Health and mortality inequalities in the US

How unequal are we when it comes to inequalities of health and mortality? Richard Florida (CreativeClass) points to an important new study on this question by public health researchers at Harvard and UCSF. (This is one of many items that Florida references in his Twitter feed -- it's certainly worth following. This bears out the academic value of Twitter!) The study is "Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States". And the answer the researchers provide to the question above is -- very. The study is worth reading in detail.

The authors analyze mortality statistics by county, and they break the data down by incorporating racial and demographic characteristics. The data groups fairly well around the eight Americas mentioned in the title:


Here is how they describe their findings:

The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.

And here is their conclusion:

Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

For example, their data show that "the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001." This is an enormous difference in longevity for the two groups; and it is a difference that tags fundamental social structures that influence health and risk across these two populations.

Here is a time-series graph of the behavior of longevity for the eight Americas:
So what are the factors that appear to create these extreme differences in mortality across socioeconomic and racial groups in America? They consider health care access and utilization; homicide; accidents; and HIV as primary potential causes of variations in mortality for a group. Most important of all of these factors for the large populations appear to be the health disparities that derive from access and utilization. And here they offer an important set of recommendations:

Opportunities and interventions to reduce health inequalities include (1) reducing socioeconomic inequalities, which are the distal causes of health inequalities, (2) increasing financial access to health care by decreasing the number of Americans without health plan coverage, (3) removing physical, behavioral, and cultural barriers to health care, (4) reducing disparities in the quality of care, (5) designing public health strategies and interventions to reduce health risks at the level of communities (e.g., changes in urban/neighborhood design to facilitate physical activity and reduce obesity), and (6) designing public health strategies to reduce health risks that target individuals or population subgroups that are not necessarily in the same community (e.g., tobacco taxation or pharmacological interventions for blood pressure and cholesterol).

These findings are squarely relevant to the healthcare debate currently underway in the United States. The country needs to recognize the severity of the "health/mortality justice" issue, and we need to reform our healthcare system so that these disparities begin to lessen.

Fair prices?

We live in a society that embraces the market in a pretty broad way. We accept that virtually all goods and services are priced through the market at prices set competitively. We accept that sellers are looking to maximize profits through the prices, quantities, and quality of the goods and services that they sell us. We accept, though a bit less fully, the idea that wages are determined by the market -- a person's income is determined by what competing employers are willing to pay. And we have some level of trust that competition protects us against price-gouging, adulteration, exploitation, and other predatory practices. A prior posting questioned this logic when it comes to healthcare. Here I'd like to see whether there are other areas of dissent within American society over prices.

Because of course it wasn't always so. E. P. Thompson's work on early modern Britain reminds us that there was a "moral economy of the crowd" that profoundly challenged the legitimacy of the market; that these popular moral ideas specifically and deeply challenged the idea of market-defined prices for life's necessities; and that the crowd demanded "fair prices" for food and housing (Customs in Common: Studies in Traditional Popular Culture). The moral economy of the crowd focused on the poor -- it assumed a minimum standard of living and demanded that the millers, merchants, and officials respect this standard by charging prices the poor could afford. And the rioting that took place in Poland in 1988 over meat prices is a reminder that this kind of moral reasoning isn't merely part of a pre-modern sensibility.

So where do contemporary Americans show a degree of moral discomfort with prices and the market? Where does the moral appeal of the principles of market justice begin to break down -- principles such as "things are worth exactly what people are willing to pay for them" and "to each what his/her market-determined purchasing power permit him to buy"?

There are a couple of obvious exceptions in contemporary acceptance of the market. One is the public outrage about executive compensation in banking and other corporations that we've seen in the past year. People seem to be morally offended at the idea that CEOs are taking tens or hundreds of millions of dollars in compensation -- even in companies approaching bankruptcy. Part of the outrage stems from the perception that the CEO can't have brought a commensurate gain to the company or its stockholders, witness the failing condition of many of these banks and companies. Part is a suspicion that there must be some kind of corrupt collusion going on in the background between corporate boards and CEOs. But the bottom line moral intuition seems to be something like this: nothing could justify a salary of $100 million, and executive compensation in that range is inherently unfair. And no argument proceeding simply along the lines of fair market competition -- these are competitive rational firms that are offering these salaries, and therefore whatever they arrive at is fair -- cuts much ice with the public.

