Social Injustice and
Public Health
Barry S. Levy
Victor W. Sidel,
Editors
OXFORD UNIVERSITY PRESS
SOCIAL INJUSTICE AND PUBLIC HEALTH
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SOCIAL INJUSTICE AND
PUBLIC HEALTH
Edited by
Barry S. Levy
Victor W. Sidel
1
Published in Cooperation with
the American Public Health Association
2006
1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
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Copyright Ó 2006 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.

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www.oup-usa.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Social injustice and public health / edited by Barry S. Levy and Victor W. Sidel.
p. cm.
Includes bibliographical references and index.
ISBN-13 978-0-19-517185-3
ISBN 0-19-517185-3
1. Social medicine. 2. Social justice. 3. Public health—Social aspects.
I. Levy, Barry S. II. Sidel, Victor W.
RA418.S6423 2005
362.1'042—dc22 2004065433
987654321
Printed in the United States of America
on acid-free paper
Dedicated to health workers
throughout the world
committed to ending
social injustice.
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FOREWORD
Despite the tremendous improvements in overall health and life expectancy
during the past century, at the start of the twenty-first century there are un-
conscionable gaps in health for many vulnerable groups, including racial and
ethnic minorities and the poor. These gaps in health thrive in a climate of

economic and social inequities. These inequities create the conditions that ad-
versely affect the health of individuals and communities by denying individuals
and groups the equal opportunity to meet their basic human needs.
Minority children and children from low-income families continue to lag
behind their counterparts in almost every health indicator. Poor children are at
least twice as likely as are nonpoor children to suffer stunted growth or lead
poisoning. Black children and children from poor families are more likely to
have disabling asthma. Infants born to black mothers are more than twice as
likely as infants born to white mothers to die before their first birthdays. Black
and Mexican-American children living in older (pre-1946) housing are more
than twice as likely to have elevated blood lead levels as are white children
living in comparable housing.
Quality health care alone, however, cannot prevent children from being
poisoned by lead paint in deteriorating homes or developing asthma from fumes
emitted by inadequately vented stoves. These disparities in children’s health
reflect the inequities in social and economic well-being of children and their
families. For example, nearly 13 million American children—more than one in
six—lived in families with an annual income below the government poverty
level in 2003. In that year, 34 percent of black, 30 percent of Latino, 13 percent
of Asian, and 10 percent of white children were poor. The racial gaps in the
poverty rate testify to generations of social injustice that have created a system
of unequal access to many sectors of American life, including education,
housing, employment, finance, and criminal justice.
Social Injustice and Public Health calls us to action to improve health
through the pursuit of social justice. This book makes a powerful and com-
pelling argument that a primary goal of public health is to address the root
causes of social injustice: widening gaps between rich and poor, the unequal
distribution of resources within our society, discrimination, and the disen-
franchisement of individuals and groups from the political process.
This system of social injustice has contributed to disparities not only in

health but also in childhood development, education, employment, income,
housing, and family and community safety. The racial and social progress of
the last half-century is in peril of being lost. This would be a moral, social,
and economic catastrophe for America. If we can remove children from the
dangerous intersection of race, poverty, and poor education where so many
young lives are wrecked, we would not only improve children’s health but
we would also help all Americans realize the core values of freedom and
justice that make America America.
—Marian Wright Edelman
viii FOREWORD
PREFACE
Social injustice underlies many public health problems throughout the world. It
is manifested in many ways, ranging from various forms of overt discrimina-
tion to wide gaps between the ‘‘haves’’ and ‘‘have-nots’’ within a country and
between rich and poor countries. It leads to higher rates of disease, injury,
disability, and premature death. Public health professionals as well as students
of the health professions need a clear understanding of social injustice in order
to address these problems, but relatively few books address the wide range of
issues involved.
The aim of this book is to offer a comprehensive approach to understanding
social injustice and its impact on public health. Part I explores the nature of
social injustice and its adverse effects on public health. Part II describes in
detail how the health of 10 specific population groups is affected by social
injustice. Part III explores how social injustice adversely affects health in
10 different areas, ranging from infectious diseases to mental health, from
prevention of assaultive violence and war to occupational health and safety.
Part IV provides an action agenda for what needs to done to prevent social
injustice and to minimize its impact on health.
This book arose from our experience and observations of the ways in which
social injustice underlies public health problems. Previously we edited War

