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Available online at www.sciencedirect.com

Public Health
journal homepage: www.elsevier.com/puhe

Symposium

Mapping injustice, visualizing equity: Why theory, metaphors and images matter in tackling inequalities
N. Krieger a, D. Dorling b, G. McCartney c,*
a

Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA, USA University of Shefeld, Shefeld, UK c NHS Health Scotland, Elphinstone House, 65 West Regent Street, Glasgow, UK
b

article info
Article history: Available online 11 February 2012

summary
This symposia discussed Mapping injustice, visualizing equity: why theory, metaphors and images matter in tackling inequalities.1 It sought to provoke critical thinking about the current theories used to analyze the health impact of injustice, variously referred to as health inequalities in the UK, social inequalities in health in the US, and health

Keywords: Theory Image Metaphor Inequality Inequity Epidemiology Geography Public Health Social Justice

inequities more globally. Our focus was the types of explanations, images, and metaphors these theories employ. Building on frameworks that emphasize politics, agency, and accountability, we suggested that it was essential to engage the general public in the politics of health inequities if progress is to be made. We showcased some examples of such engagement before inviting the audience to consider how this might apply in their own areas of responsibility. 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Theories of social inequalities in health

Epidemiologic theories of disease distribution are intended to explain why and how populations (rather than individuals) have the health proles they do. Such theories are needed to help understand both the overall health of populations and the distribution of health within and across social groups. Currently, two main groups of epidemiologic theories exist: the dominant perspective, comprised of biomedical and lifestyle approaches, and the social epidemiologic alternatives, which can be characterized as sociopolitical, psychosocial and

ecosocial.2 The biomedical and lifestyle theories are individualistic approaches that primarily focus on decontextualized individual-level pathology, biology, and behaviour; dominant metaphors portray the body as a machine and/or output of a genetic program, and choice as a matter simply of the taste of individual consumers, independent of context or constraints.2 By contrast, the social epidemiologic theories, although differing in their emphases, all share three features not found in the dominant perspective: 1) the view that the whole shapes properties of the parts and vice versa, that is, the arrows go both ways, albeit not with equal force; 2) a population-orientation; and 3) an emphasis that context matter.2

* Corresponding author. E-mail address: gmccartney@nhs.net (G. McCartney). 0033-3506/$ e see front matter 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.01.028

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The central point is that the epidemiological theory we use matters, because theory inuences what data we collect, how we analyse it, the hypotheses we test and the interpretations we make. No-one thinks or works in a social vacuum; instead, societal context, worldviews, and values inevitably inuence science.3 To tackle health inequities, it is important to challenge the dominant biomedical and lifestyle theories with more comprehensive sociopolitical, psychosocial and ecosocial alternatives.

Images and distortion: seeing is believing

Throughout history, images have been used as a political tool to reinforce the values and the ideology of their creators or sponsors. Mercator map projections of the world usually place London at the centre and emphasize the size of the Imperial powers of the time whilst diminishing the size of equatorial and tropical regions and nations including Southern Asia, Africa, Central and South America. The same is true of images used in epidemiology and public health. The theories and values which are adopted can inuence the images and graphics used to illustrate the data. There are parallels between the histories of the scientic mapping of continents and oceans and the medical mapping of human anatomy, both... Both half-millennia old traditions are now being challenged.4

Icons, models and metaphors: depoliticised analyses of health inequities

Among current social epidemiologic theories, tensions exist between those which overtly recognize power and unjust social relations as producing health inequities and those which present increasingly depoliticized descriptions of health inequalities.5 The images and metaphors employed starkly reveal these constrasts.6 For example, the inuential Whitehead-Dahlgren rainbow model places individuals with the age, sex and constitution at the centre and omits any mention of the political economy which inuences the structural determinants of health in its outer rings.7 This model contrasts with the ecosocial theory of disease distribution which combines analysis of social history and lifecourse epidemiology, system levels (from individuals and households to national and global systems) and an understanding of how health is distributed within a population by explicitly highlighting class, race/ethnicity, gender, political economy, and political ecology (Fig. 1).2 Similarly, the upstream/downstream metaphor now widely used in social epidemiology not only obscures power and agency but fails to conceptualize how people downstream, by socially organizing, have altered upstream inuences and reshaped the course of history e and social inequalities-in health.2,8 In whose interests does a depoliticisation of the models of health inequities serve? We argue that in societies whose political economy simultaneously produces social inequalities and health inequities, the benet is to the societal groups who hold power, wealth and income.

