Health

Summary

IFSW asserts that health is an issue of fundamental human rights and social justice and binds social work to apply these principles in policy, education, research and practice. All people have an equal right to enjoy the basic conditions which underpin human health. These conditions include a minimum standard of living to support health and a sustainable and health promoting environment. All people have an equal right to access resources and services that promote health and address illness, injury and impairment, including social services. IFSW will demand and continue to work for the realisation of these universal rights through the development, articulation and pursuit of socially just health and social policies.

Issues

Health: a Social Work Issue

Health is an issue of human rights and social justice. These two central social work values frame IFSW’s understanding that all people have an equal right to enjoy the social conditions that underpin human health and to access services and other resources to promote health and deal with illness.

The United Nations (UN) Declaration of Human Rights identified a range of rights which are essential to health. These include rights to life, liberty and security; to participation in policy making; to education and to just and favourable conditions of work. Centrally, the UN Declaration asserts the right to ‘a standard of living adequate for health and well-being of self and of family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control’(Article 25).

Social workers in all settings engage every day with children, men and women struggling to realise these basic rights to health. For example, social workers support families whose poverty makes securing the conditions for health and the purchase of health care unattainable, including households headed by children whose parents have died from AIDS; homeless people, migrants and other excluded groups facing barriers to securing shelter, employment or education, including indigenous peoples whose social and emotional difficulties are rooted in the violation of their cultural integrity and land rights; women and children suffering from the physical and emotional health consequences of violence and trauma, often linked to substance misuse. In every case people’s lives are compromised and impaired because of global and local inequity. The inequitable distribution of health reflects the inequitable distribution of the resources human beings require for sustainable, continuous development and growth.

Globalisation: mixed consequences for health

While global economic expansion, the development of welfare systems and technological advances in health care have brought profound benefits to many, longstanding and newly emerging factors continue to undermine population health. Gross economic and health inequalities are found between and within countries and in many places these inequalities are rapidly widening. For example, average life expectancy in Japan and Canada is now over 80 years while in Sub-Saharan Africa several countries have a life expectancy which has fallen below 40 years. In many countries, life expectancy and infant mortality show a steep gradient linked to social position. Such statistics are only an indicator of the deep human pain and suffering resulting not only from the consequences of life threatening illness, but also the increasingly common experience of living with long term illness and impairment (2) .

Since the 1970s, neo-liberal economic policies have not only failed to meet the test of protecting human rights, but have polarised living standards. International institutions, such as the UN have continued to seek to establish core health related rights. However, the International Monetary Fund and the World Bank have often been actively involved in the economic policy programmes which have deepened health inequalities and social insecurities. Structural adjustment policies (3) have produced rapid shifts in employment with devastating consequences for many developing countries’ economies. These policies have contributed to political instability and mass migration, including migration from rural communities to overcrowded, under-resourced cities. They are also implicated in the privatisation of health care services in many countries, removing or preventing universal access to health care; in the drain of skilled human resources from developing to developed countries and in the distortions in health research and provision linked to global pharmaceutical companies’ interests. Economic growth is also bringing profound threats to the physical environment and to the climate which constitute perhaps the major threat to human health in the coming decades. Meanwhile, large numbers of people continue to face being killed, maimed, traumatised and displaced from their homes and communities by war and violent conflicts.

The Social Determinants of Health

These unjust inequalities (4) in health and illness are avoidable. They are caused primarily by the impact of economic, social, political and environmental factors across the life course, the ‘social determinants’ of health. These are defined by the WHO Commission on Social Determinants of Health (Interim Statement 2007) as ‘the fundamental structures of social hierarchy and the socially determined conditions these structures create in which people grow, live, work and age.’ Genetic inheritance plays a significant part in individual health, but the major factors influencing health are socially created, that is they are the result of structural and institutional arrangements and policies which are open to change.

The inequalities in health that social work is concerned about have two key dimensions.

Health chances: a person’s chances of being ill or staying well, of living a long life or having their life cut short, are a product of economic, social, political and environmental factors; addressing these factors is social work’s core health role.
Health experience: a person’s experience of living with and combating illness, is a product of the resources they can access for preventing, treating or alleviating illness and promoting health. Helping to secure and expand these resources is social work’s secondary health role.

These are central issues for social workers in all settings. Social workers in health settings play particular roles, for example in helping people (5) access health care, negotiate treatment decisions or secure the services to manage illness at home.