and Public Health and Terrorism and Public Health, in which we identified
social injustice as a principal causative factor and as a consequence of war and
terrorism. The current book examines social injustice as a principal causative
factor and as a consequence of many public health problems.
We conceived this book with the goals of stimulating a better understanding
of the relation between social injustice and public health, promoting education
and research on these issues, and facilitating effective measures to minimize
the impact of social injustice on health and well-being.
B.S.L. and V.W.S
Sherborn, Massachusetts
The Bronx, New York
May 2005
x PREFACE
ACKNOWLEDGMENTS
Developing Social Injustice and Public Health has involved the combined
skills and resources of many people, to whom we are profoundly grateful.
We are indebted to all of the contributors, who worked, often with short
deadlines, to write chapters and boxes that reflect their observations, insights,
and expertise. Their commitment to social justice and to public health is evident
in their work and in their contributions to this book.
We thank many people for their insights that helped extend our knowledge
and sharpen our thinking about social injustice and public health. These in-
clude Philip Brachman, Paula Braveman, Jack Geiger, and Nancy Krieger.
We express our deep appreciation to Heather Merrell for her excellent
work in preparing multiple drafts of the manuscript and coordinating com-
munications with contributors. We also thank Angela Adjei and Deyanira
Suarez for secretarial support.
We greatly appreciate the guidance, assistance, and support of Jeffrey
House, who was instrumental in the development of this book, as well as Carrie
Pedersen, Keith Faivre, and others associated with Oxford University Press,

and Jean Blackburn of Bytheway Publishing Services.
Finally, our gratitude and love to Nancy Levy and Ruth Sidel for their con-
tinuing inspiration, encouragement, and support.
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CONTENTS
Foreword vii
Contributors xvii
Part I Introduction
1. The Nature of Social Injustice and Its Impact on Public Health, 5
Barry S. Levy and Victor W. Sidel
Box 1-1. Concepts of Social Justice, 8
Box 1-2. Universal Declaration of Human Rights, 14
Box 1-3. International Declaration of Health Rights, 20
Part II How the Health of Specific Population Groups
Is Affected by Social Injustice
2. The Socioeconomically Disadvantaged, 25
Michael Marmot and Ruth Bell
3. Racial and Ethnic Minorities, 46
Carol Easley Allen and Cheryl E. Easley
4. Women, 69
Stacey J. Rees and Wendy Chavkin
5. Children, 88
Sara Rosenbaum and Chung-Hi H. Yoder
Box 5-1. How the United States Compares With Other
Developed Countries, 92
Box 5-2. Saving Children’s Lives in Developing Countries, 94
6. Older People, 113
Carroll L. Estes and Steven P. Wallace
7. Lesbian, Gay, Bisexual, and Transgender/Transsexu al Individuals , 130
Emilia Lombardi and Talia Bettcher

8. People With Disabilities, 145
Nora Ellen Groce
Box 8-1. Terminology, 147
Box 8-2. Disability and Education, 150
Box 8-3. Similarities and Differences Among People With Disabilities, 153
Box 8-4. Disability During Times of Disaster and Political Upheaval, 154
9. Incarcerated People, 161
Ernest M. Drucker
Box 9-1. Prisoner Abuse and Torture in the United States
and Iraq, 167
10. Homeless People, 176
Lillian Gelberg and Lisa Arangua
11. Forced Migrants: Refugees and Internally Displaced Persons, 190
Michael Toole
Part III How Social Injustice Affects Health
12. Medical Care, 207
H. Jack Geiger
13. Infectious Diseases, 220
Joia S. Mukherjee and Paul E. Farmer
14. Nutrition, 238
J. Larry Brown
Box 14-1. Definition of Key Terms, 240
Box 14-2. Obesity, 243
15. Chronic Diseases, 253
Derek Yach
Box 15-1. Selected Actors’ Neglect of the Global Burden of
Chronic Diseases, 254
xiv CONTENTS
16. Mental Health, 277
Carles Muntaner and Jeanne Geiger-Brown

17. Assaultive Violence and War, 294
James A. Mercy
Box 17-1. War and Public Health, 298
Box 17-2. Genocide, 306
18. Environmental Health, 318
Colin D. Butler and Anthony J. McMichael
19. Occupational Safety and Health, 337
Andrea Kidd Taylor and Linda Rae Murray
Box 19-1. Epidemic of Toxic Liver Disease, 346
Box 19-2. Economic Globalization, 348
20. Oral Health, 357
Myron Allukian, Jr., and Alice M. Horowitz
Box 20-1. Social Inequalities in Oral Health Internationally, 362
21. International Health, 378
Barry S. Levy and Victor W. Sidel
Box 21-1. Trafficking in Persons, 382
Box 21-2. Hunger and Malnutrition in Developing Countries, 388
Box 21-3. Import of Hazardous Substances Into Developing
Countries, 392
Part IV. What Needs to Be Done
22. Addressing Social Injustice in a Human Rights Context, 405
Sofia Gruskin and Paula Braveman
23. Promoting Social Justice Through Public Health Policies,
Programs, and Services, 418
Alonzo Plough
24. Strengthening Communities and the Roles of Individuals in
Community Life, 433
Robert E. Aronson, Kay Lovelace,
John W. Hatch, and Tony L. Whitehead
25. Promoting Social Justice Through Education in Public Health, 449