Here is another example of public divergence from acceptance of pure market outcomes: recent public outcries about college tuition. There is the common complaint that tuition is too high and students can't afford to attend. (This overlooks the important fact that public and private tuitions are almost an order of magnitude apart -- $6,000-12,000 versus $35,00-42,000!) But notice that this is a "fair price" argument that would be nonsensical when applied to the price of an iPod or a Lexus. People don't generally feel aggrieved because a luxury car or a consumer device is too expensive; they just don't buy it. It makes sense to express this complaint in application to college tuition because many of us think of college as a necessity of life that cannot fairly be allocated on the basis of ability to pay. (This explains why colleges offer need-based financial aid.) And this is a moral-economy argument.

And what about that other necessity of life -- gasoline? Public complaints about $4/gallon gas were certainly loud a few months ago. But they seem to have been grounded something differently -- the suspicion that the oil companies were manipulating prices and taking predatory profits -- rather than an assumption of a fair price determined by the needs of the poor.

Finally, what about salaries and wages? How do we feel about the inequalities of compensation that exist within the American economy and our own places of work? Americans seem to accept a fairly wide range of salaries and wages when they believe that the differences correspond ultimately to the need for firms to recruit the most effective personnel possible -- a market justification for high salaries. But they seem to begin to feel morally aggrieved when the inequalities that emerge seem to exceed any possible correspondence to contribution, impact, or productivity. So -- we as Americans seem to have a guarded level of acceptance of the emergence of market-driven inequalities when it comes to compensation.

One wonders whether deeper resentment about the workings of market forces will begin to surface in our society, as unemployment and economic recession settle upon us.

Paying for health

A person's income determines his/her access to many things he wants and needs: food, clothing, transportation, housing, entertainment, and the internet, for example. And people who have higher income are able to consume more of all of these categories than people with lower income, if they choose to. More affluent people shop for food at Papa Joe's or Whole Food; live in larger and more luxurious homes; buy their clothing from boutiques rather than Penny's or the thrift shop; and drive multiple handsome cars. Poor people can't afford the luxury end of these forms of consumption. And in some way our culture has judged that these sorts of inequalities of consumption are a legitimate and fair part of a market economy; if you judge that inequalities of income are justifiable (perhaps with some limits on extremes), then you pretty much have to support the idea of inequalities of consumption as well.

But what about goods that have a price but that are essential to living a decent human life? Food certainly falls in this category; if 30% of society could literally not afford to purchase enough calories to provide 2200-2900 calories per day for adults and 1800 calories for children, then we would probably have a different idea about the fairness of a market for food -- the principle that says "to each according to his/her earning capacity" doesn't seem very convincing in circumstances where it leads to malnutrition or starvation. In other words, if the normal workings of a market economy left a significant segment of the population without the ability to purchase enough food for subsistence, we would surely judge that this isn't a fair or socially just way of distributing income and food. And there is an important point to be noted here: there is hunger in America, and the system of producing goods and income isn't fully satisfying the subsistence needs of the whole population. (This is exactly what makes it compelling that our government needs to provide food assistance for the very poor, through food stamps or targeted income supplements.) So there is an important issue about the justice of current actual distributions of such basic goods as food, clothing, or shelter across the U.S. population.

But push a little deeper and consider the "market for health care". Supporting one's current healthy status is a costly effort; repairing the body in times of traumatic injury or serious illness is even more costly; and our society leaves a lot of the allocation of health care services to private purchasing power. Health insurance is the primary vehicle through which many Americans provide financially for their health care needs. Some people have insurance provided or subsidized through their employers; some families purchase health insurance through the private market; and many families lack health insurance entirely. Upwards on 45 million Americans are uninsured, including 20% of adults and 9% of children (CDC link). And this includes a wide range of Americans, from the extremely poor to the working poor to the solidly middle class.

It is clear that access to doctors, hospitals, nurses, and prescription drugs is a critical need that everyone faces at various points in life. It is obvious as well that one's future ability to live and work productively and to enjoy a satisfying life is conditioned by one's ability to gain access to health care when it is needed. It is also clear that uncertainty about the availability of health care is a major source of anxiety for many, many people in U.S. society today. So it is self-evident that decent health care is one of our most basic and unavoidable needs.

So what do people do when they lack health insurance and serious illness or injury occurs? This isn't a mystery anymore; families go into debt to doctors and hospitals, they face bankruptcy, they find some limited sources of free care (free clinics, pro bono doctors' services), and they forego "optional" treatments that may well extend the length or quality of life. And it is evident that this pattern results in very serious harms and limitations for people in these groups. People who have the least access to health care through our basic institutions may be expected to live shorter lives and to suffer more.

