Public Health as Social Justice? A Qualitative Study of Public Health Policy-Makers’ Perspectives

Abstract

Social justice is often described as the ‘foundation of public health.’ Yet, outside of the theoretical literature the polysemous nature of the concept is rarely acknowledged. To complement recent contributions to normative theory specifically motivated by questions of social justice in public health, this study explores public health policy-makers’ perspectives on the meaning and role of social justice in their practice. This study involved twenty qualitative, semi-structured interviews with public health policy-makers recruited from two programmatic areas of public health [chronic disease prevention (CDP) and public health emergency preparedness and response (PHEPR)] within public health organizations in Canada. Participants’ perspectives appeared to be influenced by the perceived goals belonging to the programmatic area of public health in which they practiced. Those involved in PHEPR indicated that justice-based considerations are viewed as a ‘constraint’ on the aims of this area of practice, which are to minimize overall morbidity and mortality, whereas those involved in CDP indicated that justice-based considerations are ‘part and parcel’ of their work, which seeks primarily to address the unique health needs of (and thus, disparities between) population groups. The aims and activities of different programmatic areas of public health may influence the way in which social justice is perceived in practice. More ought to be done (in theory and in practice) to interrogate how the unique contributions that individual programmatic areas of public health can and should cohere in order to realize the broader aim that public health has as an institution to promote social justice.

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Notes

  1. 1.

    ‘Health equity’ is also a ubiquitous, justice-related value in this context. However, for reasons expounded by Smith (2015) and Smith et al. (2018), it is unclear in practice whether health equity and social justice are in fact intended to invoke distinct justice-related considerations.

  2. 2.

    Indeed, it has only been relatively recently that health has begun to figure in the philosophical treatment of social justice. For example, the most prominent contribution to the philosophical literature on social justice—John Rawls’s 1971 theory of justice as fairness—framed health as a ‘natural good,’ meaning it did not fall within the scope of social justice given that it was not considered to be directly or significantly socially produced (Rawls, 1999; Venkatapuram, 2011). This has prompted many, including Daniels (2007), Sen (2002, 2009), Nussbaum (2000), and Venkatapuram (2011), for example, to argue for the significance, if not centrality, of health to social justice, citing, among other things, the influence of social arrangements on health and the importance of health in securing opportunities and capabilities that are central to social justice. See also Trotter (2008) and Gubrium, Barcelos, Buchanan, and Gubrium (2014) regarding the general lack of engagement with theory when social justice is invoked in public health.

  3. 3.

    These sorts of statements presume that utilitarian aims, or ‘utilitarianism,’ and social justice are mutually exclusive. Yet, this may not necessarily be the case. Mill, for instance, argued that his principle of utility (in his theory of utilitarianism) is ‘the highest abstract standard of social and distributive justice’ (Mill, 1962 (1861), 318).

  4. 4.

    Though, even if this were feasible, it was considered unsuitable for the purposes of this study. Proceeding with a single definition or interpretation of social justice was also considered inappropriate as doing so would take for granted the conceptual and theoretical insights that may be conferred by other accounts, and would arbitrarily limit the conceptual and theoretical breadth of this study. Fundamentally, it would ignore the possibility that another theory (or set of theories) might provide more substantial, or simply different, analytic and interpretive insights to the study’s research questions, problem, and data. Another alternative, i.e., generating empirical data before any theoretical exploration occurs and then choosing a particular theory, or theories, as an analytic apparatus based on the nature of the data, was also considered to be less than ideal, as this would render the study design and data collection tools devoid of a robust understanding of the theoretical landscape, which would be unfortunate given the benefits of being able to recognize and respond to the contours of the theoretical terrain during these phases of study development and implementation.

  5. 5.

    Data extracts are presented here in order to illustrate the ways in which themes are supported by the data. Extracts were chosen given their ‘aptness’ in illustrating the theme discussed. Each extract includes an identifier: the first three characters (e.g., ‘P07’) refer to the participants’ numerical identifier (e.g., participant number seven), the second set of characters (either ‘PHEPR’ or ‘CDP’) indicate the programmatic area of public health practice coded for the participant (public health emergency preparedness and response or chronic disease prevention, respectively), and the third set of characters (‘F,’ ‘P,’ or ‘M’) indicate the level at which they worked (federal, provincial, or municipal, respectively). Data extracts in some instances also include the interviewer’s interaction with participants. In these instances, participants’ voices are prefaced with a ‘P’ at the beginning of quotes (‘participant’), and the interviewer’s voice is prefaced with an ‘I’ (‘interviewer’).

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Correspondence to Maxwell J. Smith.

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Smith, M.J., Thompson, A. & Upshur, R.E.G. Public Health as Social Justice? A Qualitative Study of Public Health Policy-Makers’ Perspectives. Soc Just Res 32, 384–402 (2019). https://doi.org/10.1007/s11211-019-00327-7

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Keywords

  • Social justice
  • Utilitarianism
  • Public health
  • Chronic disease prevention
  • Public health emergency preparedness and response
  • Public health ethics