Thursday, October 16, 2008

The Real-Life Complexities of Health Inequalities

Egalitarians take issue with the existence of inequality. Inequality itself is, for true egalitarians, bad.

While I am not an egalitarian myself, I am very interested in the issues that underlie egalitarian intuitions. And what I find really surprising is that many political philosophers who call themselves "egalitarians" seem to care little about the causes of real inequality in the world. Either they naively belief that these causes are self-evident or they don't really see these empirical considerations as relevant to their overall comprehension of the justice of a particular distributive outcome. I think this is a real problem. And if egalitarians took these concerns more seriously, I believe this would result in their being less egalitarian (perhaps abandoning that description all together).

This is at least what has happened to me over the past dozen years. My rejection of egalitarianism is not ideological. It is not because I believe redistribution violates some value that ought to take primacy (like liberty). In fact I support redistribution. So I also reject libertarianism. But I see myself as a contextual pluralist. When we consider the specifics of any particular dimension of well being (be it wealth or health), we see that orienting our sensibilities and deliberations around the value of distributional equality is severely limiting and problematic.

Of course equality is an important value, and sometimes it can do a lot of important work. But when applied to some metric of distributional equality, I believe it is, at best, inert, and at worst, it can do more harm than good.

In previous posts I have highlighted factors that many egalitarian philosophers ignore. Like the fact that our choice of partner has been a key force in producing unequal family incomes. Or how gender, affluence, parental encouragement and exposure to sports all have an impact on a child's schooling abilities. Such empirical realities add many different considerations to our deliberations concerning what ought to be done to create a more fair society. And in this post I will add some further considerations to these points.

Once we seriously consider a specific kind of inequality, we often find that what really troubles us is not inequality per say, but that some are more vulnerable than they need be. What troubles us is objective, not relational, considerations. And thus the solution is not to strive to reduce inequality itself, but rather to improve the situation of those who are vulnerable. And so the principles at stake here (e.g. priority or sufficiency rather than equality) are important for they can have a profound impact on our understanding of the policies we ought to pursue.

Take the health inequality that exists between the rich and the poor in an affluent country like the United States. This study in the NEJM, for example, suggests that, from the years 1960 to 1986, the link between mortality and lower educational level became stronger. In other words, the wealthy and educated enjoyed a greater decrease in mortality rates (during this time period) than did those who were poor and poorly educated.

What are we to make of this kind of data? Is it good news or bad news? I believe it is both. It is good that there has been a reduction in mortality among some Americans. Such accomplishments should not be discarded or viewed as trivial. And yet this same data should also trouble us. It should trouble us not because there is inequality, but because there is a vulnerable group of people whose health needs are not being sufficiently addressed. And if there is something we can do to also increase their enjoyment of health we should do it.

These two conflicting sentiments become evident if we ask ourselves- would we have preferred it to be the case that everyone, rich and poor alike, had a higher risk of mortality? That situation would be more equal, but it would not, "all-things-considered", be preferable. And so the value of equality itself, while it may capture our sensibilities at a superficial level, only serves to muddy the terrain when we take the realities of life (like our intrinsic vulnerability)seriously.

A paper in the latest issue of Health Economics effectively illustrates this point. The paper is entitled "WHY HAS THE HEALTH INEQUALITY AMONG INFANTS IN THE US DECLINED?" The author examines infant inequality among the rich and poor in the US from the years 1983 and 2000. This gap, measured by the Apgar score, neonatal mortality and infant mortality, has actually narrowed over the past two decades.

This data is surprising given that income inequality has increased over this time. So egalitarians should be intrigued by these findings. At first blush, it might appear that the narrowing of this gap is good. However, the reality, once we examine the distinct factors that have caused this inequality, is that the story is a mixed one. Not everything that has caused this reduction in health inequality is good. And recognising the real life complexities of health inequalities should make us realize that it is not equality itself that we should strive for.

So what accounts for this reduction in health inequality among infants? Lin identifies 3 central mechanisms that account for this reduction in inequality- (1) maternal behavior changes, (2) demographic changes, and (3) access to medical care.

So first, the good news. The single biggest factor in reducing this inequality is adequate prenatal care. Lin argues that "all else being equal, access to proper medical care accounts for 39.5% of the closing gap in low Apgar score, 28.4% of the closing gap in infant death, and 29.3% of the closing gap in neonatal death". This finding is not surprising, and it highlights the importance of access to healthcare. But access to medical care is only half the story. (1) and (2) actually account for 40% of the reduction in infant inequality. And once we consider (1) we see that certain aspects of the reduction in inequality are not good.

For example, highly educated parents are more likely to utilise fertility treatments, which increase the chances of multiple births. And this in turn increases the risks of complications and death. In other words, one important factor that explains the reduction in infant health inequality is the fact that the children of highly educated parents now have an increased risk of complications and death. And thus this "leveling down" explains part of the reduction in inequality. This is important to note, for it is clearly something that, despite its impact on reducing inequality, is bad (not good). The goal should be to reduce, not increase, the risks facing infants. And yet this is lost if we place the primary focus on reducing inequality itself.

Demographic changes also help explain the reduction in infant health inequality. Lin argues that Hispanics are healthier than African-Americans and similar in health to non-Hispanic whites. And this is the case even though Hispanics have a comparable socioeconomic situation to African-Americans and a lower situation when compared to the non-Hispanic white population. Part of this is explained by the fact that Hispanics have lower rates of smoking and drinking. And yet when it comes to maternal nativity, these positive effects are limited to immigrant (foreign-born) Hispanics (and not American-born Hispanic women). Lin suggests that this might be due to what is known as the "healthy migrant effect"; that immigrants are selected for their good health and robustness.

And so foreign born mothers actually explains part of the reduction in infant health inequality. And this finding also highlights another interesting and surprising finding from Lin's analysis-- that the immigration flux has brought health improvements to the health of the poorest infants in the United States.

Lin's examination of the real-life complexities of infant health reveals the complex factors that influence healthy inequalities. These range from obvious things like access to medical care to immigration and the age of parents. What can we learn from all of this? I think these insights have important implications for what the fundamental distributive principles of justice are (e.g. equality vs priority, etc.) and thus will have a profound impact on what we take the central prescriptions of justice to be.