And what about people at the high end of the income spectrum? How do they relate to the problems of health? Here too the answers are fairly well known: they are able to seek out the best (and most expensive) specialists, travel to national centers for specialized treatment, and undergo advanced diagnostic tests that are not covered by insurance. (Here is a news story from CNN on boutique health care.) The affluent aren't able to assure their health through expenditure -- but they can certainly improve their odds.

In other words, ability to pay influences the quality and extent of health care that an individual or family is able to gain access to; and the health status of the family is affected by these variations in quality and access. So, to some meaningful extent, our social system places health care in the category of a market good.

But here is the question I'm working around to: what does justice require when it comes to health care? Is it right to look at health care as just another consumption good like shoes -- affluent people wear Gucci and poor people wear Dollar Store, but everyone has his/her feet covered? Or is health care in a special category, too closely linked to living a full human life to allow it to be distributed so unequally?

It seems a bitter but unavoidable truth that there are very substantial inequalities in the provision of health care in our society. One person's likelihood of surviving a devastating cancer may be significantly less than another person's chances, simply based on the second person's ability to pay for premium health care services. Further, it seems unavoidable that these inequalities are flatly unjust in any society that believes in the equal worth of all human beings. And where this seems to lead is to the conclusion that some system of universal health insurance is a fundamental requirement of justice.

The struggle for racial justice

The struggle for racial justice in America was in its sharpest form in the 1960s, from the Freedom Marches in the South in the early sixties to the militant and determined struggles in the North in the later sixties. Organizers, militants, activists, leaders, and volunteers gave their best energies, brains, and courage to this extended effort to change American society. And when you think about it, this decentralized movement was remarkably successful in terms of its reach, the ability of various civil rights and activist organizations to motivate followers, and some of the concrete structural changes that were achieved. (It goes without saying that we have a very long way to go in pursuit of racial justice today, in 2008.)

One way of getting a better understanding of the Civil Rights movement is to read some of the very good historical and sociological scholarship that has been done on the period -- for example, Taylor Branch's Parting the Waters : America in the King Years 1954-63 or Doug McAdam's Freedom Summer. But another way is to talk with people who lived through the struggle -- people who went "went South", people who worked as organizers and activists in Chicago or Detroit, people who got involved in some of the militant organizations such as the Black Panthers. And often what you gain from conversations like this is somewhat different from what comes across in the organized historical scholarship. It's more intense, for one thing -- just as it must have been in the 1960s to talk with veterans of the Abraham Lincoln Brigade about their experiences in the Spanish Civil War. But it also gives you the participant's perspective on things rather than the historian's view. And it focuses often on the process of mobilization and consciousness-raising, rather than the eventual outcome.

I've done two recent interviews with scholars whose own experiences of the Civil Rights movement are genuinely absorbing. One is Ahmad Rahman, a history professor at the University of Michigan-Dearborn and the author of The Regime Change of Kwame Nkrumah: Epic Heroism in Africa and the Diaspora. Rahman is an accomplished historian and a rising authority in African and African-American history. He was also an activist and member of the Black Panther Party in Detroit in the 1960s. The second interview is with Dr. Gloria House, a professor of humanities and African and African-American Studies at the University of Michigan-Dearborn. House is a well-respected poet and author, and has played an important role in the continuing prominence of Broadside Press. She edited a great volume celebrating the press; A Different Image: The Legacy of Broadside Press: An Anthology. Her own experience of the Civil Rights movement began at UC-Berkeley, followed by time in Alabama and Detroit. Her experiences with SNCC and the struggles in the South are very intense, and she finds the voice to express what she experienced powerfully. She has spent decades as a scholar-activist in Detroit.

Both interviews are absorbing and eye-opening. One point that comes out of both Rahman's and House's recollections is the importance of the struggles for African national liberation in the development of consciousness within the African-American movements -- and the "echo" of American developments in African liberation thinking. There is a very clear demonstration of the political-intellectual work that went into framing an understanding of American society and liberation that was suited to the African-American experience. But there are dozens of other important insights -- the ways in which the struggle for Black Consciousness developed, the importance of youth engagement in the struggle, and the power of poetry during those decades. Rahman brings some of the issues forward to the present day, by comparing the struggles of French immigrant people against police brutality with the struggles of the African-American community in the earlier decades. And House shares some of her thinking about where the quest for racial justice may be going today -- emphasizing community-based activism. She also shares several of her poems about the early days of the struggle at the end of the interview.

It is a constant struggle for all of us to go beyond clichés and cartoons in our understanding of our society and our history. And a very powerful way of doing that is to listen to the voices of people whose experiences are so directly connected to the major fault lines and turning points in our history.

