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Introduction
According to the protagonists of what might be termed the social determinants of health (hereafter SDH) revolution, the contribution made by social factors exclusive of health care to the overall health of individuals is greater than has traditionally been thought, perhaps as great or even greater than that made by those ingredients of health care - access to health-care professionals, pharmaceuticals, medical technologies - that have usually been viewed as central to the 'justice-in-health' debate (Wilkinson, 1996; Wilkinson and Marmot, 2005; Wilkinson and Pickett, 2009). From this, the conclusion is drawn that the distribution of these factors ought to be made so as to realize desirable health objectives. My intention in this article is not to reject this conclusion, but to argue that the inference ought to be drawn with care, and to provide at least in broad lines an account of how the truth of the SDH thesis should be integrated to an overall view of justice.
The outcome of this debate makes an enormous difference to the future of modern welfare states. Indeed, one of the central policy debates within such regimes has to do with priority setting. What are the health-related goods that all citizens should be insured against, independently of their ability to pay, and what should be excluded from the basket of 'essential' health-related services? Debates surrounding this question and other, related ones have quite naturally focused on the cost-effectiveness of different measures. In public insurance systems, for example, citizens are required to contribute to a common fund that will see to the health of all, and so they can legitimately expect that those who administer this pool of resources will do so in a manner that attempts to maximize benefit (where, again, the idea of 'maximizing benefit' incorporates both strict efficiency and distributive considerations).
If SDH theorists and researchers are correct, we have been misallocating these funds at least to some degree over the course of the evolution of modern welfare states. Such systems have invested massively in doctors, hospitals and pills, whereas, if SDH theories are correct, they should have in order to improve health outcomes been placing resources in the increase of people's incomes (or in the closing of the income gap), in improving education, in...