Solidarity and Health: A Public Goods Justification

In “Solidarity and Justice in Health Care,” Professor ter Meulen persuasively argues that solidarity provides an important complement to justice in determining the arrangement of health care practices. This is an important insight. As Prof. ter Meulen explains, ‘[t]he philosophy of justice interprets society and the problem of just distribution of resources in terms of a social contract based on the concept of autonomous individuals negotiating their interests.’^[1] Solidarity in contrast, ‘is associated with mutual respect, personal support and commitment to a common cause.’^[2] These attributes, ter Meulen convincingly demonstrates, are vital to ensuring that a health care system is not simply just, it is also decent.

Yet in arguing for the recognition of solidarity as a valuable counter-balance to justice, ter Meulen may both overstate the individualism inherent in conceptions of justice, and understate the strength of solidarity’s connection to health. Although as ter Meulen explains, liberal theories of justice take the autonomy of individuals as their starting point, in recent years theorists within the liberal tradition have increasingly emphasized the significant degree to which human health is socially-determined. For example, in his more recent work, Norman Daniels has moved away from the highly individualistic conception of health justice explicated in his 1985 book, Just Health Care, to consider what justice means in terms of population health.^[3] Likewise, building upon the capabilities approach pioneered by Martha Nussbaum and Amartya Sen, Sridhar Venkatapuram in Health Justice presents a theory of health justice that is deeply rooted in social epidemiology and the recognition of population-level determinants.^[4] While both of these works are firmly in the liberal camp, they are nevertheless several steps away from the atomism ter Meulen ascribes to theories of justice.

The social epidemiology that Daniels, Venkatapuram and others consider points to another vulnerability in ter Meulen’s account. By failing to consider the significant role that social factors play both in our understanding of health (and disease) and in its incidence, ter Meulen underestimates the extent of mutual dependency and thus the importance of solidarity with respect to health. Health has an important public good dimension. Recognizing the public good dimension of health can help highlight our mutual dependency and, in turn, the need for solidarity.

Public goods, such as clean air, have two common features: their benefits are non-rivalrous in consumption and non-excludable. Unlike private goods, in the case of public goods, consumption by one does not diminish the good. Thus one person’s breathing clean air does not reduce the air available to others. The same is not true for private goods, such as computers and candy. Non-excludability, the second critical feature of a public good, means that people cannot be excluded from the good. Consider clean air again. It would be difficult, if not impossible, to exclude people from breathing clean air. Although health is often understood to be a private good, we think that it can also be viewed as a public good.

Health is non-rivalrous in the sense that everyone can enjoy good health. One person’s health does not deprive others of health. Indeed, very often the opposite is true. Healthy people foster health in others. According to network theorists like Christakis,^[5] good health spreads within networks. Likewise, the herd immunity provided by vaccinations shows how the presence of a healthy population can protect the health of others. Thus health seems to be non-rivalrous.

Showing that health is non-excludable is a more complicated matter. Nonetheless, the reasoning is compelling. Although some of the access goods for health are excludable, such as medications and medical devices, many other access goods are non-excludable. Again network theory can be helpful in understanding why this is so. Christakis, for example, found in a study that the average obese person was more likely to have obese friends and friends of friends. Obesity tends to spread within multi-centric networks.^[6] Obesity is itself a significant illness, but it is also associated with many others. The Christakis study shows that networks can be non-excludable even with respect to non-communicable diseases. Although networks can be exclusive, many are not, and it is very often difficult to exclude people from them, especially in large urban centers. Practically speaking, very often the costs (including transaction costs) of excluding people from a network would be too great to justify exclusion. Many people simply do not want to live in gated communities. And others cannot afford to do so. Since networks are associated with good and bad health, and it is often difficult, and sometimes impossible, to exclude people from them, networks act as non-excludable access mechanisms for health.

There are other examples of social context’s importance for health. The health choices that people make are based on the options they have, and these options are largely determined by what is on offer, nudging people in one direction rather than another. According to Linda Fried,

as … behavioral and environmental risks have been imported from developed to developing countries, and as we learn that community norms and social networks reinforce the uptake of adverse health behaviors, this puts into question whether, in fact, we should contain these risk factors and the resulting diseases “non-communicable”.^[7]

Put differently, diseases such as type two diabetes and cervical cancer, typically associated with private choices, are often the result of nudges which are outside the individual’s control. In this way they are not unlike communicable diseases.

Social epidemiology has also demonstrated a connection between health and the so-called social determinants of health. The social determinants have a considerable impact on health and include factors such as the economy, physical environment, income, and social status. According to the WHO, ‘the social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national and local levels.’^[8] We know from the work of researchers such as Wilkinson and Pickett that not only is income important for health, but so too are inequalities and social gradients.^[9] Sometimes social determinants directly harm health, as illustrated by the effect of lead paint on the health of children who digest it. However, the health impacts can also be indirect as when a disease such as AIDS devastates a community’s economy, and has economic consequences internationally.

