerful risk factor for
violence, disease, and overdose. But, once again, it is
not just that health explains causal pathways between
social vulnerability and HIV/AIDS. It also produces
ideas for measurable change beyond the simple pre-
scriptions of criminally oriented policy (stop using
drugs, stop sex work). Syringe exchange programs
deal with the immediate barriers to safe injection —
lack of equipment, information, support — but as a
broader movement, harm reduction has also worked

Public health attention and interventions are often drawn to the most
proximate causes of illness, and public health’s scientized discourse often
ignores or even obscures social causes. The allure of the magic bullet is eternal.
Indeed, this is one of the chief moral hazards standing between public health
and any very vigorous self-congratulation in the social justice sphere.

less of their value to health. But it also points to inter-
ventions that are immediately feasible and that can
to some degree turn back the assaults of inequality.
Interventions aimed at children, for example, offer
real leverage in battling health problems in the whole
population.38 In the words of the Commission, “If gov-
ernments in rich and poor societies were to act while
children were young by implementing quality [early
child development] ECD programs and services as
part of their broader development plans, these invest-
ments would pay for themselves many times over.”39
Examples include monitoring children being released
from hospitals for numerous risk factors associated
with readmission and other poor health outcomes,40
and reducing school fees to increase school attendance
by girls.41
A third example of how epidemiology anatomizes
injustice can be found in the serious racial and class
and gender disparities in HIV. Many of these are to be
found among the most marginalized people in society,
like drug users and sex workers. But their high rates of
HIV do not just reflect class or gender or race broadly;
public health research has shown how the operation of
criminal justice systems works as a powerful mecha-
nism for changing low social status into a bad health
outcome.42 For those who lack the resources to inject
in relatively hygienic private spaces, criminal laws have
to change the orientation and behavior of police and
the social construction of drug use. As with other pub-
lic health problems, many of best health interventions
in this area are directly influenced by recognition of
power disparities. If you know, for example, that HIV/
AIDS is killing sex workers due in part to traditional
power imbalances that impede widespread use of
condoms, then it makes sense to empower sex work-
ers to make safer behaviors possible. This is the well-
known story of the Sonagachi Project, which has been
hailed by the WHO as a model health intervention.43
After observing that sex workers lacked the bargain-
ing power as individuals to require clients to use con-
doms, public health advocates helped form a collective
of over 60,000 sex workers. The results were striking:
the use of condoms among sex workers changed from
4 percent to between 65 and 80 percent.44 Even with-
out better health results, sex worker collectives seem
to improve perceived well-being of sex workers45 and
may even change their power relations with police.�
These are just a few instances of how health research
chips away at the abstraction of social injustice. Pub-
lic health research, like stories (“The Jungle”47), is a
medium for showing that racism or sexism or social
inequality are not just “big” concepts brooding some-
where above us all but ways of being that are enacted
every day in particular places and times. In an age

584 journal of law, medicine & ethics


when millions believe in “intelligent design,” its char-
acter as a science may or may not give health research
a special credibility, but it does give its practitioners,
and the public health community, the necessary tools
to advance collective knowledge through the use of
methods widely accepted in a global culture.
We do not claim that health is unique in its use
of research and data to illuminate the workings of
inequality. Indeed, this “health” work is in fact not just
epidemiology but sociology, anthropology, economics,
psychology, and even law. Public health research does,
however, enjoy a relatively large and durable fund-
ing stream. By no means all public health research is
aimed at, or even acknowledges, social determinants,
but even risk factor epidemiology can add value to
social justice work. Research is often ignored, but that
is a good reason for supporting a framework conven-
tion, which in its design and implementation could
direct attention, and even require a response, to the
evidence base.
We do not forget the fact that public health attention
and interventions are often (most often?) drawn to the
most proximate causes of illness, and public health’s
scientized discourse often ignores or even obscures
social causes. The allure of the magic bullet is eternal.
Indeed, this is one of the chief moral hazards standing
between public health and any very vigorous self-con-
gratulation in the social justice sphere. Wilkinson and
Pickett point out, for example, that the U.K.’s exem-
plary (albeit ineffective) efforts to blunt the effects of
health inequities operated tacitly as an alternative to
actually addressing the root causes.48 Drafters and
implementers of a framework convention would be
challenged to keep that social map of ill-health and
its structural determinants clearly in mind, and to
direct serious action at social pressure points, and not
simply to rely on health technology and health care to
deal with the most proximate causes of morbidity and
mortality.
