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By analysing debates between member states of the World Health Organisation (WHO) over health inequities experienced by sexual and gender minorities (SGMs) from 2013 through to 2015 and 2016, this paper interrogates a WHO decision to 'do nothing', and the relationship between this decision and the production of ignorance and non-knowledge. This paper problematises state representatives' discursive practices regarding the lack of evidence on SGM health inequalities, drawing on the sociology of ignorance. Informed by the sociology of nothing, two analytical categories – non-recognition (omissive) and mis-recognition (commissive) of SGM communities – are proposed to critically understand the production of 'no-bodies' and the tolerance of the lack of evidence. The lack of evidence, rather than prompting WHO action, was used as a rationale for intentionally neglecting the health concerns of particular social groups due to their invisibility in health research. Therefore, the paper argues that the lack of evidence in itself is symptomatic of the existence of SGM health inequities, which require the WHO to take action such as formally expressing concerns about and endorsing research on the topic. [ABSTRACT FROM AUTHOR]

Ethnic diversity and racism have not featured strongly in English research, policy or practice centred on understanding and addressing health inequalities. However, the COVID-19 pandemic and the Black Lives Matter movement have shone fresh light on deep-rooted ethnic inequalities and mobilised large segments of the population into anti-racist demonstration. These recent developments suggest that, despite strong counterforces within national government and the mainstream media, there could be a shift towards greater public awareness of racism and potentially a willingness to take individual and collective action. This paper addresses these developments, and specifically engages with the contested notion of 'allyship'. We bring together the experiences of 25 young adults living across England and prior literature to raise questions about whether and how racialized White individuals can play a role in dismantling systemic racism and reducing ethnic inequalities in health. Our analysis reveals a variety of complexities and obstacles to effective and widespread allyship. Findings suggest the need to nurture contingent, responsive and reflexive forms of allyship that can attend to the harms inflicted upon racially minoritized people as well as push for systemic transformation. White allyship will need to take a variety of forms, but it must be underpinned by an understanding of racism as institutional and systemic and a commitment to tackling interlocking systems of oppression through solidarity. The issues addressed are relevant to those occupying public health research, policy and practice roles, as well as members of the public, in England and other multi-racial settings. [ABSTRACT FROM AUTHOR]

It has long been recognised that human health is indelibly shaped by a variety of factors. These include pathogens such as bacteria and viruses, but also broad-ranging social, economic and political forces operating at different spatial scales. In seeking to understand the nature and effects of these forces, two concepts have become particularly influential: the 'social determinants of health' and 'structural violence'. In this paper, we critically examine their origins, tracing their 'prehistory' and little-recognised intersections, based on searches of both concepts in PubMed and Google Scholar, and a critical reading of the range of texts our searches produced. This forms the groundwork from which we examine their similarities and differences, and their potentialities and limitations. We demonstrate that both concepts operate largely as black boxes. Their usage has thus become tied to disciplinary and methodological projects, with attendant implications for their wider usage – especially given the respective statuses of the fields of medical anthropology and social epidemiology in public health. We conclude that structural violence and the social determinants of health have both been influential in research and policy, but have struggled to effect the kinds of political change that their moral commitment to social justice promises and that further dialogue between them is required. [ABSTRACT FROM AUTHOR]

Recent interdisciplinary scholarship has drawn increased critical attention to issues related to race, gender, class, and culture within public physical activity (PA) spaces, foregrounding the importance of rethinking dominant narratives of PA and promoting diverse and more inclusive practices within these contexts to address PA disparities. This paper addresses issues related to diversity and inclusion within community fitness spaces by examining the experiences of stakeholders and members involved in 'The Collective' Free Fitness Group (CFFG), a free, open-to-the-public fitness community based in Oakland, Ca (the original name has been changed for purposes of anonymity). This organization has made intentional efforts towards addressing diversity and inclusion across its membership and is located in one of the most ethnoracially diverse regions of the country. Drawing on McGee's (1980) concept of ideographs, we explore the potential limitations and consequences of how the CFFG Oakland community members communicated discourses and lived experiences of and to one another and the broader Oakland community. Specifically, we argue that by emphasizing certain expressions of and while deemphasizing alternative forms, participant responses reflected a 'paradox' of diversity, despite their shared in-group identification around as an important individual moral virtue and their open and community. This study contributes new knowledge to the 'paradox' literature and may inform future physical activity interventions and theoretical directions of study. [ABSTRACT FROM AUTHOR]

