HEALTH EDUCATION RESEARCH
Theory & Practice
Vol.13 no.3 1998
Pages 451—457
Linking health promotion and social justice: a rationale
and two case stories
Nina Wallerstein and Nicholas Freudenberg1
Abstract
Although health promotion and social justice
come from distinct traditions, their integration
can strengthen the field of health education.
This paper explores the complexities and ethical
dilemmas of incorporating social justice into
health promotion, including differing agendas
among agencies, communities and health educators; role conflicts; ideologic differences in
the field; and lack of willingness of health
educators to take risks. Two case studies, a
transitional program to assist incarcerated
women and youth to return to communities,
and a statewide youth policy initiative, illustrate
these issues and argue for the value of linking
social justice and health promotion strategies to
create a powerful health education agenda for
the next century.
Introduction
Health promotion and social justice are commonly
used terms within the field of health education, yet
discussion of the relationships between these two
concepts and their integration in practice settings
has been lacking. This paper examines the different
traditions and assumptions of each concept, and
argues that the field of health education can be
Department of Family and Community Medicine, School
of Medicine, University of New Mexico, 2400 Tucker NE,
Albuquerque, NM 87131 and 'Center on AIDS, Drugs
and Community Health, School of Health Sciences,
Hunter College, 425 East 25th Street, New York,
NY 10010, USA
© Oxford University Press
strengthened by a critical analysis of their separate
and overlapping dimensions; and by an awareness
of practitioner successes and failures in integrating
the two perspectives. The complexities and moral
dilemmas of attempting to practice health promotion and social justice simultaneously are illustrated
by two case studies: a transitional program to assist
women and adolescent inmates return to their
communities from a New York City jail, and a statewide initiative for youth policy in New Mexico.
Health promotion has been defined in two different ways (Minkler, 1989). The first, more popular
in the US, has emphasized wellness and behavioral
changes in exercise, diet, sexual behavior,
and avoidance of drugs, alcohol and tobacco
(O'Donnell, 1986). Environmental strategies are
recognized as they support individual behavior
change (Green, 1980). The second, more favored
in Europe, Canada and Australia, is based on the
Ottawa Charter for Health Promotion which defines
health promotion as a comprehensive process of
'enabling people to increase control over, and
improve their health' (Ottawa Charter, 1986). Three
of the five Ottawa Charter strategies, i.e. healthy
public policy, supportive environments and community action, for health overlap substantially with
the goals of social justice.
In recent years, most health promoters have bypassed the polarity between individual and social
action to emphasize both. Nevertheless, much of
the practice of health promotion in the US is
still weighted heavily towards individual behavior
(Green and Raeburn, 1990; Glanz et al., 1997).
In contrast to health promotion, the concept of
social justice comes from a long philosophical and
political tradition. In public health, Beauchamp's
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N. Wallerstein and N. Freudenberg
seminal article (1976) compared a social justice
ethic, defined as collective action to distribute
resources equitably to protect and restore health,
with a market justice ethic, denned as fair play
that respects individual efforts and rights.
A key question is the role of public health
educators in supporting collective action to promote equity (Last, 1992). Equity is often confused
with equality or equal opportunity, a concept based
on individual merit and market justice. Equity
refers to conditions largely out of individuals'
control that create unjust differentials in health
status (Whitehead, 1991). Equity and inequality
are defined clearly below (Draper, 1989):
If you live longer than I do or if you suffer
from less sickness and disability, our health
status is unequal. There is inequality between
us, but not necessarily inequity. The difference
may not result from our living conditions which
may be essentially the same, but from accidents,
genetics or lifestyle choices.
If, however, the differences in our health
status result from different living conditions,
mine being less satisfactory than yours, a question of inequity arises. I may have less access
to nutritious foods, difficulty in finding decent
housing or high-quality health care sensitive to
my particular needs. My income may be lower,
and my work stressful and demoralizing, punctuated by frequent periods of prolonged unemployment. In this case, inequalities in health
status are the result of inequities in life.
The public health literature demonstrates that
people who are disenfranchised, without power, in
low socio-economic status or, in general, with life
demands that outstrip their control, experience
worse health status (Syme, 1988; Karasek and
Theorell, 1990; Wallerstein, 1992; Kaplan et ai,
1996). Countries with greater inequities between
rich and poor have lower health status than
countries with smaller income gaps (Evans et al.,
1994; Power, 1994). Lack of social justice, therefore, can be considered a risk factor for disease.
Conversely, promoting social justice—through
strategies of health promotion, community
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development, empowerment and advocacy—
becomes a driving mission of public health education.
Though health promotion and social justice come
from different traditions, the following two case
studies illustrate how health promotion and social
justice can be integrated in practice.