The video interviews with Rahman and House are posted on YouTube, and audio versions are posted as well; Rahman, House part 1, House part 2. The audio interviews are also included in the UnderstandingSociety podcast, available through iTunes.

Visit also this relevant posting on Jim Johnson's blog, with information about the recent publication of Breach of Peace: Portraits of the 1961 Mississippi Freedom Riders.

Dr. Martin Luther King, Jr.

Today is a sad day of remembrance in America and the world. Forty years ago today Dr. Martin Luther King, Jr. was murdered in Memphis. And, followed by the murder of Robert Kennedy only a few months later, America's heart and history were jolted.

Dr. King's life devotion to the cause of racial justice in America is one of the most important legacies we have in this country. His moral clarity and his personal courage provided our generations with signposts we still haven't fully absorbed. And the work to which he devoted his life is unfinished. It is crucial for our future as a country that we make intelligent and compassionate progress based on this legacy.

It is so remarkably striking to me to see the different life experiences that white and black Americans have lived, especially the generation who are in their fifties and sixties today. These men and women were in their teens and twenties in 1968. They have clear, personal memories of that day in April forty years ago, and of the months that followed. For most African-American people in this group there are very specific, vivid, and personal memories of segregation and racism in their years of childhood and adolescence. Whether their experiences were of growing up in Arkansas or Chicago in the 1950s, most African-American people of this age cohort have deep and personal experiences of racism. And their memories of the murder of Dr. King have an urgency and personal sorrow that feels very different from the experience of white Americans of the same age.

My discipline is philosophy and I have taught social and political philosophy intermittently throughout my teaching career. At this stage of my career it is very striking to recall how mute this field of philosophy has been to the experience and structure of American racism. The ideas of equality, liberty, and justice are defining values in the field of social philosophy. And yet the topic of racial justice has not been a central focus; only rarely has it been even talked about as we consider the theories of Kant, Rousseau, Mill, or Rawls. And yet my whole education and career are framed by the murder of Martin and the candidacy of Barak. How could race not have been the central problem of social philosophy in America during these decades? It is a failure of collective social cognition, an instance of willful social blindness.

I think there is a connection between these two points. A part of teaching about principles of social justice should be a serious learning of the lived experience of injustice.

The majority in America is inching its way towards a commitment to racial justice. We can make further progress along this road if we will only listen in humility and silence to the experiences of racism that shaped the lives of so many millions of our fellow citizens.

Martin Luther King's journey

Today we celebrate the legacy of Dr. Martin Luther King, Jr. It is easy enough to be discouraged about the current state of racial inequality in this country. We have not made nearly the progress on economic inequalities and inequalities of opportunity that seemed possible in 1966. But Dr. King was an optimistic man and a man who always looked for ways of moving forward. So I want to honor him today by reflecting on some of the difficult but real efforts that are underway today to prepare our society for a more racially just future. And examples can be found in my own city of Detroit.

I think first of a youth opportunity program that is having significant impact in Detroit. The program is called YouthVille. Located in a repurposed warehouse, YouthVille is filled with young people finding some of the resources and support they need to take charge of their lives -- succeed in school, develop the confidence that they can achieve their dreams, and successfully negotiate the challenges of being a kid in a tough city. Young people from over 270 schools in the Detroit area have participated in programs at YouthVille, and the numbers are growing.

Next I think of an African-centered after-school program for middle and high school students, the Alkebu-lan Village. Founded by committed community activists and sustained by the daily efforts of these same dedicated men and women, the Village gives inner city kids a supportive and safe environment where they can develop their own dreams about the futures they want to achieve. The mission statement of the organization describes it as "an African-centered community-based organization committed to developing and nurturing an environment where families work together to build healthy minds, bodies and communities." It is inspiring to spend time at Alkebu-lan Village and to witness the caring concern and commitment that these Detroiters give to their mission. The village provides tutoring and homework help, and it measurably improves the kids' experience in school. It offers sports, dance, and music activities for the kids who attend, and it organizes summer camp experiences for inner-city kids. Throughout it gives all its kids a better chance at success. This is a community-based organization that has successfully harnessed the energies of a community of people in service to the futures of Detroit's youth.

Finally, I think of CityYear Detroit and the wonderful team members and staff who are devoted to providing meaningful service to their community. CityYear exists in over a dozen cities throughout the country and, recently, South Africa. Its team members can be spotted in their red jackets, providing tutoring, establishing urban gardens, and helping to improve the lives of children and adults in the cities they serve. I have met quite a few team members and leaders in Detroit and elsewhere over the years, and their commitment and energy are inspiring. These young people, often inner city kids, are learning about team work, leadership, and service in ways that will affect them throughout their lives. And because CityYear is successful in recruiting a highly diverse group, each kid learns very deeply and personally about other people's experiences in life. This is the kind of learning that universities haven't yet succeeded in creating. But a year of service in CityYear (and other AmeriCorps programs) is transforming for almost every young person who does it. And the CityYear alums have a vison for their futures that we all can learn from.