III. Institutional Capacity
Much of the commentary on Global Health Gover-
nance (GHG) has been critical, and justifiably so.
National governments can be corrupt, inefficient,
and preoccupied by political rivalry. United Nations
(UN) agencies can be cautious, bureaucratic and turf-
obsessed. Rich foundations can throw their weight
around and evade accountability (we’re not mention-
ing any names). A proliferation of public-private part-
nerships aimed at particular causes can bring incoher-
ence to the system as a whole, and siphon off scarce
resources from generalist bodies like WHO.49 For all
the reasons Gostin and others note, there is surely
a need to refocus and structure global public health
global health governance • fall 2010 585
Burris and Anderson
efforts. But let us not paint public health as an inverse
Lake Wobegon, where every institution is ugly and
every leader is below average. In the grand scheme of
real life muddling-through, public health’s institutions
at all levels have much to be proud of, and bring valu-
able capacities to the cause of social justice.
To begin with, public health agencies are in the
field, doing good, just about everywhere. The num-
ber and diversity of health departments, hospitals and
clinics, WHO agencies and non-governmental orga-
nizations (NGOs) around the globe working to solve
specific problems is staggering.50 To the extent that
poor health itself undermines social justice, 51 even
strictly biomedical interventions (e.g., anti-retrovi-
rals), targeting narrow health problems, can at least
sometimes advance social justice. Misery reduction
may not seem as grand as poverty reduction, but it
can feel pretty good to the miserable. Too often, per-
haps, we undervalue the concrete advances dedicated
funders and interventionists achieve. Whether it is
George Soros’ Open Society Institute (OSI) funding
initiatives to drive down HIV/AIDS rates for prisoners
and prison workers in Eastern Europe and the former
Soviet Union,52 the Rotary Club reinventing itself as a
champion of vaccinations,53 or the WHO agitating for
better access to controlled medicines,54 global health
actors are saving, or at least improving, millions of
lives. Just some of the more dramatic examples include
the two million saved through HIV/AIDS ARVs,55 the
estimated 2 million saved per year by the eradica-
tion of smallpox,56 the 300,000 children saved by the
National Control of Diarrheal Disease Project’s treat-
ment of diarrhea,57 the thousands saved through the
elimination of polio as a public health threat in Latin
America and the Caribbean,58 and perhaps most strik-
ingly, the 10,000 children saved per day due to basic
public health interventions over the last 2 decades.59
Practical public health work can claim to be address-
ing all the major “poverty traps” — malnutrition, dis-
ease, poor infrastructure, and high fertility60 — that
characterize and to an important degree cause ongo-
ing distributive injustice. As Gostin writes, there may
be “no clear solutions to complex problems in global
health. But, we do know how to ameliorate much of
the suffering and early death.”61
Saving lives where one can must be part of social
change in any humane vision of practice, but the social
impact of health institutions is not to be counted only
in direct health or preventive services. Health agen-
cies often work in an explicit social justice framework,
doing what they can to align their immediate disease
prevention activities with a larger strategy for pro-
moting social justice.62 The global network of health
institutions also can and often does enable progressive
SYMPO SIUM
thinking and activity at all levels of social organization.
