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Health Justice - Dr Sebastian Fonseca


Dr Sebastian Fonseca

Junior medical doctor with affinity to social determinants of health and its relation to social justice theory applied on health through the lenses of critical social theory. Originally from Colombia, with previous studies on philosophy, politics and economics of health. Currently involved in the Colombian Medical Federation as a health policy analist.

Research at KCL involves elucidating what the role civil society and social movements ought to be in realizing health justice. For this purpose, the research is divided in two.  Firstly, approaching social justice applied on health from a focus on civil society. This is done two ways - taking the stance on the social determinants of health scholarship, which bases its enquiries on population-based approaches; and endorsing the Tripartite Theory of social justice, developed by Nancy Fraser (critical theory), with its particular emphasis on radical democracy and the public sphere. Secondly, once social justice theory on health has centred on civil society, the research query can be properly approached.

Modules and projects encountered for the purpose of the current research include Social Justice Theory by Nancy Fraser, Foucault and Genealogy, Critical Theory Summer School, Third School of Frankfurt Critical Theory, the Civil Society Project: what went wrong?, Critical Reason: the basics, State Phobia and Civil Society, Critical Global Health (Teaching Assistant). 



Hello, I'm Nigel Warburton. Joining me today is sebastian fonseca from the department of global health and social medicine at kcl. the topic is health justice. What do you mean with this term?

Health justice is the way we come to analize equality in society, particularly in health – the equality of health. when we think about health, we tend to associate its definition with causes of ill-health. from three decades ago, we have changed our paradigm on the way we think about the causes of ill-health – from a biomedical causes to the social factors that determine health.

So the biomedical model is that there are infectious agents that cause ill-health and how well i feel is to do with the way things around me, the environment, affects me?

Yes, exactly. the biomedical perspective includes communicable diseases (infections) and non-communicable diseases (chronic diseases, genetic diseases, environmental exposure, health-behaviour diseases).

So this is the paradigm you said has changed.

Yes. as a result of different medical studies during the 70s-80s (whitehall study, the black report) by sir michael marmot, data showed how causes not related to biological agents come to have a great impact on health outcomes. these studies, particularly, were looking at the social standing (social economic status) of british public servants. researchers saw that, as servants kept on going up to social scale, their health status improved – a phenomena known as “social gradient”. the higher the standing, the better life expectancy. this developed into a theory in health, claiming that different social factor had a high impact on health.

So what we are talking about is how these social determinants of health, rather than biological means to health

This opens up a field of understanding health that goes beyond the tipical biomedical approach, a very individualistic strategy to understand health. the social determinants of health allows other discipline to come in and help – thinking about health, for example, from political philosophy, anthropology, sociology, international relations, etc. political philosophy is where my research stands.

Just to make clear, you are not saying this research proved that the head of the british civil servants will never get ill or could not get an infection. it is nothing like that.

Not at all. it is more understanding how these social factors, not commonly used in health analysis, have high influence in the health outcomes of populations as a whole. we are not thinking about what will happen to the single civil servant at the top of the social scale – but rather how the system of “social status” impacts the population as a whole.

You mentioned marmot´s research – i want to clarify what sorts of factors he picked up as “the social factors” that impact health outcomes.

The scholarship and research related to social determinants of health is very broad and considers all sorts of different factors. but one thing sir michael marmot does, and it´s included in his last book “the health gap”, is to organize these factors in three different domains. firstly, factors that are related with material resources and the economic relationship they contain. that is, because of the distributive principles and policies, how lack or wealth of resources will impact their health status. secondly, includes a symbolic domain. given different cultural contexts (social networks, cohesion, social capital, etc.), people will have different outcomes in health. and thirdly, is related with the political factors which considers political participation, representation and having a political voice. how the population is able to gain political power to influence the social context where people are embedded. within these three domains there are many different factors – but i have sketched a very quick overlook.

You are suggesting that your ability ot participate politically could affect your health outcomes.

Yes. well, marmot´s approach to social determinants of health has a rather material focus. for example, if you have a higher political participation, this translate into higher empowerment over your own life. this will lead to different biological pathways that will determine your health status. emphasis on biological pathways makes the claims materialistic.

Is there a particular example you can give to illustrate this?

Yes. neglected ethnic groups or minorities. these groups are often exposed to negative factors including marginalization and exclusion of social affairs. they are not able to control, manage or impact the social conditions where they are embedded. they are stuck in the same social patterns of injustices – labour explotation and segregation. as a result, their health outcomes is really bad. once they are empowered to have a voice, get claims through against oppression, regain capacity for self-governance – their health outcomes change as a result.
n: it strikes me that the social determinants we are talking about seem like indirect causes of ill-health, while the biological ones are direct. 

The way research has been framed is not related to whether the social factors are direct or indirect causes of ill-health. rather, it is more to know the causative mechanisms that lead into health impact. you may think it is indirect because there doesn’t seem to be a clear connection between the social factors and health outcomes, in the traditional sense of causation. but, precisely, what the social determinants of health scholarship have been able to proof is that these factors do have a direct impact on health status and the pathways can be pinpointed. there is a biological aspect of cascades happening eventually, but this is not independent from what happens in the social. part of the paradigm shift is to stop thinking in a straight-jacket way, having on one side the biological causes and on the other the social factors; but see how both are integrated, co-imbricated and conjoined.

We have been talking about empirical research but how does that relate into justice?

The fact that empirical work has risen does not necessarily translate into political impact. we need to build up proper normative arguments that joing the two dimensions together, so that we may shape the way society is organized. this is where social justice comes in. what we see in the empirical research is that there are inequialities in health – disparities between populations due to factors that can be changed and, therefore, because of unfair circumstances. circumstances that are avoidable. this allows the claim against health inequities. social justice is all about dealing with inequities and what do you do to have a fair society.

Do you have a political model that you follow?

Yes, i do. there are many theories of social justice. there is one particular model i find that ressembles the work advanced by michael marmot: the tripartite theory of social justice developed by nancy fraser (critical theory). nancy fraser works with three different types of injustices, much like three causes of injustice. the root of her theory.

Root in the sense of her pathways of analysis?

Yes, pathways of analysis. the way injustice works. the three dimensions are: first off, a distributive paradigm or the way resources are distributed among the population. economic-based analisis. second off, refers to recognition and it is closely attached to politics of difference. cultural problems over minority groups, the way society can marginalize or excludes social groups over arbitrary criteria. third off, the political side of injustices – representation. the way people are able or not to have a voice over the political debates that impacts their well-being.

Sound to me that it is a theory of injustice and inequalities in unfair distribution of resources, lack of recognition by others and a lack of equality in the democratic process.

What is interesting about nancy fraser is that she connects the three by one principles: parity of participation. this is, equal social standing for participation in social affairs. in other words, everyone ought to have the status of interacting with each other as peers. by having this principle, she argues that any of the three dimensions of injustice, in essence, attack or injure this principle of equality.

From the discussion so far, you have given a descriptive account of social determinants of health. now you are giving a normative account, by nancy frasers tripartite theory of social justice. how do you blend the two?

What is interesting about these two is that they are very similar. my intuition is that this similarity is an opportunity to compare and contrast empirical evidence with normative accounts. earlier i spoke about the importance of enriching evidence with normative arguments to generate social and politica impact, this is exactly what the tripartite theory gives me. it is a solid normative ground to take the empirical research and turn it into a political tool. in a sense, my research aims at extending the tripartite theory of justice by nancy fraser into the social determinants of health – creating an alternative of how we view health justice.

Sebastian Fonseca, thank you very much.

Thank you.

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