Fig. 1 e Ecosocial theory and embodying inequality: core constructs. 1. Embodiment, referring to how we literally incorporate, biologically, in societal and ecological context, the material and social world in which we live; 2. Pathways of embodiment, via diverse, concurrent, and interacting pathways, involving adverse exposure to social and economic deprivation; exogenous hazards (e.g., toxic substances, pathogens, and hazardous conditions); social trauma (e.g., discrimination and other forms of mental, physical, and sexual trauma); targeted marketing of harmful commodities (e.g., tobacco, alcohol, other licit and illicit drugs); inadequate or degrading health care; and degradation of ecosystems, including as linked to alienation of Indigenous populations from their lands. 3. Cumulative interplay of exposure; susceptibility, and resistance across the lifecourse, referring to the importance of timing and accumulation of, plus responses to, embodied exposures, involving gene expression, not simply gene frequency; and 4. Accountability and agency, both for social disparities in health and research to explain these inequities.

Making health inequities a public issue: attempting to reach out

We argued that public health professionals and epidemiologists need to work with the people whose health is harmed by economic deprivation and discrimination to challenge health inequities. Without public awareness, agitation and people working together to create change, the power imbalances will go unchallenged.9 Four examples of attempts to raise awareness, engage with non-academic audiences and agitate for change were shown. First, Worldmapper images, which change the area of the nations of the world to represent the prevalence/incidence of various factors across the world (such as mortality and gross domestic product), were sequenced with the music of Money by NASA, using the lyrics to demonstrate the unequal distribution of social, economic, demographic and health outcomes (available at http://www.youtube.com/ watch?v1f39BTnL09k). These images come from a larger set of maps which have also been recently put in video format and which are shown here: http://www.youtube.com/watch? v-45uS6-qeos. Second, a short lm (one of ve made over

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the course of two days for a total cost of 200) discussing the inequalities in Danny Dorlings home town was shown (available at http://www.youtube.com/watch?vU-y1QWtBPo). Third, the opening scenes from a documentary series, Unnatural causes, which discusses the causes of social inequalities in health in the USA and which featured on national PBS television during 2008 and has been shown at over 15,000 local events (available at http://www. unnaturalcauses.org/). And, fourth, a YouTube video on Whats Your Health Codes (available at: http://www. youtube.com/watch?vDtLGXrxA8wk), inspired by maps of neighbourhood health inequities,10 that was produced by the Boston Public Health Commission as part of a new campaign to encourage people to move from viewing causes of ill-health as solely rooted in individual behaviour to instead thinking about social causes of community health that can be changed by community action (see: http://www.whatsyourhealthcode. com/take-action/). Together, these demonstrate what can be done with varying levels of resources to engage the general public on the issue of health inequalities.

references

Where next for tackling social inequalities in health?

To address societal determinants of health and reduce health inequities, public health professionals and epidemiologists should employ and expand upon existing alternative theories which encompass political economy, political ecology, history, class, race/ethnicity, gender and other unjust social relations (e.g., involving sexuality, immigration status, disability, geographic location, etc.) to provide a more comprehensive basis for study and for action. The images, metaphors and icons we use are powerful and we should be aware of both the potential for these to mislead e and also to engage the broader public to make a difference in rectifying health inequities.

1. Krieger N, Dorling D, McCartney G. Mapping injustice, visualising equity: a joint presentation on situating and tackling health inequities. World Epidemiology Congress, Edinburgh, 9th August 2011 [abstract available at]. J Epidemiol Community Health 2011;65:A60e1. doi:10.1136/jech.2011.142976b.77. 2. Krieger N. Epidemiology and the peoples health: theory and context. New York: Oxford University Press; 2011. 3. McCartney G, Collins C, Garnham L, Gunson D. When do your politics become a competing interest? BMJ 2011;342:d269. 4. Dorling D. Anamorphosis: the geography of physicians, and mortality. Int J Epidemiol 2007;36(4):745e50. 5. Krieger N, Alegr a M, Almeida-Filho N, Barbosa da Silva Jr J, Barreto ML, Beckeld J, et al. Who, and what, causes health inequities? e reections on emerging debates from an exploratory Latin American/North American workshop. J Epidemiol Community Health 2010;64:747e9. doi:10.1136/ jech.2009.106906. 6. Krieger N. Ladders, pyramids, and champagne: the iconography of health inequities. J Epidemiol Community Health 2008;62:1098e104. 7. Dahlgren G, Whitehead M. Tackling inequalities in health: what can we learn from what has been tried? Working paper prepared for the Kings Fund International Seminar on tackling inequalities in health, Ditchley Park, Oxfordshire. London, Kings Fund, 1993. 8. Krieger N. Proximal, distal, and the politics of causation: whats level got to do with it? Am J Public Health 2008;98:221e30. 9. Robert SA, Booske BC. US Opinions on health determinants and social policy as health policy. Am J Public Health 2011;101:1655e63. 10. Chen JT, Rehkopf DH, Waterman PD, Subramanian SV, Coull BA, Cohen B, et al. Mapping and measuring social disparities in premature mortality: the impact of census tract poverty within and across Boston neighborhoods, 1999e2001. J Urban Health 2006;83:1063e85.