Government health agencies campaign politically and
diplomatically for policies that reduce inequality and
empower the weak. NGOs sustained by health fund-
ing do more than deliver interventions; they become
more or less potent actors for social change in commu-
nities, nations, and at the global level.63 Health fund-
ing — and health thinking — support a wide range of
community-based organizations working for justice
for poor people, women, drug users, sexual minorities,
migrants, and other marginalized populations, con-
stituting a web of institutions that can more broadly
enable local collective efficacy.64
Gender inequity, to take one example, is routinely
addressed in both general statements and specific
programmatic activities. In recent years, the OSI has
funded local efforts to illuminate and redress gender-
based violence from the Congo to Cambodia.65 Gender
equity policies have been adopted as guiding princi-
ples of the largest AIDS funding entities over the last
few years, as discussed in July 2008 UNAIDS special
report.66 The Gates Foundation recently identified
gender equality as a critically necessary element of
successful agricultural development in formulating a
Gender Impact Strategy for supporting farming in the
developing world;67 it has supported the replication of
the Sonagachi sex worker organization in communi-
ties across India.68
Health agencies are a potent force for good at the
local level. They also constitute a credible force in
global governance, even if the health ministry is always
the weakest and the WHO is no World Trade Organiza-
tion (WTO). Foundations like Gates, the Atlantic Phi-
lanthropies, Ford, and OSI influence a range of impor-
tant issues of social justice in the course of their health
work, either directly or through the advocates and
interventionists they fund. Even the often-maligned
WHO and the World Health Assembly (WHA) occupy
a relatively impressive position of normative power
and institutional authority among actors in the global
arena.69 WHO’s record in influencing international
and national policy and practice compares very favor-
ably with that of a wide array of human rights and
development bodies charged with promoting social
justice under the UN system.70 Its clear health mis-
sion and the capacities of its staff amplify the norma-
tive power of its recommendations and pronounce-
ments. Few organizations have scientific credibility
to match the WHO imprimatur in matters of health,
a power more often evident in lesser developed than
rich countries. As a result, WHO pronouncements can
move domestic policies on the merits, or by provid-
ing political cover to local leaders to take on otherwise
intractable and controversial sociocultural issues (e.g.,
586 journal of law, medicine & ethics
female genital mutilation). To actively mobilize policy
reform, the WHO and WHA have institutional and
legal tools that extend beyond the shaming-centered
approaches available to social justice actors, includ-
ing most pertinently the power to generate aspira-
tional guidelines like the Declaration of Alma Ata, and
legal instruments like the Framework Convention on
Tobacco Control (FCTC).71
The WHA is, structurally, a global coordinating
body for health policy, and, as Ilona Kickbusch has
suggested, can use its authority to help coordinate
the activities of actors in GHG.72 The WHO and
WHA, supported by the array of global, national, and
local health institutions, have the legitimacy and the
authority to create “constitutional” instruments in
the broadest sense of the term, as well as to generate
international law in the strictest sense of the term.73
We are not implying that human rights efforts have
not accomplished a lot (though some make that argu-
ment).74 Our point is that global health actors — for all
their perceived faults and imperfections — extend and
save lives each and every day. In theory, there may be
better governors for justice and humane development
than WHO, foundations, ministries of health and do-
gooding NGOs, but if for no other reason that “cur-
rent policies and practices … are not working on the
ground and are unlikely to do so in the future,”75 it falls
to health institutions to act for social justice.76
A framework convention as proposed by Gostin
could strengthen and focus health institutions’ con-
tribution to social justice. As an organizing tool, even
the idea of a convention brings together the public and
private actors in global health to work on a common
agenda. In legal terms, a properly drafted convention
could commit states to specific action, guided by the
sort of particularized health evidence we have already
praised, targeting the unhealthy conditions that
combine with poverty to exacerbate and perpetuate
inequality.77 In a broader constitutional guise, it would
— or could — make explicit the problematic links
between injustice and health, and define obligations
of global collective action. In the work of the Commis-
sion and in countless other documents and activities,
public health institutions have made the link between
health and social justice and taken action aimed at
addressing public health harms by redressing social
justice disparities.
This is not to say that health work always, or even
most of the time, addresses social injustice. Talking is
not the same thing as doing, and some health agencies
do not even talk the talk. A recent report prepared for
the Commission on the Social Determinants of Health
found that the programmatic objectives of three major
Global Health Initiatives are insufficiently attuned to

the role that social structure concerning gender plays
in driving health inequities and overall disease inci-
dence.78 AIDS funding provides a clear instance in
which even massive spending that brings something
closer to health care equity for people in their struggle
against one disease may not ultimately change the
fate of those people or the underlying social inequi-
ties in the society.79 To be fairer as well as more effec-
tive, global health actors must take on the underlying
social determinants of the harms they seek to address
through more carefully targeted interventions, better
conceptualized measurements, and more thorough
evaluation of disparities in intended and actualized
outcomes.80 Much will depend on whether both the
terms and the implementation of a framework con-
vention take on social determinants of health. Even
then, it may be that a health analysis can support
but does not replace a more fundamental diagnosis,
as Wilkinson and Pickett suggest in their argument
that developed economies must abandon their essen-
tial commitment to economic growth as the driver of
policy.81
We also worry that national and global health insti-
tutions will act like, well, institutions. Our happy
painting of global health governance belongs with the
folk art of Grandma Moses or Henri Rousseau, at least
as far as a certain flatness of perspective is concerned.