So there are some compelling examples of people and organizations that are addressing the issues of poverty, race, and inequalities of opportunity that have proven so intractable. One thing that ties all three examples together is the ethic of community service that they reflect, and the determination by so many leaders and activists to live this comitment out. And there is inspiration here at every level -- in the men and women who have dedicated their energies to create these organizations, and the young people who have gained such good values and skills within them. Let's all find ways of joining in this important work. And in doing so, let's notice that we're helping with the work that Martin began.

Inequality based on prior inequality

Many people think that grossly unequal outcomes across a society with respect to the amount and quality of social goods each enjoys are profoundly unjust. (By social goods I am thinking of things like income, wealth, power, healthcare, and education.) Why should some members of society have such a lower level of access to the things that constitute contemporary life? And if, as people like Amartya Sen maintain, some of these goods are necessary components of full human development, how can it be just that some people are less able to develop their capacities as full human beings (Development as Freedom)? So gross inequalities in the current distribution of social goods are bad enough.

But what if it is also true that a low bundle of social goods in one time period is the largest factor in determining a low bundle in the next time period as well? And what if that is true across generations as well as across stages of individuals' lives? What if current poverty of a family is itself a primary cause of the next generation's poverty? Is this not a particularly unacceptable form of inequality?

And yet this cross-generational transmission of poverty and reduced life chances is precisely what we observe. Children born into poverty have less access to crucial resources necessary to their personal and social development. They are exposed to opportunities that are very different from children in other levels of wealth. And, not surprisingly, their probability of winding up as adults in any more affluent segment of the population is markedly lower than that of other children.

So the phrase "the recurring cycle of poverty" is exactly descriptive of the social realities of our society.

What a progressive society promises is that every person will have a reasonable chance of success in life. That means that every person -- and every child -- should have access to the resources that are necessary for full personal and social development, in order to develop the talents and capabilities that will permit him or her to be creative, productive, inventive, and successful. A democracy based on the equality of all men and women promises exactly this -- the idea of unfettered social mobility and real equality of opportunity.

But it is quite evident that American society today falls short of this goal, in large ways and small. The likelihood of graduating from high school if you live in an inner city neighborhood in Chicago, Detroit, or New York is only a fraction of the comparable likelihood in the suburbs; likewise for college attendance and for eventual college graduation. And the likelihood of a high school senior from the lower-quintile of family income is only one-seventh that of a high school senior with the same SAT and high school qualifications from the top quintile of family income -- the same qualifications! (This example is taken from William Bowen, Eugene Tobin, and Martin Kurzweil, Equity And Excellence in American Higher Education.) So it seems fairly evident that opportunities are very differentially offered to young people, irrespective of "merit" or qualifications.

So where does this take us? It seems to convey a pretty deep issue about justice in our society: that we have done a very poor job of ensuring that persons from all levels of income and wealth have a decent chance at fulfilling their human talents and achieving their aspirations. And that is a pretty serious thing! And it also puts the spotlight on public education as a crucial component of a just society. If we were to succeed in providing effective K-12 schools to all children, and made it possible for every young person to pursue a university education at a good public university -- think of the step forward that this would represent in the basic justice of our society.

Labor abuses in China

Today's New York Times has an important article about the conditions of workers in many of the factories in China devoted to manufacturing goods for export to the United States and other countries (In Chinese Factories, 1/5/08). The reportage is eye-opening but not surprising. Times reporters have documented excessive hours of work, pay that is lower than what Chinese law requires, working conditions that are chronically unsafe, and persistent exposure to the very dangerous chemicals that American toy consumers have been so concerned about. One of the authorities quoted in the article is Professor Anita Chan from the Australian National University, and Professor Chan has been documenting these conditions for years. Her book, China's Workers Under Assault: The Exploitation of Labor in a Globalizing Economy (Asia and the Pacific), is a detailed and factual examination of some of these conditions. She documents the fact that the most vulnerable groups of workers -- in the range of tens of millions! -- are the internal migrants of China, who have left their home regions in search of jobs. Very significantly, Professor Chan bases some of her fact-finding on the slowly emerging field of local investigative journalism in China.