In public health research and reporting, there is an increasing interest in eco-social theory and intersectional approaches to understand health inequity. Both approaches focus on the macrosocial causes determining health inequity and work under the premise that public health must be tied to an ethical project of engaging with the populations it serves. This paper critically reviews emerging literature on intersectionality in public health to identify, first, how it extends eco-social theorizing. Second, we identify how it may challenge broader premises in public health research which are aligned with reductionist, biomedical rationales. To do so, we draw on Patricia Hill Collins' definition of intersectionality as both a knowledge project and a social justice project, inviting an entire range of theoretical, epistemological, methodological and ethical questions. As such, a more critical reading of intersectionality as initially envisioned by Black feminism has the potential to contribute to a paradigm shift in understanding public health research and reporting as a means for engaging with injustice rather than a tool for describing a population and its burden of disease. [ABSTRACT FROM AUTHOR]

Persistent health inequalities pose a challenge to researchers and policymakers. Decades of research have illuminated mechanisms that underlie health inequalities, now we must move beyond these observations to enable policies that can reduce them. In this paper, we highlight tensions in the field of health inequalities research regarding the relationship between social determinants and health outcomes, and the effectiveness of welfare policies. We draw on recent evidence to analyse and discuss these areas of debate and provide insight into the evidence on causality, welfare systems and policies aiming to address the social determinants of health inequalities. First, we examine the evidence that inequalities in the social determinants of health are causally related to health inequalities. Second, we discuss whether more egalitarian social policies provide a solution to redressing health inequalities. In conclusion, we suggest that current debates around causal understandings risk sending the field down 'rabbit holes' that distract from solution. We argue that, if we combine epidemiological evidence with the broader canon of social science evidence, the case for causal inference is sufficiently strong to suggest we now need to focus on effectively supporting and promoting research-informed policy responses to health inequalities. [ABSTRACT FROM AUTHOR]

Research recruitment, eligibility, and who chooses to participate shape the resulting data and knowledge, which together inform interventions, treatment, and programming. Patterns of research participation are particularly salient at this moment given emerging biomedical prevention paradigms. This paper explores the perspectives of Black and Latino young men who have sex with men (BL-YMSM) regarding research recruitment and eligibility criteria, how their experiences influence willingness to enroll in a given study, and implications for the veracity and representativeness of resulting data. We examine inclusion and recruitment as a complex assemblage, which should not be reduced to its parts. From April to July 2018, we conducted in-depth interviews with 30 BL-YMSM, ages 18–29, in New York City. Interviews were recorded, transcribed, and analyzed using the constant comparative method. Black and Latino YMSM's responses unveiled tensions between researchers', recruiters', and participants' expectations, particularly regarding eligibility criteria (e.g. age, sex frequency), assumptions about 'risky behaviors,' and the 'target' community. Men preferred peer-to-peer recruitment, noting that most approaches miss key population segments. Findings highlight the need to critically examine the selected 'target' community, who sees themselves as participants, and implications for data comprehensiveness and veracity. Study eligibility criteria and recruitment approaches are methodological issues that shape knowledge production and the policies and programs deployed into communities. These findings can inform how future research studies frame recruitment and eligibility in order to better meet the needs of participants and ensure future research engagement. [ABSTRACT FROM AUTHOR]