Social Work Principles

Social workers locate people’s experience of health and illness in their social, economic, political and environmental contexts. Health and illness are viewed as social experiences, affecting people’s identities, relationships and opportunities. This social perspective is rooted in the IFSW Statement of Principles for Ethics in Social Work. Social workers respect the inherent worth and dignity of all people. This involves treating each person as a whole; respecting the right to self-determination; promoting the right to participation; and identifying and developing strengths.

Therefore, in providing professional health and social services, social workers aim to give primacy to the understandings of those they work with, unless that would contravene the rights of another person. Health has diverse meanings for human beings. For example, it is sometimes seen as positive feelings of well being or energy, as the physical and cognitive ability to carry out daily tasks or as the quality of relationships. People rarely define health only in terms of the absence of illness. Meanings change across the life course and are influenced by social identities and attitudes including those associated with age, gender, sexual orientation, abilities, social status, faith and ethnicity. People may not give the same priority to their health that a professional or another person might, or may disregard their own health in favour of the health of someone they care about.

Co-workers for Health

Social workers also recognise adults and children as co-workers; working for their own health at individual and collective levels. As human beings we are constantly engaged in health work for ourselves and for those we care for and about. Examples include encouraging children to brush their teeth; working long hours to secure the income to buy food; taking collective action to secure human rights; caring for an elderly relative or friend. In that sense, most health work is done by lay people, not professionals. Social workers recognise the people they work with as experts on their own lives and circumstances, with the right to participate in decisions both about their lives and the policies and social conditions which affect them.

In order for this health work to lead to socially just outcomes, people need equity of access to basic resources. This includes resources which underpin health such as income, food, shelter, warmth, clean water, safety and access to information and education; personal resources such as resilience, clarity of thought and social skills; informal resources such as personal and social supports; and professional resources in the form of health and social services.

Background

The context of the IFSW policy statement on health is globalisation. While health and illness often involve the most intimate and personal of feelings and relationships, hopes and fears, these occur in and are influenced by the economic, social, political and environmental context in which people live: the social determinants of health. This context is now global as well as national and local. International political and financial institutions and corporations impact on the standards of living of billions of people. Current patterns of economic growth are affecting the climate, the quality and availability of food, water and clean air, and the safety of people’s homes and livelihoods throughout the world. Warfare and political conflict spirals out across national boundaries. Globalisation also directly affects the experience of living with illness. International companies control pharmaceutical treatments, medical equipment, hospitals and care facilities. Governments trade expenditure on their population’s health care against competing priorities.

Definition of Health

Social work supports the World Health Organisation (WHO) definition of health enshrined in the WHO Constitution as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ This definition should be read in conjunction with the second clause which states: ‘The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.’

Although social workers see health as a dynamic process rather than a fixed state, this definition reflects core social work principles, not least by identifying health as a fundamental right. The holistic understanding of health as integrating bodily, emotional and relationship aspects and the recognition that health is more than the absence of illness reflect social work’s focus on the whole person in the context of their social and physical environment and on people’s strengths.

Core Principles

The basic principles outlined in the WHO constitution were elaborated in a declaration from the Alma Ata conference. Although written in 1978, these principles express core elements of international health policy underpinned by social justice and human rights and have social work support. They are also endorsed by international social movements such as the People’s Health Movement and by the extensive network of civil society representatives created under the auspices of the WHO Commission on Social Determinants of Health (CSDH). They were also reflected in the international commitments made at the 1995 World Summit on Social Development. As the CSDH puts it, ‘The development of society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health. Health equity is central to this premise.’

The key principles are that:

gross inequalities in health, particularly between developed and developing countries are unacceptable;
economic and social development are essential to the fullest attainment of health for all but also that promoting and protecting individual and population health is essential to sustained economic and social development and contributes both to quality of life and world peace;
population health is the responsibility of governments and should not be left to market forces or to individual responsibility;
participation in decision making about health care both individually and collectively is both a right and a duty.

The final principle does not only mean allowing people to make decisions about their own health, to improve their access to services or even to improve their conditions of living. Fundamentally changing the causes of health inequality through participation and empowerment, like realising human rights, will involve significant shifts in power over economic relations, conditions of work and of living, and access to resources at a global, as well as national and local levels.

A key dimension of power lies in gender relations as women currently bear a disproportionately great responsibility for formal and informal health work and disproportionately little control over economic and political resources to secure or maintain their own or others’ health.

Health undermined

The Alma Ata conference established the objective of Health For All by 2000. However, this was not achieved and in some respects conditions for universal health have deteriorated. It is only possible to sketch out some of the key elements here; many of these are explored in greater depth in other IFSW Policy statements.