Why do these abuses occur? For several related reasons. First, the motive of generating profits in the context of a rapidly growing economy. Since China's industrial economy was reformed in the 1990s, permiting private ownership of factories and enterprises, there have been strong incentives to be successful in business and to become rich. There is tremendous demand for low-cost Chinese-manufactured goods, and great fortunes are being made in consumer electronics, toys, clothing, and dozens of other sectors. But the profit motive leads factory owners and managers to strive hard to keep wages and factory expenses as low as possible; and the vast population of poor rural people in China who are available for unskilled factory work makes the bargaining position of the factory owner very strong. (Chan documents some of the forms of coercion and intimidation that are used in some Chinese factories to keep workers on the job and to prevent them from leaving or resisting.) And, as the Times story points out, the American purchasers are insistent about cost-cutting and price-cutting on the finished goods. So the result is -- a chronic competitive "race to the bottom" in which each factory tries to produce at the require level of quality with the absolutely lowest level of cost; and this means continuous pressure on working conditions, health and safety conditions, and environmental effects.

So part of the story has to do with the economic incentives and advantages that factory owners have relative to a large working population that has few alternatives. But this part of the story is familiar from other economies as they have developed through intensive industrialization. It has been learned elsewhere in the world that the imperatives of profitability by themselves almost mandate the abuse of labor; so government regulation and inspection are a necessary part of a manufacturing system if it is to succeed in treating all the population fairly and humanely. We might have imagined that the Chinese government would have been prepared to provide the regulatory environment that was necessary to protect the best interests of farmers and workers; it is, after all, governed by the party of farmers and workers. However, this is not the case. China has been so concerned to support economic growth that it has been very slow to implement effective regulatory systems to protect labor and the environment. Moreover, the balance of power between factory owners and local officials seems to be tilted towards the owners; other Times reporting has documented the fact that local officials cannot impose their will upon the owners. And, of course, there is ample opportunity for corrupt collusion between owners and officials.

This failure to regulate has been evident in other areas besides labor; the Chinese government has shown itself to be unwilling or unable to enact effective environmental regulations or to establish an effective regime of inspection and regulation for foods, drugs, and other potentially harmful products. It appears that middle-class Chinese consumers themselves are now expressing anxiety about the absence of this kind of regulation within their food and drug system.

So what other avenues exist for improving the conditions of workers in China?

There are three possibilities -- all mutually compatible. First, workers themselves can protect their interests in fair wages, safe working conditions, and limited hours of work -- if they are permitted to organize in unions. Woody Guthrie had it right: as individuals, workers are weak, but together they are strong. It seems inescapable that a major part of the problem is the enormous imbalance that exists between the powers associated with ownership and management, and those assigned to workers and their organizations. So a more just China will need to permit the development of real independent labor unions that work hard for the interests of their members.

Second, labor mobility can improve the conditions of labor everywhere. It is not an accident that some of the worst abuses documented by Professor Chan have to do with the forms of coercion that factory owners use to keep workers in their factories. If workers can vote with their feet, then we would expect that they will migrate to factories and other employers who offer better conditions of work and pay. And this will force employers to bid for qualified labor on the basis of improved working conditions.

And finally, there is obviously a role for consumers and companies in North America and Europe in all of this. North American consumers benefit from the low manufacturing costs currently available in China; but these low costs are unavoidably associated with the labor abuses we see today. We have a model for how international companies can take responsibility for the conditions of labor and environmental behavior, in the form of the Fair Labor struggles of the 1990s on university campuses in the United States. Large apparel manufacturers took on the responsibility of subjecting their suppliers to standards of conduct, and they subscribed to third-party organizations that undertook to "audit" the level of compliance with these standards by the supply chain. (Visit the Fair Labor website for an example of such an organization.) As the Times story observes, this is a tricky business, given the substantial degree of sub-contracting that occurs in the manufacturing process in China. But it can have a measurable effect.

China is plainly destined to be a major economic and political power in the coming fifty years. But to succeed in creating a society in which everyone has a continuing stake in a good quality of life and a fair deal from society, it will have to solve the problems of regulation of labor, health, and environment. And this will mean a degree of redistribution of China's wealth and power towards its poorest people.

Is there a right to healthcare?

It is worth unpacking, first, why healthcare is so crucial to everyone's life. Everyone faces illness and accident in life. Maintaining and restoring health and function are crucial to our quality of life and our ability to live fully, freely, and independently. So access to healthcare is one of those core needs that are so closely connected to a good human life that they can be regarded as an essential human good (for example, nutrition, education, and freedom). A life deprived of access to decent healthcare is likely to be one of unnecessary pain, anxiety, and limitation.