Case study 1
Since 1992, Health Link, a project of the Hunter
College Center on AIDS, Drugs and Community
Health, has helped women and adolescent inmates
at Rikers Island Detention Center, the largest jail
in the US, to return to the South Bronx and Harlem,
two of the poorest communities in the US. Health
Link has referred nearly 500 ex-offenders to drug
treatment, housing, health care and other services,
and has also assisted several community organizations to expand their services for ex-offenders.
Through a network of community groups serving
women, adolescents, drug users and ex-offenders,
the project has advocated for changing criminal
justice policies by expanding resources devoted to
community aftercare.
Health Link is a health promotion project
because it seeks to provide participants with the
knowledge, skills and services that will help them
to reduce drug use, stay out of the path of the HIV
and other pathogens, and lower the rates at which
they become victims or perpetrators of violence.
Health Link addresses social justice because its
target population is a disenfranchised, stigmatized
population that many in our society believe is
expendable. It seeks to bring resources to low
income communities to help them reintegrate
people who return from jail. It also seeks to change
criminal justice policies that emphasize punishment
at the expense of both rehabilitation and public
safety.
Case study 2
In New Mexico, for the past 3 years, New Mexico
Advocates for Children and Families, with Kellogg
Foundation funding, has sponsored a youth policy
Linking health promotion and social justice
project, called Youth Link. The project was created
to address fragmentation in youth prevention programs throughout the state and the excessive
reliance on service provision, rather than on organizing youth to be involved in public policy.
Youth Link's strategy focuses on youth health
promotion through involving youth, ages 12-21,
in intergenerational Community Action Teams (or
CAT groups) throughout the state to develop projects for their communities, to listen to community
needs and to formulate action plans. Fourteen
CATs were initiated, representing the ethnic and
geographic diversity of the state, including: a
Navajo high school CAT, two Pueblo Indian
CATs, Carlsbad's middle school CAT, Questa and
Mora predominantly Hispanic CATs, and three
Albuquerque based CATs (an African-American,
immigrant Mexican and leadership group).
Youth Link is about social justice because its
mission is to create opportunities for youth, who
are traditionally disenfranchised, to organize with
adult support so that their voices, their needs and
their strengths will be heard by policy makers. The
social justice strategy was to bring together the
CATS with other youth into a state-wide Youth
Policy Town Hall that would propose specific
policy changes for increasing youth participation
in civic decision making.
Discussion
How are the quests for health promotion and social
justice similar? The key word that brings these
concepts together is power. Lack of power at the
individual, community and societal levels is a
major risk factor for poor health. This suggests
that empowering the disadvantaged—or disempowering those who use their privilege to benefit
themselves at the expense of the well-being of
the community—is an important tool for health
promotion (Freire, 1970; Wallerstein and
Bernstein, 1994).
To return to the example of Health Link, giving
the young men and women released from jail the
skills that will help them find a job, protect
themselves and their partners from HIV infection,
and settle disputes without resorting to violence
will both promote their health and lower the
barriers that often block them from participating
more fully in society. Increasing resources for
community aftercare for ex-offenders will help to
reduce drug use and improve the ability of women
with substance abuse problems to care for their
children. It will also reduce the disproportionate
burden that criminal justice policies impose on
low-income urban Black and Latino communities.
While the case studies illustrate some of the
overlap between the concepts of health promotion
and social justice, their differences can be a source
of tension. Promoting health may not always lead
to more social justice, and promoting social justice
may not improve health.
Health promotion may only focus on individual
behavior change, i.e. smoking cessation or indoor
air ordinances, or increased support for individuals,
i.e. lay health advisor programs that legitimize
neighbor support. Authoritarian governments may
impose health promotion on people with no intention of participatory democracy, i.e. Singapore's
ban on smoking in public places. In the long run,
however, a lack of participation or inattention to
inequity may damage health.
On the other hand, social justice efforts may fall
outside our role as health professionals. Typically,
mass mobilizations around social issues or civil
disobedience tactics are not undertaken in our role
as health professionals or as part of bureaucracies
(Labonte, 1994). Social justice activities may conflict at times with public health goals. Fighting
against apartheid, for example, put people in danger
for injury and death, although the goal was greater
societal equity.
These independent spheres of activity are well
represented within Youth Link. In the first year,
the CATs primarily adopted a health promotion
agenda, such as personal skill development through
alternative activities, creating supportive environments or public policy. The Navajo CAT, for
example, sponsored alcohol prevention programs,
such as CAT participation in the annual sacred
journey to save lives (a DWI march) and a sobriety
pow-wow. In Hispanic rural Mora county, with
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N. Wallerstein and N. Freudenberg
32% below poverty, the CAT worked on nosmoking school and restaurant policies, and on
starting a high school youth center.