Robert S. Lawrence
26. Researching Critical Questions on Social Justice and Public
Health: An Ecosocial Perspective, 460
Nancy Krieger
Contents xv
27. Protecting Human Rights Through International and National Law, 480
Peter Weiss and Henry A. Freedman
28. Promoting Equitable and Sustainable Human Development, 493
Richard Jolly
Appendix: Some Organizations Addressing Social Injustice, 509
Index 519
xvi CONTENTS
CONTRIBUTORS
Carol Easley Allen, PhD, RN
Professor and Chair
Department of Nursing
Oakwood College
7000 Adventist Boulevard
Huntsville, AL 35896
256-726-7297
256-726-8338 (fax)

Myron Allukian, Jr., DDS, MPH
Oral Health Consultant
Massachusetts League of Community Health
Centers and Lutheran Medical Center
46 Louders Lane
Boston, MA 02130
617-654-8920
617-542-0777 (fax)


Lisa Arangua, MPP
Senior Research Analyst
Department of Family Medicine
David Geffen School of Medicine at
UCLA
Los Angeles, CA 90095-1683
310-794-6094
310-794-6097 (fax)

Robert E. Aronson, DrPH, MPH
Assistant Professor
Department of Public Health Education
University of North Carolina at
Greensboro
437J HHP Building
PO Box 26170
Greensboro, NC 27402-6170
336-256-0119
336-334-3238 (fax)

Ruth Bell, PhD
Senior Research Fellow
Department of Epidemiology and Public
Health
xvii
University College London
1-19 Torrington Place
London WC1E 6BT
United Kingdom

þ44 020 7679 1684
þ44 020 7813 0242 (fax)

Talia Bettcher, PhD
Assistant Professor
Department of Philosophy
California State University, Los Angeles
5151 State University Drive
E & T A405
Los Angeles, CA 90032-8114
323-343-4179
323-343-4193 (fax)

Kathryn L. Bolles, MPH
Child Survival Specialist
Save the Children/US
54 Wilton Road
Westport, CT 06880
203-221-3778
203-221-4056 (fax)

Paula Braveman, MD, MPH
Director, Center on Social Disparities
in Health
Professor of Family and Community
Medicine
University of California, San Francisco
500 Parnassus Avenue, Room
MU-306E
San Francisco, CA 94143-0900

415-476-6839
415-476-6051 (fax)

Joseph E. Brenner, MA
Director, Center for Policy Analysis
on Trade and Health (CPATH)
98 Seal Rock Drive
San Francisco, CA 94121-1437
415-933-6204
415-831-4091 (fax)

J. Larry Brown, PhD
Distinguished Scientist, Brandeis
University
Executive Director, Center on Hunger
and Poverty
The Heller School for Social Policy
and Management
Mailstop 077
60 Turner Street, First Floor
Waltham, MA 02454-9110
781-736-8885
781-736-3925 (fax)

Colin D. Butler, BMed, MSc, PhD
Research Fellow
National Centre for Epidemiology and
Population Health
Medical Director, Benevolent
Organization for Development Health

and Insight (BODHI)
Australian National University
Canberra, ACT, 0200 Australia
61 2 6125 5624
61 2 6125 0740 (fax)

Wendy Chavkin, MD, MPH
Professor of Population and Family Health
and of Obstetrics/Gynecology
Department of Population and
Family Health
Mailman School of Public Health
60 Haven Avenue, B2
New York, NY 10032
212-304-5220
212-305-7024(fax)

Ernest M. Drucker, PhD
Professor, Departments of Epidemiology
and Population Health, Psychiatry
and Behavioral Sciences, and Family
Social Medicine
Division Head, Division of Public Health
& Policy Research
Albert Einstein College of Medicine
Montefiore Medical Center
111 East 210th Street
xviii CONTRIBUTORS
Bronx, NY 10467
718-920-4766