The medical resources that are available today for addressing the challenges of illness and disability are incredibly powerful, compared to the first half of the twentieth century. But they are also very expensive -- socially and privately. Insurance is a way of spreading out these costs over a population of people with varying levels of risk; each contributes part of the cost of this risk-sharing system, and each is assured of help when the occasion arises. And people lacking health insurance are faced with cruel choices: do without the effective therapies that exist for their illnesses; or do without other crucial things like food, gas for their cars, or paying their rent.

This gives us reason to judge that healthcare is not simply another consumable resource which people have more or less of; it is a good that a decent society needs to ensure that no one is deprived of. Like hunger or illiteracy, it is a social bad that a decent society must be urgently concerned about.

Could a just society take the position that healthcare is simply another private good that people need to purchase with their own resources? That depends essentially upon the circumstances of social inequality. If in fact everyone in society has sufficient income to purchase healthcare or private insurance, then the "private good" approach may be sustainable. In a society in which there is substantial inequality and poverty, however, this position is untenable. Low- and middle-income people do not have the resources to purchase healthcare as a private good. And if social arrangements required this, then unavoidably there would be a disadvantaged population which was more disabled, more ill, and less long-lived than the more affluent population. This is plainly not a just or defensible outcome -- anymore than starvation or malnutrition in the midst of plenty is a just outcome.

The general answer our society has provided rests on two legs: employer-provided health insurance and state-funded insurance programs for the elderly, the disabled, and extremely poor children. What this system leaves out is a very large population of ineligible uninsured adults. And there are tens of millions of people in this situation. What does our society do to handle this situation? Very little. Basically we require hospitals to provide free care to extremely ill uninsured poor people, and we provide no avenue to affordable insurance for this group beyond the emergency room.

So, back to our question here : do people have right to healthcare? My answer is that it is a requirement of basic justice that all members of society should have access to healthcare, because this is essential to living a normal human life; that our society essentially recognizes this fact about justice (witness the emergency room contingency); but that this society does a simply terrible job of satisfying this requirement of justice. The tens of millions of people who are uninsured because they cannot afford to privately purchase health insurance are sufficient evidence for that.

So what is the solution? It seems inescapable that there needs to be a system of publicly provided and means-adjusted universal health coverage. This doesn't mean a national health system. It doesn't even necessarily mean a single unified national health insurance program, or abolition of private insurance. But it does mean that we must succeed in designing and implementing an affordable option for those not served by the current patchwork quilt of coverage systems. (Several states such as Massachusetts and Maine have made bold attempts to do this.) To date, however, we have not faced up to this simple requirement of justice. Let us look at the moral issue honestly and let us design a just and sustainable system.

(Philosopher Norm Daniels has thought about these issues deeply for many years. His recent book, Just Health: Meeting Health Needs Fairly, is a great contribution.)

Gradient of justice

Given that there is significant injustice in our society, and granted that we are a long ways from a society that establishes what Rawls called the circumstances of justice -- can we at least have the confidence that we are moving in the right direction?

Some people would argue that our society is doing just that. They sometimes point to the fact of rising nutritional and health status in the poorest 40 percent of our population during a 50-year period, and they might say that the situation of institutionalized racism -- and with it the circumstances of middle-class African-Americans -- has also improved measurably in 50 years.

Unfortunately, these impressions are misleading. In fact, it is more likely the case that inequalities of income, wealth, and well-being have worsened in the past twenty years. Lower-middle income and poor people have the smallest share of the nation's affluence that they have ever had. And many of the programs designed to provide a social safety net have been gutted or have disappeared altogether.

And on the racial justice side -- if general social racism has diminished, the depth of racial inequality and lack of opportunity in large cities has almost certainly increased in thirty years. The lack of opportunity and hope that exists in Cleveland, Detroit, Chicago, or Oakland is truly staggering -- and it is worsening. This wall of deprivation is drawn largely along racial lines. And all too often this impacted lack of opportunity leads to crime and violence.

So we don't seem to be on a trajectory of general improvement when it comes to social justice. The myth of the "trickle-down society has turned out to be more trick than truth. The benefits of economic growth have not lifted the lower middle class. This growth has not dissolved the knot of urban poverty. The public is turning its back on public schools -- surely one of the surest mechanisms of greater social justice over time. And we don't seem to have a public commitment to the basic value of allowing all members of society to fully develop their talents. Even more disturbingly, we seem to be entering a period of time that will involve even greater economic anxiety. And anxious times seem to bring out the worst in people when it comes to competition for scarce resources and opportunities.