It was only 18 months later, when preparations
began for the 1996 Youth Town Hall, that Youth
Link embraced social justice. Before the Town
Hall, youth-led mind mapping focus groups asked
youth throughout the state to critically examine
problems, underlying causes and solutions for
youth. The mind-maps identified five major problems: alcohol/substance abuse, violence and crime,
gangs, school issues, and teenage pregnancy; as
well as root causes which connected the symptoms
to social justice: racism by school personnel and
police; lack of support and respect from adults;
poor environments and poverty, including unjust
social policies and lack of traditional community
values; and low self-esteem and relationship
problems.
In the development of Youth Link, the link
between the two strategies is clear. Both social
justice and health promotion strategies are intervention oriented; they attempt to change conditions and
behaviors; both can value equity and community
mobilization to redistribute power; and both require
advocacy (Minkler, 1994; Freudenberg et al., 1995;
Schwartz et al., 1995).
Because of the activist approach, professionals
who adopt either strategy may at times overstep
important boundaries. By not listening to community needs and issues, professionals may impose
their values, believing that the community is misinformed or misguided. On the other hand, health
professionals may glamorize communities, overlooking homophobia, sexism, racism or xenophobia. Communities are not monolithic but subject
to a dynamic process of competing values. The
tensions between health promotion and social
justice can surface when health workers maintain
a strong social justice ethic in their work.
Some of the conflicts between promoting health
or justice come when health educators are confused
about their roles. Most of us wear many hats: we
are public health workers; members of professional
organizations; employees of state agencies; nonprofits or universities; tax payers; citizens; parents
454
or activists. Which hat we wear may affect where
we choose to position ourselves within the overlapping circles of health promotion and social
justice. Those who work for public agencies may
not be able to speak out against those agencies'
policies, even when they damage health. Usually,
however, we can provide information, skills and
access to resources to others who have the luxury
of longer leashes. In addition, as voters, citizens,
parents, church goers or activists, health educators
may make important contributions to public
health—and social justice.
In recent years, many people have talked about
the importance of rebuilding civic society—that
public space in which people experience bonds with
each other. Community organizations, churches,
neighborhood associations, the informal networks
that people form to socialize or to work together
constitute civic society or the social capital of
personal connection (Chrislip and Larson, 1994;
Putnam, 1995, 1996). Civic society may be the
ideal place in which to create interventions that
combine health promotion and social justice. Its
function as the foundation of American democracy,
its potential for social intimacy and passion, and
its acceptance of collective action all make civic
society a fruitful place to experiment in new ways
to improve health and reduce inequity.
In the civic society of the low-income neighborhoods in which the Health Link jail transition
project operates, people are receptive to the
message that locking up drug users is not the
solution to crime and drug problems. They know
that their brothers, sisters, neighbors and friends
have drug problems, and they experience directly
the adverse consequences of policies that push
African-American young people out of universities
and into prisons. Health Link's goal is to support
and strengthen their commitment to alternative
policies and to hope, in time, alternatives can
become the mainstream political agenda. Civic
society becomes an incubator for new policies to
be nurtured.
Defining civic society as a key arena for health
promotion raises important questions about the
role of educator. To what extent is health education
Linking health promotion and social justice
a life calling, in which educators seek opportunities
to raise issues of health and justice with whomever
crosses their path and in whatever setting they
work? A different view is that health educators
are first and foremost professionals. As a profession, work is based on a scientific body of evidence;
practice is routinized, in part to ensure quality;
and credentials that distinguish us are established.
If we accept the belief that increasing social
justice is an appropriate outcome of our work, then
we must be willing to travel down the activist road
and to relinquish some of the privileges that go
with traditional views of professionalism. This is
not a call for reducing standards or quality in our
work, rather it is a plea to define a more inclusive
style of work.
To return to the Youth Link Project, in the Town
Hall policy document, youth made recommendations that require New Mexican health and social
service professionals to become comfortable as
social activists and advocates for youth. These
changes may facilitate moving youth to a position
of more influence. In the document, the youth
demanded a voice in policy arenas. They wanted
youth voting authority on school governing boards,
a lowered voting age to 16 for state and local
elections, and equitable distribution of resources
between rural and urban school systems. The
discussion was heated around affirmative action,
with debates on ethnic classification on SAT forms,
maintaining cultural identities and recognizing
school racism. Teen pregnancy recommendations
focused on a lack of equitable access to condoms
in rural areas and the need for reality-based education. To reduce violence, they recommended jobs
for youth, and dialogue to deal with prejudice,
hate, greed and gangs.
These strategies proposed by the youth extend
far beyond typical health promotion practice. They
address conditions of inequitable access, the relationship between stereotyping and poverty and
health, and the role of youth in making decisions.