Discourse regarding public health problems disproportionately affecting marginalized communities may shape and sustain health inequities. Analyses of news media and public health communications in the wake of infectious disease outbreaks provides opportunities to examine how discourse produces dominant public perceptions about the drivers of health emergencies and who is responsible for protecting community health. Guided by Bacchi's "What is the Problem Represented to Be?" analytic approach, this paper critically examines the discursive construction of problems and solutions in news media (n = 35) and public health communication (n = 18 press releases, n = 1 governmental report) regarding an unprecedented hepatitis A outbreak in San Diego, California, USA (2016–2018) that disproportionately affected people experiencing homelessness. We organize our findings around three elements of problem and solution representation with respect to the outbreak: 1. The inequitable attribution of risk and deservingness; 2. assumptions divorced from socio-structural factors and perspectives of marginalized populations; and 3. political theatre as a means of blame-shifting and (in)action. Overall, our findings suggest that even when structural-level issues were acknowledged within news media and public health communication as undergirding the 'problem' of the hepatitis A outbreak, outbreak discourse focused on individual-level responsibility for both the causes of and solutions to it (e.g. vaccines, criminalization of homelessness), and on shifting blame between government actors. These findings have implications for understanding the role that news media and public health agencies play in shaping public perception of the causes, consequences and solutions to infectious disease outbreaks that disproportionately affect marginalized populations. [ABSTRACT FROM AUTHOR]

This paper examines the experiences of healthcare providers (n = 10), policymakers (n = 5), and drug users (n = 5) in Puerto Rico (PR) after Hurricane Maria hit in September 2017. We draw upon ecosocial theory and theories of coloniality to interpret the findings from semi-structured interviews conducted between 2018–2020. The data from the study reveal the unacknowledged absence of illicit drug use in public policies on emergency management in response to the catastrophe and its association with barriers in the provision of health care services (i.e. mental health, opioid agonist therapy, and harm reduction) for drug-using patients. These individuals have been largely invisible in policy discussions on healthcare post-Maria. Our analysis highlights three intersecting factors that should be addressed in post-disaster policymaking addressing substance users. First, changes in the government's medical plan one year after the Hurricane hampered the coordination of services for patients and providers. Therefore, the aid offered tended to be exclusively economic rather than addressing disparities in health service access. Second, policies have not addressed the mistreatment and prejudice toward substance users in hospital and emergency room settings. Third, there was evidence of relapses in the use of controlled substances and the replacement of routine drugs with fentanyl due to the interruption of regular transportation, affecting supplies and illegal substances. Failure to address addiction constitutes a real threat to the survival of a significant population in PR and embodies the historical oppression wrought by colonialism, discrimination, and stigma in a society that dismisses substance users in its public and budgetary policies. [ABSTRACT FROM AUTHOR]

A wide range of evidence shows systematic differences in health status among social groups, which are associated with unequal exposure to and distribution of the social determinants of health (SDH). However, the role of these SDH has not been studied extensively in low-income countries, where most studies focus on access to medical care. In this paper, we undertake a retrospective cross-sectional analysis of the SDH in Mozambique for the period 2002–2014 based on a set of household budget surveys, covering 152,259 observations. We run logistic regression models, comparing various sets of determinants of health status proxied by two measures: self-assessed overall health and number of days ill. The results, which include models stratified by sex, age and year, consistently show that neither better access to healthcare nor material conditions are related to better health. Rather, macro factors, proxied by place of residence, are the dominant predictor of health inequalities. In the stratified models, women and elders appear more vulnerable to poor health. The policy implication is that a narrow focus of health policy on selected services ignores the underlying economic and social context and their role in producing well-being or poor health. More integrated approaches are required to address the health equity gap in low-income countries. [ABSTRACT FROM AUTHOR]

The health and ecological harms created and spread by firms active in many unhealthy commodity industries (UCIs) have received considerable attention from the public health community. However, less focus has been paid to analysing the distribution of wealth and income – important social and economic determinants of health – by these industries. This study aimed to examine long-term trends in wealth and income distribution by publicly listed corporations active in four UCIs: fossil fuels; tobacco; ultra-processed foods; and alcohol. Quantitative analysis of a range of data was conducted for firms listed on stock exchanges in the United States (US). Wealth and income distribution metrics were analysed at the industry level, including effective corporate tax rates and shareholder value ratios. The equity ownership structures and investor location of 20 of the largest firms were also explored. Since the 1980s, US-listed firms in the examined UCIs have distributed much less of their wealth and income to governments and much more to shareholders and investors mostly based in high-income countries. The study provides evidence that firms active in UCIs create a 'double burden of maldistribution': their externalised social and ecological harms disproportionately affect disadvantaged population groups and governments in low- and middle-income countries; whilst, simultaneously, they are increasingly transferring wealth and income to a group over-represented by a small and privileged elite. The identified distributive injustice warrants increased policy attention. [ABSTRACT FROM AUTHOR]