We have so far treated governments, international
organizations, and NGOs — and by implication strong
states, weak states, and localities — as if they all occu-
pied the same level playing field. In fact, of course, the
unequal distribution of power and resources is the
starting point for global health governance reform,
and its greatest challenge is to afford the weak some
opportunities to constrain the powerful, and objects
of action some chance to inject their knowledge and
interests into the deliberations of global deciders.
There is a risk — perhaps “risk” isn’t even a strong
enough word — that “new” global health governance
will merely decorate the current roster of institutions
and their relations. The very capacity that makes
health agencies useful for social justice can also make
them powerful agents of the status quo. Between the
idea that governance arrangements should be “realis-
tic” (i.e., make sense, and grant concessions, to those
who already have power) and the notion that resources
should be spent accountably (and therefore on activi-
ties that have measurable outcomes conducted by
agencies that can readily be audited), the impetus for
centralization and top-down approaches becomes very
powerful, whether that impetus takes shape as global-
level partnerships or sector-wide approaches. It is
not that experience, accountability, transparency, and
effectiveness are bad values — far from it — but rather
global health governance • fall 2010 587
Burris and Anderson
that they are a route back into the very institutional
fetishism that thinking intensely about governance is
supposed to treat, if not cure.82 It is essential to spread
decision-making power and resources downward from
the top and out from the center so that those strug-
gling to meet the survival needs of their communities
have a real share of the power to make change. This is
a matter both of justice and effective governance.83 If
in the end, a reform of the global health governance
system leaves in charge the same people, with power
lodged in global institutions and ministries of health,
then it will have failed.
IV. “It’s a Collective Action Problem, Stupid”
The claim of the Commission and most social epide-
miologists is that social justice is good for all of us, not
just the poorer, weaker and more oppressed. As com-
fortable as we may be in global suburbia, we would
actually live longer and better lives if we invested more
in health for all and a little less in elite private schools,
gated communities, and alarm systems.84 Alas, most of
the basic necessities for global health are public goods
— “global public goods for health”85 — and therefore
pose the challenge of mobilizing collective action to
pursue ends that help everyone but profit no one.86
Public health can help, offering social justice both a
banner and a fig leaf.
Fear is good. If men were angels, Hamilton said,
we would not need governments. He failed to add
that if men were altruistic, we would not need health
scares. People in the developed world have an impres-
sive capacity to endure the suffering of poor people far
away (or even, it seems, around the corner). Getting
them to feel that that suffering might entail a risk to
self seems to help in getting support for action. In a
selfish world, the fear of contagion is thought to be
a reliable, potent source of policy traction. We may
accept the abstract proposition that poverty and insta-
bility in a flat world are actually causing risks — and
harm — to the well-off, but nothing says “You’re at
risk!” like a brand new flu virus. People tend to think
illness is contagious, even when it is not; contrariwise,
they seem to think that social injustice can be safely
isolated somewhere else.
Many in global and public health fields have been
pressing this theme of global mutual vulnerability.87
Infectious diseases constitute obvious shared global
threats, which may be powerful catalysts of political
action and policy mobilization for improving living
conditions. The environments that encourage patho-
gen mutation are frequently the ones populated by
people living in poorer health (e.g., populations where
a significant percentage of people are immune-com-
promised by HIV/AIDS) or chronically exposed to
SYMPO SIUM

unhealthy contaminants (e.g., populations sharing
water and sewage sources with animal populations).88
But wealthier countries have an interest, the argu-
ment often dramatically goes, in promoting the health
of poorer countries for many other reasons.89 Indeed,
evidence suggests that health is even more determina-
tive of conflict than poverty.90 Poor population health
destabilizes countries threatening trade and national
security.91 This was noted in a UN Security Council in
Resolution in 2000 in the context of HIV.92 It has been
evident, for example, in areas of Africa where skyrock-
eting rates of AIDS have corroded military command
structures, producing younger and less experienced
correct, or how much support for health action comes
from fear versus altruism. Either way, funding for
international health efforts from public and private
sources has grown tremendously over the last couple
decades. Between 1990 and 2007, funding has almost
quadrupled from $5.6 billion to $21.8 billion.97 Even in
the face of a historic downturn in the world economy,
support for global health efforts remains robust.98
And the social justice connection? Well, there is
much to be said for throwing money at problems fun-
damentally constituted by lack of money. We have
already made the case that public health can foster
social justice by bringing to bear resources in the pal-

Public health can give something back to social justice. There is a path
before us along which a framework convention on global health could help
ameliorate the chronic injustice of our global socioeconomic order.