Health educators encounter various obstacles in
trying to expand their practice to address social
justice issues. First, categorical funding often
forces health professionals to justify their work on
the basis of a single outcome. In many communities, separate agencies operate programs to
prevent teen pregnancy, HTV infection, infant mortality or substance abuse. Yet many of these programs use the same strategies, reach the same
target populations and address the same social
conditions. Categorical funding makes it harder to
get at deeper causes and to tap into people's
broader concerns. Fortunately, a growing number
of funders now support more comprehensive
programs.
Second, most health educators are employed by
mainstream organizations that have an investment
in maintaining the status quo. Whether it is making
elected officials look good or ensuring that the
local hospital does not lose money, many health
educators are forced to take actions that may be
in the best interests of their employer, but are not
in the best interests of the health of the public.
Conversely, health educators who take on social
justice aggressively may put their jobs in jeopardy.
Each person has to decide what professional
risks to take or avoid. However, health educators
often censor themselves before their employer
does. Professional training programs need to do
more to teach health educators how to be skillful
in finding the limits of professional freedom. Health
educators also need successful strategies to stiffen
the spines of bureaucracies fearful of challenging
a health damaging status quo.
Third, health education training and professional
culture emphasize consensus strategies, rather than
confrontation. The reality is that many threats to
health come from individuals and organizations
who knowingly benefit themselves at the expense
of others. Obvious examples of disease promoters
include the tobacco, alcohol and gun industries.
Some might even include our national leaders who
passed into law a welfare bill that will push an
estimated 1 million children into poverty, the single
greatest predictor of ill health for children. To
change the behavior of those who deliberately act
to harm health, consensus may not be as effective
as adversarial strategies, such as community organizing, voting people out of office or lawsuits.
Fourth, our ideology emphasizes the individual.
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N. Wallerstein and N. Freudenberg
Although within health education, we have
developed more sophisticated ecological models
that explain the links between individual and social
responsibility, much practice still targets individual
knowledge and behavior, rather than the environments that shape them. Why? Reasons include
a national discourse that emphasizes individual
responsibility, the reality that social change is hard
and social justice threatens the status quo, and
methodologies to evaluate such change are not
adequate.
Fifth, there may be personal risks in taking on
social justice issues, in fear of job loss or in
moving beyond one's own comfort and anxiety in
working with empowerment strategies.
Despite the risks and the difficulties, there are
benefits and personal satisfactions that come from
linking health promotion to social justice. In our
view, connecting the two is the most challenging
and satisfying part of health education. It provides
us with an opportunity to make a difference, to
influence the health of the public, our ultimate
concern.
Linking social justice to health promotion offers
a chance to tap into people's deepest aspirations.
Frankly, not too many people are excited for long
about campaigns for seatbelt use, condoms or 30
min of daily exercise, important as these goals are.
However, if health educators can connect these
mundane health issues and people's daily activities
with deeper desires for a safe community, an end
to gender discrimination or a fair chance for
children, they have offered people an incentive to
stick with a program for the long run. For the most
disenfranchised members of society, those who
experience the most serious health problems, this
connection to a broad vision of a better life can
be a powerful incentive to participate in health
programs.
Combining social justice and health provides
satisfaction in taking on the bad guys in society,
the disease promoters who pursue their own interest
at the expense of the public. Public health has a
noble tradition of protecting the disadvantaged
and righting the wrongs that spread ill health.
Connecting health and justice, helping people
456
create healthier, more democratic and just communities, makes it easier to keep doing this work,
to get through the inevitable frustrations and disappointments. For us, working and teaching in the
university environment has provided an opportunity to legitimize a perspective of social justice
and empowerment as part of public health and
health education.
An important strategy for tackling social justice
is to find allies, to build relationships with people
from diverse communities doing this work, to
speak across difference and learn from other perspectives, to share in the frustrations, and to
celebrate the successes. Health educators need to
look for opportunities to engage in the critical
reflection that can lead to empowerment, such as
when the youth in the mind-mapping process found
the connections between health symptoms and root
social causes, and had a wonderful moment of
recognition.
Linking health promotion and social justice has
the potential to mobilize powerful new constituencies for health. By themselves, health educators
have little chance of addressing the underlying
conditions that create current patterns of health
and disease. People in power have mixed incentives
for promoting health. If promoting disease makes
bigger profits or maintains positions of privilege,
they will often choose disease over health. Against
these forces, broad-based coalitions, such as the
recent successes of anti-tobacco coalitions, demonstrate that linking health promotion and social
justice can be a practical strategy for creating
healthy communities in the next century.
Notes
This report is based on a dialogue between the authors that
took place at a session of the SOPHE Annual meeting in
November, 19% in New York City.
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Received on March 14, 1996; accepted on June 23, 1997
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