People with low socio-economic status often have relatively poor health. That is unjust, says Beatrijs Haverkamp. Health is not so much an individual as a societal responsibility, argues the philosopher in her thesis.
When is a person unhealthy, actually?
‘I think it’s good to link the definition of health to the context in which you are aiming at it. In biomedical research, it is relevant to talk of health as the absence of disease. But for the chronically ill, it is more a matter of wellbeing. Together with the Netherlands National Institute for Public Health and the Environment (RIVM), I did a small-scale study on what people mean by health. People from lower socio-economic classes said health meant not being ill and getting through the day alright. People from higher socio-economic classes set the bar higher in their definition of health: for them it’s all about wellbeing and enjoying life, as well as the impact of your own behaviour.
To what extent are people responsible for their own health?
‘It’s a complex issue, because differences in health status have a lot to do with differences in lifestyle. We know, for instance, that Dutch men with lower levels of education smoke significantly more. This is largely determined by the social norm within the group. Another thing that doesn’t help is the fact that financial stress often leads to an unhealthier lifestyle. Social housing is often in less healthy locations, with more air pollution and less scope for taking a walk in the park. This leads to some groups being worse off in every way. And conversely: if you have had a good education, you often earn more and you can live in a better location and have a healthier lifestyle. So I don’t agree with the assertion that lifestyle is a personal choice, and that there is no injustice in some people falling ill more easily than others. Health is determined by a whole complex of social factors and we all help to keep them going. By the way our education system works, for instance, and how different professions are remunerated. So health is a shared responsibility in society.’
Your thesis is about the question of whether health differences are an injustice. How do you decide about that?
‘Justice is about how we treat each other and whether we treat each other equally. Intuitively, you would think there must be something wrong if there are such big discrepancies in health status. But it is quite difficult to say what justice would look like. You can’t distribute health among people, like you can money. Justice could mean that everyone has the right to equal opportunities. In that case, you look at the underlying socioeconomic differences that lead to health differences. Or you could say that everyone has the right to a certain minimum level of health, and that there is such a thing as being “healthy enough”. But it’s not easy to identify that minimum. I look mainly at the impact of health on someone’s social position. Health problems can lead to a higher risk of being stigmatized or unemployed, or of having a shorter retirement.’
What are the policy implications?
‘People often think the government should reduce health differences, but that is incredibly difficult. I argue that we should acknowledge that these are persistent differences, and go about it differently, namely by looking more at the inequalities that come about as a result of the health differences. Such as a shorter retirement. You could consider measure such as differentiation in pensionable age based on profession, income or level of education.’