In 2011 Raphael identified seven discourses on the social determinants of health (SDH). These discourses ranged from 'SDH as identifying those in need of health and social services' to 'SDH and their distribution result from the power and influence of those who create and benefit from health and social inequalities'. Developments since then have led us to identify an eighth: 'SDH and their distribution result from the processes inherent to capitalism – capital accumulation, competition, and exploitation'. We identify scholarship espousing the view that quality and equitable distribution of SDH will require the creation of a post-capitalist socialist state. While the form this state will take remains uncertain, means of moving towards it are available. Specific steps the public health community can undertake are identified. [ABSTRACT FROM AUTHOR]

This commentary reflects upon power-knowledge dynamics and matters of epistemic, procedural, and distributive justice that undergird epidemiological knowledge production related to racial health inequities in the U.S. Grounded in Foucault's power-knowledge concepts—"objects", "ritual", and "the privileged"—and guided by Black feminist philosopher Kristie Dotson's conceptualization of epistemic violence, it critiques the dominant positivist, reductionist, and extractivist paradigm of epidemiology, interrogating the settler-colonial and racial-capitalist nature of the knowledge production/curation enterprise. The commentary challenges epidemiology's affinity for epistemological, procedural, and methodological norms that effectively silence/erase community knowledge(s) and nuance in favor of reductionist empirical representations/re-presentations produced by researchers who, often, have never stepped foot inside the communities they aver to model. It also expressly names the structurally racist reality of a "colorblind" knowledge production/curation system controlled by White scholars working from/for an invisibilized White scientific gaze. In this spirit, this commentary engages the public health critical race praxis principle of "disciplinary self-critique", illuminating the inherent contradictions of a racial health equity discourse that fails to interrogate the racialized power dynamics underlying its knowledge production enterprise. In doing so, this commentary seeks to (re)frame and invite discourse regarding matters of epistemic violence and (re)colonization as manifest/legible within epidemiology research, suggesting that the structural racism embedded within – and perpetuated through – our collective work must be addressed to advance antiracist and decolonial public health futures. In this regard, I suggest the value of engaging poetry as praxis—as mode of knowledge production/expression to "center the margins" and offer counternarratives to epidemiology's epistemic violence. [ABSTRACT FROM AUTHOR]

Does social class matter in understanding health inequalities in early 21st century China, when the country experienced unprecedented social stratification? Using nationally representative data from the latest waves of China Household Income Project surveys, we examine to what extent an individual's health is structured by social class and how that structure evolved. We draw on a neo-Marxist measure of social class to tap into the hidden mechanism that engenders and sustains inequalities. Four classes are defined based primarily on their relationships to productive resources: owners/managers, professionals/skilled workers, less-skilled workers, and farmers. Such a measure has not been considered in the health gradient literature in the Chinese context. Our results show that, despite remedial policies that helped mitigate economic inequalities, inequalities in health have mostly widened during the early years of the current century between the 'haves', who own productive assets and/or managerial authority, and the 'have-nots'. In 2002, self-rated health (SRH) was not clearly associated with class rank; in 2007, when China's economic inequality reached a historical zenith, a gradational pattern between SRH and class emerged, and the largest health gap was found between the class of owners/managers and farmers; in 2013, when China's income inequality reached a plateau, the health gap between owners/managers and less-skilled workers grew larger. Further, we identify job security as a mediator that links class and health among the lower social strata. In addition to improving the health of the disadvantaged, policies designed to narrow health inequalities should be orientated towards addressing social stratification. [ABSTRACT FROM AUTHOR]