Cheryl E. Easley, PhD, RN
Dean and Professor
College of Health and Social Welfare
University of Alaska Anchorage
3211 Providence Drive
Anchorage, AK 99508
907-786-4407
907-786-4440 (fax)

Carroll L. Estes, PhD
Professor and Founding Director
Institute for Health & Aging, UCSF
3333 California Street, Suite 340
San Francisco, CA 94118
415-476-3236
415-502-5404 (fax)

Paul E. Farmer, MD, PhD
Presley Professor of Medical Anthropology
Department of Social Medicine, Harvard
Medical School
Chief, Division of Social Medicine and
Health Inequalities, Brigham and
Women’s Hospital
Founding Director, Partners In Health
641 Huntington Avenue
Boston, MA 02115
617-432-3718
617-432-6045 (fax)


Henry A. Freedman, LLB
Executive Director
Welfare Law Center
275 Seventh Avenue, Suite 1205
New York, NY 10001-6708
212-633-6967
212-633-6371 (fax)

H. Jack Geiger, MD, MSciHyg
CUNY Medical School
City College of New York, H-401
138th Street at Convent Avenue
New York, NY 10031
212-650-6860
718-802-9141 (fax)

Jeanne Geiger-Brown, PhD, RN
Assistant Professor
Family and Community Health
School of Nursing
University of Maryland at Baltimore
655 West Lombard Street
Baltimore, MD 21202
410-706-5368

Lillian Gelberg, MD, MSPH
George F. Kneller Professor
Chief, Health Research
Department of Family Medicine

David Geffen School of Medicine at
UCLA
50-071 CHS Box 951683
Los Angeles, CA 90095-1683
310-794-6092
310-794-6097 (fax)

Nora Ellen Groce, PhD
Associate Professor
Global Health Division
Yale School of Public Health
College Street, Room 320
New Haven, CT 06520
203-785-2866
203-785-6193 (fax)

Sofia Gruskin, JD, MIA
Associate Professor of Health and Human
Rights
Program on International Health and
Human Rights
Francois-Xavier Bagnoud Center for
Health and Human Rights
Department of Population and
International Health
Harvard School of Public Health
FXB Building, 7th Floor
Contributors xix
653 Huntington Avenue
Boston, MA 02115

617-432-4315

John W. Hatch, PhD
Keenan Professor Emeritus
Department of Health Behavior and
Health Education
University of North Carolina at
Chapel Hill
Rosenau Hall CB #7440
Chapel Hill, NC 27599-7440
919-966-3761

Alice M. Horowitz, PhD
Senior Scientist
National Institute of Dental and
Craniofacial Research
National Institutes of Health
45 Center Drive, Room 4AS-37A
Bethesda, MD 20892-6401
301-594-5391
301-480-8254 (fax)

Sir Richard Jolly, MA, PhD
Professor
Institute of Development Studies
University of Sussex
Brighton BN1 9RE
United Kingdom
44(0)1273 606261
44(0)1273 621202 (fax)


Nancy Krieger, PhD, MS
Associate Professor
Department of Society, Human
Development, and Health
Harvard School of Public Health
Kresge 717
677 Huntington Avenue
Boston, MA 02115
617-432-1571
617-432-3123 (fax)

Robert S. Lawrence, MD
Edyth H. Schoenrich Professor of
Preventive Medicine
Associate Dean for Professional Practice
and Programs
Director, Center for a Livable Future
Johns Hopkins Bloomberg School of
Public Health
615 N. Wolfe Street, W1033
Baltimore, MD 21205
410-614-4590
410-502-7579 (fax)

Barry S. Levy, MD, MPH
Adjunct Professor
Department of Public Health and
Family Medicine
Tufts University School of Medicine

PO Box 1230
20 North Main Street, Suite 200
Sherborn, MA 01770
508-650-1039
508-655-4811 (fax)

Emilia Lombardi, PhD
Assistant Professor
Graduate School of Public Health
Department of Infectious Diseases/
Microbiology
University of Pittsburgh
3520 Fifth Avenue, Suite 400
Pittsburgh, PA 15213-3313
412-383-2233
412-383-1513 (fax)

Kay Lovelace, PhD, MPH
Associate Professor
Department of Public Health Education
University of North Carolina–Greensboro
437M HHP Building
PO Box 26170
Greensboro, NC 27402-6170
336-334-3246
336-334-3238 (fax)

xx CONTRIBUTORS
Sir Michael Marmot, MBBS, MPH, PhD
Professor

Director, International Centre for Health
and Society
Head of Department
Department of Epidemiology and Public
Health
University College London
1-19 Torrington Place
London WC1E 6BT
United Kingdom
þ44 020 7679 1717
þ44 020 7813 0242 (fax)

