Introduction

Previous chapters have exemplified the contribution that social work can make to understanding and tackling global health inequalities. They have also located that practice and its policy implications in a global context, including the processes of globalisation. In doing so they have begun to map out:

• • How socially constructed global health inequalities are a central issue for social work.

• • The key features of social work's contribution to tackling global health inequalities.

• • Implications for the further development of social work's role in tackling global health inequalities.

In conclusion, we distil the main lessons concerning these issues.

Global health inequalities: a central issue for social work

Much of the analysis of health inequalities is based on epidemiological evidence about the relationship between measures of socio-economic position and health outcomes in terms of mortality and morbidity (Graham, 2007). While many of our authors take a whole population approach to their work, most strikingly social work contributes added depth to understanding the mechanisms by which social inequalities become inequalities in health at the level of individuals or communities. As preceding chapters have shown, social workers’ direct encounters with people who have been on the receiving end of health-damaging cumulative ‘insults’ put them in a position to listen to and reflect on that experience. From these relationships five themes have emerged which provide compelling evidence of the centrality of socially constructed health inequalities as a global social work issue.

Specific populations facing adverse global social conditions

First, our authors highlight the profound impact of adverse social conditions, often rooted in globalisation, on the health of specific populations. Across all locations they highlight how, as a result of social disadvantage, certain groups lack the basic resources for good health, such as homeless women in the US (Moxley and Washington); or experience discrimination, for example, on grounds of their sexual orientation (Fish) or their ethnicity (Quinn and Knifton, and Ho); or disablist marginalisation, in the course of living with cancer (Lethborg and Posenelli) or other life-threatening illnesses (Quin and Clarke). Making links between individuals’ stories and global forces is not always easy. However, the impact of structural economic forces, privatisation and commodification, climate change and environmental destruction, and political conflict and violence are apparent.

Introduction

This book explores health inequalities as a central global issue for social work. Authors drawn from many countries analyse key questions and practice and policy initiatives, to develop understanding of social work's contribution to addressing this profound and pervasive social problem. In doing so, social work practice is treated as multifaceted. Direct interventions with individuals, families, groups, communities and populations are considered, together with policy formulation, service design, and development, research and education. Throughout, we also take a holistic view of health, emphasising the interconnectedness of psychological or emotional well-being and physical dimensions to health.

Socially constructed health inequalities profoundly influence the quality and length of life of everyone on the planet. They result in avoidable physical and emotional human suffering, damaged relationships, lost opportunities, pain and grief. Tackling health inequalities, defined as ‘disparities in health (and in its key social determinants) that are systematically associated with social advantage/disadvantage’ (Braveman and Gruskin, 2003, p 256), needs to become a central focus of social work action, worldwide and in all settings (IFSW, 2008).

There are three basic arguments which underpin this position. First, inequalities in health are unjust and a breach of the fundamental human right to health (see Chapter 2). ‘Social justice is a matter of life and death’, as the opening words of the final report of the World Health Organization's Commission on the Social Determinants of Health expresses it (CSDH, 2008, p 1, Preface). Social workers are therefore bound by the international statement of ethics to work to prevent and reduce avoidable inequalities in health (IFSW/IASSW, 2004).

Second, inequalities in health are socially determined (CSDH, 2008). ‘Inequalities in people's health are intimately and inextricably connected to inequalities in their material and social circumstances’ (Graham, 2007, p xi). Consequently social workers cannot choose whether or not to involve themselves with health inequalities, the social context of their practice means they are involved. It is unavoidable.

Because social workers deal on a daily basis with the social determinants of health inequalities, it is hard to think of a social work contact in which damaged health is not already a factor or in which the issues under discussion will not influence future health (McLeod and Bywaters, 2000).

Introduction

Unlike other disciplines represented in this book, a focus on addressing inequalities in physical health was not already established in social work discourse at the time of the Acheson Inquiry. However, in the intervening period, a major theoretical shift has occurred. Social work's contribution to tackling inequalities in physical health has gained recognition as a crucial component of theorising social work's engagement with inequality (Mullender, 1999; McLeod and Bywaters, 2000; Davies, 2002). The fundamental reasons why inequalities in physical health should be on social work's agenda are that:

• • inequalities in physical health are endemic among social work service users;

• • social work may compound social disadvantage implicated in unequal chances and experience of physical health;

• • evidence is accumulating that social work generally – not simply in healthcare settings – that targets health inequalities and addresses unequal social conditions can contribute to more equal chances and experience of physical health.

In presenting this account, we are not perpetuating a false division between mental and physical health – our position is that physical and psychological well-being are intertwined – but registering the emergence of a further critical dimension to social work analysis. For the sake of brevity, in the remainder of the discussion physical health will be referred to as health.

A pervasive problem

Social work service users are overwhelmingly drawn from people experiencing social disadvantage. Therefore it is not surprising that inequalities in health are endemic among them. The majority live in relative poverty (Jones, 2002), cross-cut by other dimensions to social disadvantage such as racism (Cambridge and Williams, 2004) and disability (Swain et al, 2003). Disproportionately high levels of ill health and inferior treatment in the course of ill health have, for example, been evidenced for care leavers (Broad, 2005), asylum seekers and refugees (Gray, 2003), and service users with learning disabilities or who are mental health service users (Kmietowicz, 2005). This should constitute a key issue for social work practice, as a situation of social injustice endured in individual pain and suffering (McLeod and Bywaters, 2002).

Social work's complicity

Despite the prevalence of inferior health and healthcare among service users, social work's engagement with socially constructed health inequalities remains marginalised in social work policy and practice.