Because social status affects the health of all people, rich and poor, it is best understood as a non-excludable mechanism for health. So too are other social determinants. National income, equality, public health laws, and even social norms, all affect population health, and all do so in ways that cannot be limited to distinct individuals. In effect, these access mechanisms are non-excludable and public in their reach.

The recognition that health is a public good – that in a deep sense the health of individuals is determined by the health of the populations which they comprise, suggests that solidarity both in its descriptive and normative aspects, is an especially important concept for health. As ter Meulen explains, solidarity draws upon the appreciation of mutual interdependency; the sense that we are “all in this together.” Because health is a public good, we are all indeed in it together.

This is most obvious in the case of communicable diseases. Thus efforts to control Ebola and stop its spread both within and from West Africa depended upon people in North America and Europe recognizing the common humanity of people in West Africa, and being willing to provide resources and even medical care (despite the dangers) to those at most risk. Likewise, Ebola did not spread broadly within North America or Europe because health care workers were willing to put themselves at risk and treat those who were ill, while those who were exposed were willing to monitor their own health, to avoid infecting others.

Solidarity, however, is not only critical to prevent the spread of contagious epidemics. It is also vital to efforts to reduce the prevalence of non-communicable diseases, such as obesity and cancer, which as noted above, are affected by social factors. After all, the laws and norms against indoor smoking that have played a large role in reducing cigarette smoking presuppose that individual smokers must refrain from doing something they enjoy for the benefit of others. Even firmly paternalistic public health laws, such as those requiring individuals to wear seatbelts, emanate from the recognition that the health of individuals matters to others. Indeed, it is this appreciation of mutual interdependence, as well as the understanding that health can be secured only when people act in solidarity to ‘assure the conditions for people to be healthy’ that defines public health endeavors.^[10]

This is not to say that solidarity as a principle for health, whether respecting health care services or public health more broadly, is wholly unproblematic. As ter Meulen notes, ‘conventional solidarity has a problem of exclusion by the construction of “us” against “them”.’^[11] That problem is often evident in the stigma and demonization that typically develop in the wake of new diseases, such as HIV or Ebola. So too solidarity’s exclusionary attributes are often cited as justifications for barring non-citizens from health programs. Nevertheless, once health is understood to be a public, rather than a private good, solidarity for health can be viewed as a more inclusive concept than some have assumed. In particular, excluding people from healthcare, for example, because they do not share a common identity or citizenship, ignores the multiplicity of ways that our health depends upon the health of other people. When the other is sick, the health of citizens is also threatened and when the health of citizens suffers, the health of others suffers as well.

The public good dimension of health underscores the importance of coming together for the sake of health. Some accounts of solidarity have stressed the role of social interaction in the creation of solidarity. Thus citizens and non-citizens often come together for the sake of health. International nannies care for children; elder care is often assumed by women from other countries. Many nurses and physicians move from poor countries to rich countries, creating a veritable medical brain drain. These numerous interactions among people from different national and socio-economic backgrounds are very often for the sake of health. Similarly, when physicians worldwide descend upon West Africa to help fight Ebola, they are acting in solidarity with people in West Africa for the sake of the health of others. When it comes to health it seems that we are all in this together. The public good dimensions of health highlight this. No doubt there is an element of working together for all our shared and mutual benefit, but health is also a universal language, one that we all understand. We suffer alike when we are sick or injured regardless of the other differences we may have.

In some quarters, it is thought that solidarity may be difficult among diverse people. Robert Putnam^[12] has commented on the difficulty of creating social capital among diverse peoples, and Paul Collier,^[13] in his book Exodus notes that mutual regard is most prevalent among families and local communities and in high-income societies, among citizens. We are not in a position to review this literature here. However, it is worth noting that other studies provide reasons to be optimistic. Research in social psychology supports the view that people have a strong desire to belong, and that in-group behavior can be created on the basis of trivial factors such as the toss of a coin. Another study showed that people come to have good views of previously disliked groups, and that living close by can help. According to Baumeister and Leary,

[…] people seem widely and strongly inclined to form social relationships in the absence of any special set of eliciting circumstances or ulterior motives. Friendships and group allegiances seem to arise spontaneously and readily, without needing evidence of material advantage or inferred similarity. Not only do relationships emerge quite naturally, but people invest a great deal of time and effort into fostering supportive relationships with others. External threat seems to increase the tendency to form strong bonds.^[14]

Health may be one of the external threats that brings people together in solidarity, creating a willingness to carry costs for others. Of course, for solidarity to be triggered, it is helpful if people understand the public dimensions of health, namely, that it is non-rivalrous and non-excludable. If people assume in contrast that health is private, they may not recognize the mutual threat to them.