Global health policymakers have identified Myanmar as a source of high drug resistance and informal pharmaceutical markets in need of tighter state regulation. The World Health Organization drafted a Global Action Plan on antibiotic resistance (often referred to as antimicrobial resistance) that seeks to address it. Myanmar is one of over a hundred countries that has followed the World Health Organization's prescription and drafted its own National Action Plan. Through participating in the everyday life of a family pharmacy, we observed that in practice the outcomes of global plans for AMR, such as regulating access to antibiotics, are shaped by people's limited access to affordable health care, low salaries, and the military's authoritarian role in Myanmar politics. We followed how negotiations between state officials and drug vendors evolved towards a mutual understanding (as opposed to following written rules) after a Food and Drug Administration raid, intended to enforce the regulation of the sales of illegal medicines. Rather than uncritically pushing state-centric action, those working to promote the regulation of medicines must attend more carefully to how different modes of political authority and governance, combined with histories of health provision, shape drug policy in practice. Otherwise, they risk contributing, if not intensifying, already existing health and social injustices, whilst also failing to generate their intended outcomes, such as meaningful changes to antibiotic sales and reductions in resistance. [ABSTRACT FROM AUTHOR]

Evidence suggests that despite the popularity and influence of key health equity concepts, they often fail to shift the thinking and actions of health workforces towards the social and structural determinants of health inequalities. These findings tend to be attributed to institutional constraints, along with the role of influential discourses which promote a focus on individuals and behaviours. However, questions have also been raised about the clarity and utility of the concepts themselves, and the extent to which the language they use works (or indeed fails to work) in reorienting thinking and action. The purpose of this study was to explore how partners in an applied health research collaboration in England interpreted the popular 'upstream-downstream' story, and what it means to work 'upstream' to reduce health inequalities. Where participants were not familiar with its academic or technical usage, the story was taken to be a metaphor for prevention generally, or it prompted a root cause analysis of the more discrete ways in which inequalities were encountered in participants' research or work. Even in instances where participants did hold more socio-political perspectives, these were often not evoked by the metaphor itself. Two of the 18 participants were unable to equate the metaphor with particular actions or ways of working, while others found it to be a poor fit with how they understood inequalities. The study findings illustrate and explain the challenges that arise when technical metaphors from the health equity literature are opened-up to interpretation by wider audiences. [ABSTRACT FROM AUTHOR]

In May 2017, the Saskatchewan Transportation Company (STC), a 70-year-old bus company in Saskatchewan, Canada, was shut down through an austerity budget that saw several cuts. The government justified its decision on budgetary grounds although opponents cited possible negative impacts of the decision. A Foucauldian Discourse Analysis (FDA) was employed to examine discourses used by different actors to explain the closure and the implications of these discourses for health and health equity. Data from 47 days of parliamentary debates, 751 newspaper articles, and 2 focus group discussions were imported into NVivo software for analysis. Discourses and counter-discourses surrounding the closure were explored and interpreted in the broader context of austerity and the politics of health. The evidence suggests that the closure of STC was facilitated by several contextual factors anchored around discourses of economic rationalization, minimization, government discretion, and the representation of the bus as a relic of a socialist past. Opponents of the closure defended the bus on the grounds of its utility and the possibility of marginalization/victimization of former bus users. A democratic and an evidence deficit as well as secondary discourses of human rights and environmental/climate impacts were used to argue against the STC closure. The research reveals the critical role of power in the creation of health inequities through austerity measures, particularly through discourses that negate the existence and associated rights of vulnerable users of public services such as public transportation. [ABSTRACT FROM AUTHOR]