Anthony J. McMichael, MBBS, PhD
Professor
Director, National Centre for
Epidemiology and Population Health
Australian National University
Canberra, ACT, 0200 Australia
61 2 6125 4578
61 2 6125 5608 (fax)

James A. Mercy, PhD
Associate Director for Science
Division of Violence Prevention
National Center for Injury Prevention
and Control
Centers for Disease Control and Preven-
tion
4770 Buford Highway, NE
Mailstop K-68

Atlanta, GA 30341
770-488-4362
770-488-4221 (fax)

Joia S. Mukherjee, MD, MPH
Medical Director, Partners In Health
Assistant Professor, Division of Social
Medicine and Health Inequalities,
Brigham and Women’s Hospital
Department of Social Medicine,
Harvard Medical School
641 Huntington Avenue
Boston, MA 02115
617-432-3735
617-432-6045 (fax)

Carles Muntaner, MD, PhD
Professor and Chair
Psychiatry and Addictions
Nursing Research
Culture, Community and Health Studies
Social, Policy and Prevention Research
Department
Center for Addictions and Mental Health
University of Toronto
250 College Street
Toronto, Ontario M5T 1R8
Canada
416-979-6905
416-979-0564 (fax)


Linda Rae Murray, MD, MPH
Chief Medical Officer–Primary Care
Ambulatory & Community Health Network
Cook County Bureau of Health Services
621 South Wood Street, Suite 331
Chicago, IL 60612
312-864-0748
312-864-9879 (fax)

Alonzo Plough, PhD, MPH
Director, Department of Public Health,
Seattle and King Counties
Professor, School of Public Health and
Community Medicine, University of
Washington
999 Third Avenue, Suite 1200
Seattle, WA 98104-4039
206-296-1480
206-296-0166 (fax)

Stacey J. Rees, CNM, RN, MA
Former Program Director
Soros Reproductive Health and Rights
Fellowship
Mailman School of Public Health,
Columbia University
Contributors xxi
Midwife, Clementine Midwifery and
Natural Birth

247 Mulberry Street, Suite 14
New York, NY 10012
646-519-7209
646-519-7209 (fax)

Sara Rosenbaum, JD
Hirsh Professor and Chair
Department of Health Policy
The George Washington University
Medical Center
School of Public Health and Health
Services
2021 K Street NW, Suite 800
Washington, DC 20006
202-530-2343
203-530-2361 (fax)

Ellen R. Shaffer, PhD, MPH
Director, Center for Policy Analysis on
Trade and Health (CPATH)
98 Seal Rock Drive
San Francisco, CA 94121-1437
415-933-6204
415-831-4091 (fax)

Victor W. Sidel, MD
Distinguished University Professor of
Social Medicine
Albert Einstein College of Medicine
Montefiore Medical Center

111 East 210th Street
Bronx, NY 10467
718-920-6586
718-654-7305 (fax)

Andrea Kidd Taylor, DrPH, MSPH
Assistant Professor
Morgan State University
Public Health Program
1700 East Cold Spring Lane
343 Jenkins Hall
Baltimore, MD 21251
443-885-2044
443-885-8309 (fax)

Michael Toole, BMedSc
Centre for International Health
The Macfarlane Burnet Institute for
Medical Research and Public Health
GPO Box 2294
Melbourne 3001, Australia
61 3 9282 2216
61 3 9482 3123 (fax)

Steven P. Wallace, PhD
Professor of Community Health
Sciences
UCLA School of Public Health
Associate Director, UCLA Center for
Health Policy Research

10911 Weyburn Avenue, 300
Los Angeles, CA 90024
310-794-0910
310-794-2686 (fax)

Peter Weiss, JD
Vice President
Center for Constitutional Rights
5022 Waldo Avenue
Bronx, NY 10471

Tony L. Whitehead, PhD, MSHyg
Professor of Anthropology
0123 Woods Hall
University of Maryland
College Park, MD 20742-7415
703-620-0515

Derek Yach, MB, ChB, MPH
Professor of Global Public Health
Yale University School of Medicine
Department of Epidemiology and Public
Health
60 College Street, Suite 319
New Haven, CT 06520
203-785-3927
203-785-6193 (fax)

Chung-Hi H. Yoder, JD, MS



xxii CONTRIBUTORS
SOCIAL INJUSTICE AND PUBLIC HEALTH
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