A convention could promote the use of public health research and analysis
to particularize pathological social injustice, and the use of public health
skills and resources to intervene.

armed services.93 It is seen where food shortages and
malnutrition have triggered regional strife and cross-
border violence.94 It follows logically that health pro-
motion efforts can be a means of reducing security
threats and societal discord.95 Wilkinson and Pickett
do an excellent job presenting the data that many of
the wicked problems that beset developed countries
— crime, drug dependence, obesity, mental illness —
can be attributed to inequality, and so that increasing
equity makes everyone better off.96 Whether or not
these arguments prove to be correct, they sometimes
manage to attract the attention of policy makers and
give health advocates an occasional seat at the table.
To be fair to the global North, it is not all fear. Pub-
lic health sometimes can appeal successfully to altru-
ism. A lot more money has been raised for HIV/AIDS
than for SARS or even avian flu, yet it has been a long
time since HIV in the global South (or even on the
other side of town) was a powerful source of personal
insecurity among the well-off. Nor can we necessarily
attribute support for sanitation, health care, or other
interventions more or less unrelated to contagion to
the public’s grasp of sophisticated arguments about
political destabililization of the global socioeconomic
order. Sometimes people just feel too sorry for the
ragged brown child with the big eyes to turn the page.
It does not matter, for present purposes, whether all
the various claims of mutual vulnerability are strictly
liation of unfairly distributed ills, by exposing the
social determinants and specifying mechanisms of
health injustice, and by supporting institutions both
global and local that work to address unhealthy, unfair
social structures and their consequences. As a banner
for social mobilization, health helps bring home to the
world’s haves their stake in the lives of its have-nots. As
we see clearly in the Millennium Development Goals,
health becomes both an object of and a reason for the
global investment in human and social development.
To say that the banner of health can attract support
and funding is not to say that it raises enough money,
nor that the money is being well spent. Virtually no
countries have met even the modest funding commit-
ments of the Millenium Development Goals,99 and the
problems with the development project, even if some-
times overstated, are serious.100 Health has its own
peculiar vices as an exercise in social mobilization for
fundamental change. Public health advocates readily
acknowledge — and blame and exploit — the public for
its tendency to latch on to sympathetic beached-whale
causes to the detriment of broader “survival needs”
like malnutrition, let alone deeper determinants in
the global economic order. But we in health can also
be parochial — focused for a professional life-time on
a set of health challenges that, though important, do
not comprise the whole story. Our priorities can drive
us to spend money in ways that, at the macro-level, are

588 journal of law, medicine & ethics


not closely related to the global burden of disease.101
And we do dearly love our magic bullets, whether they
be pills or circumcisions. Health spending concen-
trated on symptoms of injustice cannot claim much
credit for treating the disease. Public health may be a
good banner, but a banner does not make those wav-
ing it any smarter.
The final argument for talking about health when
we talk about social justice is that we can thereby avoid
talking about social justice. Just as health can effec-
tively specify social injustice, it can also ambiguate it
for those who are not sure social justice is really such
a good thing after all. Social justice smacks of radical-
ism, redistribution, “color revolutions,” and crowds in
the street, whereas health is professional, timid, and
mostly takes place in hospitals. Even when leaders
are willing to talk about social justice, there is seldom
the necessary political capital to operationalize their
words. Perhaps, as other authors in this volume argue,
this is changing. The vision of Alma Ata may be rising
above the fog of neo-liberalism that has obscured it for
so long.102 Maybe the crisis in the global financial sys-
tem has pricked the balloon of unfettered markets.103
It is enticing to think that people learn from their mis-
takes, but we will believe it when we see it. Recently,
we noted the absence of both social justice and public
health arguments from the health care reform debate
in the U.S. Weak as it may be, health is a platform
that can accommodate supporters who have very dif-
ferent opinions about economic and social ordering.
