Health Inequalities: Law & the Pain of Others
| Published date | 01 August 2023 |
| DOI | http://doi.org/10.1177/09646639221123028 |
| Author | Michael Thomson |
| Date | 01 August 2023 |
| Subject Matter | Articles |
Health Inequalities: Law &
the Pain of Others
Michael Thomson
University of Technology Sydney & University of Leeds
Abstract
Health inequalities are a social injustice experienced globally.State action to address this has gen-
erally been insufficient, with inequities persisting, or - as in the case of the UK - worsening. This
article contends that social epigenetics has a role in generating morerobust state responses and
makes two related arguments. First, it is argued that an epigenetic explanation of avoidable
health inequalities has the potential to provoke change because it works within the gene para-
digm. Second, epigenetics provides an opportunity to challenge a different paradigm, that of the
liberal legal subject. This fictive figure has long impoverished understandings of harm and
responsibility; including in the context of health inequalities. Martha Fineman’s model of the
vulnerable subject is engaged as an alternative to this figure. The original and expansive articu-
lation of the epigenetic landscape - an idea now significantly narrowed–is articulated as a space
for an interdisciplinary exploration of the role of epigenetics in securing a state more respon-
sive to inequalities.
Keywords
health inequalities, inequality, social determinants of health, epigenetics, social epigenetics,
genetics, social justice, metaphor
[I]mages cannot be more than an invitation to pay attention, to reflect, to learn, to examine
the rationalizations for mass suffering offered by established powers. Who causes what the
picture shows? Who is responsible? Is it excusable? Was it inevitable? Is there some state of
affairs which we have accepted up to now that ought to be challenged? All this, with the
understanding that moral indignation, like compassion, cannot dictate a course of action.
Sontag (2003)
Corresponding author:
Michael Thomson: University of Technology Sydney & University of Leeds.
Email: michael.thomson@uts.edu.au
Article
Social & Legal Studies
2023, Vol. 32(4) 586–605
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/09646639221123028
journals.sagepub.com/home/sls
Introduction
Inequalities in the distribution of resources, opportunities, and power have long been
understood to correlate with the unequal distribution of ill-health (Marmot et al., 1978,
1991, 2010, 2020). Health outcomes are shaped by the ‘contexts in which people live,
learn, work and play’(WHO, 2008). These Social Determinants of Health (SDH) have
a determinative impact on individual health outcomes, the distribution of both commu-
nicable and non-communicable diseases, and life expectancy (Marmot and Wilkinson,
1999; Marmot, 2004; WHO, 2008). Social epidemiologists have long mapped a health
gradient (Marmot, 2004) whereby ‘health outcomes line up on a steady slope from the
have-leasts to the have-mosts’(Burris, 2011: 1652). As Scott Burris continues, ‘the gra-
dient turns up reliably at the intersection of social status (whether measured by wealth,
income, education, or other common proxies) and virtually any health or social pathology
you could name’(2011: 1652-3).
The link between social inequalities and health means that we should be concerned by
health inequalities for the intrinsic harms these cause, and because they indicate other
inequalities and social injustices (Peter, 2001). Further, adverse health outcomes can
compound and deepen the social inequalities with which they correlate. This can have
intergenerational effects. Recognition of the indivisibility of health inequalities from
broader structural inequalities has provoked concepts such as health justice (Ruger,
2009; Venkatapuran, 2013) and health equity (Sen, 2002; Labonte and Ruckert, 2019).
These recognise that inequalities in health are inequalities in freedom and that improved
population level health is essential for greater social justice (Anand, Peter and Sen, 2004).
Concepts are political interventions (Bacchi, 2012), and these conceptual developments
have been an important part of the significant work in recent decades to draw public and
political attention to avoidable health inequalities. Notwithstanding such work, state
action has remained inadequate. Indeed, in some high income countries such as the
UK where the potential to address health inequalities is greatest, health inequalities are
worsening, particularly in the poorest communities (Marmot, 2020: 1). This is deepening
the broader inequalities and deprivations experienced.
Responding to inadequate government action, this article turns to social epigenetics,
an emerging science of disadvantage (Müller et al., 2017). Epigenetics refers to the
study of potentially heritable alterations in gene expressions that occur in the absence
of changes to the DNA sequence itself. Social epigenetics implicates environmental or
social insults in epigenetic processes, where they may impact on health outcomes and
life expectancy. Epidemiological and laboratory studies point to detrimental epigenetic
impacts from malnutrition, neglect, child abuse, systemic racism, and other social
insults or injury (Kundakovic and Champagne, 2015). Recent work on epigenetic
clocks identifies biological markers that can be used to quantify the impact of social
and environmental harms on morbidity and mortality. These provide a causal mechanism
(epigenetic processes) and a quantum of damage (illness and lost years). They offer a
physical causal mechanism linking social disadvantage to ill-health that has previously
been lacking in SDH research. Thus, social epigenetics and epigenetic clocks carry
with them the potential to explain the consequences of inequality in the sort of ‘physical
register’that law finds intelligible (Karpin 2018: 1133).
Thomson: Health Inequalities 587
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