What we seem to need is a greater sense of community, a greater recognition of our inter-connectedness and inter-dependence, and a greater common commitment to making sure that our society and its policies work to improve the lot of all its citizens. But most regrettably -- this sense of the strands of community is exactly what is most imperiled by the facts of current inequalities. It is difficult to maintain the strands of civic commitment to each other when fundamental inequalities separate us further and further.

So perhaps we ought to consider the unhappy possibility that our society may be inching towards the deepening chasm of inequality that characterizes South Africa, Mexico, or Brazil today. And if this is true, then the future is ominous.

A good society ...

What sort of society should we aim to achieve in the twenty-first century?

Here is one clear vision. It is a society based on equality and dignity for all citizens. It embodies the idea of social responsibility — the conviction that society has some meaningful obligations to all its members. It embodies institutions that somehow effectively assure a reasonably high minimum quality of life for all. It provides real equality of opportunity for its citizens. It avoids discrimination among citizens based on gender, race, ethnicity, and other irrelevant factors. It is a democratic society: individuals have genuine opportunities to discuss and influence the decisions that affect them — both public institutions and private. And it is a society that commits itself to environmental sustainability and progress towards global justice.

This vision entails numerous rights — rights of expression, association, and participation. And it implies the guarantee of quite a number of social goods by society to all citizens — education and training, access to healthcare, policies that assure housing and food under all circumstances, …

The existing state-society configuration that best matches this set of values is Scandinavian social democracy — of the 1970s. (See Esping-Anderson, The Three Worlds of Welfare Capitalism, for a good discussion of Scandinavian social democracy.)

"Too much" inequality? Yes!

How much inequality is too much? The range of income and wealth inequalities in the US has increased sharply in the past 20 years. The share of income flowing to the top 10% and 1% has increased significantly. And the level of income for the bottom 40% has slightly declined during these years. But to say whether that's a bad thing, we need first to think clearly about what inequality means for our society -- for the quality of life for people at the bottom end, for the strands of community that knit a society together, and for the idea that every member of society is equally worthy of respect and consideration. And we need to think about the mechanisms through which these inequalities are created in our economy -- and through which these inequalities have increased so sharply.

First, the effects. It appears also to be a fact that the symptoms of poverty are more extensive today than they were twenty years ago. The demands on food banks have increased; homelessness appears to be more extensive in many major cities; and of course the problem of lack of access to health insurance and affordable health care appears to be even more pressing. So it would appear that the increase in income inequality in the past 20 years has had a depressing effect on the lives of the least-well-off in our society. At least the economic processes that have improved the incomes to the rich and the super-rich have not also improved the incomes of the middle-income groups and the poor. So the philosophers' argument -- inequalities are not inherently bad if the bottom end is pretty well off -- doesn't apply to today's circumstances.

Second, there is some evidence that the social distance between the very-well-off and the not-well-off has increased, with fewer points of contact between social groups. This is sometimes described as the "disappearance of the middle class." The substantial transformation of the American economy that has occurred in manufacturing and the auto industry is emblematic: the jobs that created the possibility of a blue-collar, middle class life in Michigan, Ohio, and Illinois are disappearing, and the next generation of manufacturing jobs are creating incomes that are perhaps only 60% of the levels of the previous generation. So rising inequality is manifest, in part, in the loss of well-paying jobs in the middle -- producing a greater degree of social separation.

This brings us to respect and equality. It isn't too much of a stretch to infer that in a society increasingly separating into "affluent" and "poor", the idea of basic democratic equality -- that everyone is in the same boat; that everyone has an equally worthy life; that we all depend on each other; and that everyone is equally worthy of respect -- has less and less social reality. These widely separated groups have less and less lived experience that reinforces these ideas of connection and equality among all citizens.

So there are ample reasons for judging that the rising material inequality in America is a very bad thing. It is bad because of the consequences it has for people on the lower end of the spectrum; it is bad for the corrosive effects it has on basic democratic values of fundamental human equality; and ultimately it has to be bad for the civic values that undergird a peaceful and harmonious society. How much inequality can a community absorb before it begins to pull apart into mutually antagonistic groups? How many more gated communities will this society need if we continue to fail to achieve the kind of material fairness that allows every citizen to look the other in the eye and say, I respect you and I know that all our benefits depend upon our mutual contributions to society?

If our economy continues to separate our society into rich and poor -- if our largest cities continue to intensify the inequalities of access, opportunity, and quality of life between the urban poor and the suburban affluent -- then surely we have some seismic social conflicts brewing.