A framework convention on global health could be a
means to get people of significantly different political
orientations to talk a while in a common vocabulary
about addressing health threats whose amelioration
would advance social justice.
V. Conclusion
Gostin’s call for a framework convention for global
health gets much of its immediate emotional power
from the evocation of social injustice in the world’s
indifference to the survival needs of the have-nots.
Social justice does illuminate — and often drive —
public health work. We have argued here, though, that
public health can give something back to social justice.
There is a path before us along which a framework
convention on global health could help ameliorate the
chronic injustice of our global socioeconomic order.
A convention could promote the use of public health
research and analysis to particularize pathological
social injustice, and the use of public health skills and
resources to intervene. In so doing, a convention could
draw upon — coordinate, optimize — the institutional
capacity of health institutions in addressing social
injustices endangering health, and it could well mobi-
global health governance • fall 2010 589
Burris and Anderson
lize public support — and thus political pressure and
resources — for action that will directly address unjust
social conditions. Whether it does so or not depends
of course upon those who really wield power globally
and in the nations of the world (which is not the public
health community). But we may also foil ourselves: by
failing to meet the challenges posed by social epidemi-
ology; by clinging to hierarchical governance arrange-
ments that deliver too few resources and choices to
local institutions; by flying flags of convenience that
ultimately do not announce to the public their stake
in — and our commitment to — a fair distribution of
well-being.
We have argued that public health work can be
good for social justice. We do not argue they are the
same thing. Public health is — or at least in our view
should be — an art of the possible, an endless series of
utilitarian concessions to limited resources, deployed
based on available evidence to optimize the level and
distribution of health in and across populations. The
same data — and orientation to data — that make
public health a good map of social injustice may lead
to accidents if social justice advocates try to use it as
a GPS machine. In a recent American Journal of Pub-
lic Health editorial, Leslie Roberts wryly recounts that
sad story of a young doctor who essentially left pub-
lic health work in Thailand to embark on an arduous
crusade to secure treatment for one child’s cancer.104
The fact that a child, by accident of rural Thai birth,
was excluded from the benefits of medical science that
surely could cure it, was pure injustice. But investing
so many scarce public health resources in righting this
wrong was, Roberts argued, just as surely poor pub-
lic health. Roberts analogizes this story to the case
of PEPFAR: the billions devoted to HIV/AIDS care,
no matter how justly spent, would, he contends, have
done far more lasting good had they been invested in
prevention. Yet even here, at its cold Benthamite core,
public health has something to offer social justice:
more insight into the impossible (all the more because
sometimes false) choice between repairing the dam
and saving the downstream victims of the flood.
Let’s face it: public health is a liberal, rational enter-
prise, a creature of the Enlightenment. Against the
brute facts of injustice it will offer data collection and
analysis. In the face of the raw power of those who
benefit from injustice, it will pursue more or less incre-
mental amelioration. This, so often a source of frustra-
tion and shame to practitioners, is also a virtue. And in
this it is not different from GHG or the whole project
of bourgeois democracy. All of them rest on the hope
that human beings, and the complex systems they
inhabit, can somehow operate intelligently enough
to walk and chew gum at the same time. As modern
SYMPO SIUM
history has repeatedly shown, snipping the code for
liberalism and rationality out of the sociopolitical
software invariably crashes a complex system. Public
health is a slow road to social justice, but it is one of a
finite number of reasonably straight paths. As we walk
it behind the banner of a framework convention, no
one should confuse us for a folksong army, with noth-
ing much beyond guitar strings to tie our rhetoric to
action. We are the public health army: ready, measure,
intervene.
Acknowledgements
The authors thank Joanne Csete for her insightful comments on a
draft of this paper, and Ave Craig and Aaron Stemplewicz for their
work in preparing the paper for publication.
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104. L. Roberts, “A Plea For Cost-Effectiveness, or at Least Avoid-
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99, no. 9 (2009): 1546-1548.