Public health agencies tasked with improving the health of communities are poorly supported by many 'business-as-usual' funding practices. It is commonplace to call for more funding for health promotion, but additional funding could do more harm than good if, at the same time, we do not critically examine the micro-processes that lead to health enablement – micro-processes that are instigated or amplified by funding. We are currently engaged in a university-and-policy research partnership to identify how funding mechanisms may better serve the practice of community-based health promotion. We propose three primary considerations to inform the way funds are used to enable community-based health promotion. The first is a broader understanding and legitimising of the 'soft infrastructure' or resources required to enhance a community's capacity for change. The second is recognition of social relationships as key to increasing the availability and management of resources within communities. The third consideration understands communities to be complex systems and argues that funding models are needed to support the dynamic evolution of these systems. By neglecting these considerations, current funding practices may inadvertently privilege communities with pre-existing capacity for change, potentially perpetuating inequalities in health. To begin to address these issues, aspects of funding processes (e.g., stability, guidance, evaluation, and feedback requirements) could be designed to better support the flourishing of community practice. Above all, funders must recognise that they are actors in the health system and they, like other actors, should be reflexive and accountable for their actions. [ABSTRACT FROM AUTHOR]

This study aims to identify strategies for the advancement of intersectoral networks and equity in the context of vulnerable territories in Brazil; this is a qualitative study based on community-based participatory research (CBPR). The population of the study was composed of managers, health care and social assistance professionals, members of social movements and non-governmental organisations (NGOs); a total of 86 participants were recruited for the study. Data were collected through interviews, focus groups and a participatory forum. Data analysis was applied according to the methodological background of the dialectic hermeneutics of Jürgen Habermas, which considered communicative action theory and CBPR. The intersectoral strategies were occurring without the integration of sectors, people, and action. There is a lack of an institutional approach by the municipal government in establishing priorities, as well as shared and integrated agendas; there is a lack of human resources qualification and communities for the development of the actions to address the social determinants of health. According to the participants, the current strategies to tackle social inequities are not systematic, are insufficient, lack appropriate resources and have a limited impact on the communities. Furthermore, the civil society representatives reported that they were not included as a stakeholder or even regarded as a social mechanism to support vulnerable groups, to achieve a solution, to lead on or manage their context of poverty and inequity. [ABSTRACT FROM AUTHOR]

Within a neoliberal environment that prioritizes the individual over the community, understanding challenges associated with advancing population-level or universal interventions is important if public health is to remain a relevant collective institution. As a case example, we considered a controversial public health intervention – community water fluoridation – and undertook focus groups with dental hygienists in Calgary, Alberta, Canada, to explore ways that fluoridation (a population-level intervention) is understood and discussed in their day-to-day clinical interactions as frontline cavity prevention experts. The overarching theme in our data centered around a key public health conundrum – that is, the difficulties reconciling individual and community- or population-level responsibility for health. Dental hygienists wrestled with the transdisciplinary nature of population-level public health interventions; acknowledged changing roles and relationships between themselves and their patients; and revealed dissonance in their own beliefs about individualism and collectivism in health. Our findings shed light on communication challenges where public health information delivery intersects with clinical encounters, in the context of empowered and knowledgeable health consumers. A challenge for the public health community is to reflect on how to better address a contemporary public's reasonable information requests and negotiate the clash between individualism and collectivism more effectively. [ABSTRACT FROM AUTHOR]

This article documents, contextualizes, and theorizes the significance of technological divides and inequalities of access, along with diverse accommodations, adaptations, resistances, and alternatives to health and communications technologies that have unfolded in two South American countries during the COVID-19 emergency: Ecuador and Argentina. Based on a shared qualitative interview methodology that focused on issues of social inequality and digital divides, perceptions of and experiences with public health systems, and levels of trust relative to governmental, media, and other sources of information about the pandemic, our emergent comparative analysis demonstrates both shared and divergent patterns. While interview data from both countries emphasize deepening crises of poverty and inequality that reverberate in differential access and usage of communications technologies, there are distinct patterns with regard to confidence in medical systems and public health information. In Argentina, citizens may question or doubt official sources of information and public health systems but, on the whole, tend to maintain higher levels of cautious trust, while in Ecuador, an erosion of trust, along with higher levels of cultural diversity, drives an adaptive response towards systems and practices of medical pluralism, particularly in indigenous and rural contexts. Explanations for these differences may lie in the distinct forms the project of colonial modernity, and resistance or adherence to it, has taken in each country. [ABSTRACT FROM AUTHOR]