Health and social justice



Lawrence O Gostin*

O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, 20001, United States of America



Jennifer Prah Ruge. Publisher: Oxford University Press, New York, 2010; ISBN: 978-0199559978; 224 pages, US$ 74

The International Covenant on Economic, Social and Cultural Rights (ICESCR), ratified by 160 States, confers on all human beings the core entitlements essential to human fulfilment, e.g. the rights to work, social security, family life, education and participation in cultural life. Although all are vital, the ICESCR's guarantee of "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" may be the most fundamental. 1 Why is this so?

Health has special meaning to individuals and communities at large. Good health is necessary for human well-being, providing intrinsic value for comfort, contentment and pursuit of the joys of life. But good health does more than that. It is important in allowing individuals to exercise a range of human rights - both civil and political (e.g. physical integrity, personal security, political participation), social and economic (e.g. employment, education and family life). Just as important, health is necessary for well functioning societies. If a population does not have a decent level of health, it is very difficult to ensure economic prosperity, political participation, collective security and so forth.

Jennifer Prah Ruger is one of a handful of scholars who have been steadfast in defending the right to health and the imperative of reducing unconscionable health inequalities around the globe. Her latest book, Health and social justice, stands, by far, as her most systematic and vital contribution.

In this seminal work, Ruger presents a theory of health and social justice, which she calls the "health capability paradigm" - whereby she says that all people should have access to the means to avoid premature death and preventable morbidity. Hers is a vision that incorporates the philosophical, economic and political to make a compelling case that all societies (through public-private partnerships) can design and build effective institutions and systems to achieve health capabilities. Although she focuses (perhaps overly so) on the provision of medical care, Ruger offers a rich explanation of the essential drivers of health, such as surveillance, preventive measures, clean air, safe drinking water and nutritious food.

In the book's foreword, Amartya Sen helpfully distinguishes "good health policy" from "good policy for health", explaining that it is the latter that is needed for health justice. This supports the World Health Organization's (WHO's) "all-of-government" or "health-in-all-policies" approach, recognizing that the health sector is not the only contributor to good health.

The WHO Commission on the Social Determinants of Health concluded that "the social conditions in which people are born, live and work are the single most important determinants of good health or ill health, of a long and productive life, or a short and miserable one". 2 Ruger does not shy from the imperative of resource redistribution - from the rich to the poor and the healthy to the sick - offering a cogent pathway on how redistribution can take place in society.

The health capability paradigm envisions "shared health governance" where researchers, health insurers, governments, health professionals and citizens work together to build consensus around health priorities - including the legislative process, coalition building, citizen participation and commitment. Adopting a theory of "incompletely theorized agreement", Ruger argues that constituent members of society do not need to agree on every element to reach consensus about key health goals. Priorities would include child/maternal health, alleviating hunger, and supply of safe drinking water.

If society ensures health capabilities, individuals have a corresponding obligation to take personal responsibility, Ruger argues. Individuals have an obligation to use their "health agency" to pursue good health, for example, by eating nutritional foods, engaging in physical activity and complying with medical advice. For this to happen, of course, governments must structure the built environment to make it easy to choose healthy behaviours - such as making fruit and vegetables accessible and affordable.

It is good to imagine a world where society maximizes health and closes the health gap; where all constituent members can build consensus and coalitions; and where individuals accept personal responsibility. Yet, societies often fail to ensure basic survival needs and universal health care. Constituent members often fail to agree on health priorities, regretfully acting in their self-interest rather than the common good. And often individuals find it exceptionally hard to eat a nutritious diet, exercise and engage in safe sex.

Even if achieving health and health equality are exceedingly difficult, it is reassuring to know that there exist rare scholars such as Jennifer Prah Ruger who strive for social justice. This is a book that demands attention and determined action, for nothing is more important for the world's population than the passionate pursuit of health and social justice.



1. International Covenant on Economic, Social and Cultural Rights. Geneva: Office of the United Nations High Commissioner for Human Rights; 1976. Available from: [accessed 25 November 2010]          .

2. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008. Available from: [accessed 25 November 2010]          .



* Correspondence to Lawrence O Gostin (e-mail:

World Health Organization Genebra - Genebra - Switzerland