‘Structural Adjustment’ and Neo-Liberal Economics

From the 1980’s onwards the World Bank has required ‘structural adjustments’ be made by many national economies as a condition of economic support. These have involved reduced public expenditure and state intervention in industry; cuts in taxation and in social security protection; and limiting the regulatory powers of states to protect individuals, families and communities. A number of health damaging consequences have followed. At best, economic growth has been achieved at the cost of radically widened inequalities; at worst, economic collapse has been overseen by corrupt and dictatorial political regimes. Unemployment has increased accompanied by reduced social protection; conditions of work and access to compensation for industrial injury have worsened; land rights have been lost and education and health services have been cut and privatised.

Unfair Trade

International policies and treaties covering world trade have also often damaged local economies or transferred economic benefits from small local producers to large, often multi-national, companies. These factors have been disruptive of established livelihoods and ways of life, leading to large scale population movements including from rural to urban living and from developing to developed countries. Human trafficking has thrived in these conditions with fatal and degrading consequences for many. A further concern in relation to health policy has been the drain of health (and social work) professionals, often trained at great cost to their home country, to support the health and social services in developed nations.

Privatisation

The privatisation of health and social services has been highly profitable to international businesses. Privatising health services and health service assets has changed their purpose from service to profit while removing responsibility for ensuring universal access. For hundreds of millions of people in both developing and developed countries, newly introduced or increased health care costs have meant that either health services are not accessed or that families enter into a vicious circle of payments leading to poverty, resulting in worse health and the need for further costly treatment.

For social workers, privatisation and managerialism have frequently meant the erosion of services. Most important has been the drive to reduce lengths of hospital stay often without sufficient investment in community services. The opportunity to pass costs between service providers leads to poor quality experiences for patients and their families, with costs being transferred from the state and from private companies, to individuals and families: the domestication of suffering. These trends contradict what recipients of social work say they value: ‘People value a social work approach based on challenging the broader barriers they face and safeguarding and advancing their rights and needs. They place a particular value on social work’s social approach, the social work relationship and the positive personal qualities they associate with social workers’ (Shaping Our Lives 2007).

Commodification

Implicit in privatisation is the perception that health and health care are products which can be bought and sold rather than services or rights, replacing the allocation on the basis of need with the ability to pay. This process of commodification also involves the creation of new markets in health related products such as cosmetic treatments, reproductive technologies and organs for transplant as well as claims of commercial ownership over genetics. Failures of regulation have resulted in avoidable suffering and created unrealisable expectations of the perfect body.

Yet there is widespread evidence that treating health care and treatments as commodities cannot deliver socially just or efficient health systems. For example, pharmaceutical research is heavily skewed towards the treatment of conditions which are prevalent in developed countries where there is the potential for a large financial return on investment. Where new treatments become available, as with the combination drugs used to manage HIV/AIDS, the market has failed to meet the standard of access according to need with lethal consequences for individuals and devastating effects on economies and on families. International attempts to solve the problem of intellectual property rights and the inhibition of incentives to invest in treatment development without such safeguards have not yet been successful.

Environmental Destruction and Climate Change

Amongst the multiple health damaging dimensions of this issue are: water and air pollution; ozone layer depletion, nuclear waste, toxic chemicals and pesticides; loss of biodiversity, deforestation and soil erosion. Effective international agreements are needed covering both the direct effects of toxicity on health and the indirect effects of loss of livelihoods, homes and ways of life. Poor neighbourhoods, communities and countries are more affected than others by the impact of unsustainable methods of economic production and consumption. Both as consumers of the world’s resources with ethical responsibilities for future generations and because of the impact on people’s physical and emotional health, this is also an issue for social workers.

Peace and Security

War and violence of all kinds, including domestic violence, rape, sexual slavery, trafficking, racial and homophobic hatred and violence, bullying and child abuse are opposed by social workers. Such violence directly damages the health of many people. It forces people to leave their homes, destroys their livelihoods, supportive relationships and opportunities for personal development, and their sense of identity and personal security, causing both physical and emotional difficulties. The Alma Ata Declaration rightly referred to military expenditure as wasted and damaging lost opportunities to fund improved health.

Social Work Roles and Responsibilities

Social workers in all settings are engaged in health work whether in creating the conditions for improved health chances or working alongside people to manage the impact of poor health on themselves or those close to them. IFSW believes that the right to social services as an inseparable part of health and health care, alongside formal medical care and other resources is correctly part of Article 25 of the UN Declaration on Human Rights. It is vital that social work articulates and advocates for its social understanding of health and the roles social work can play in working for better health for individuals, families, communities and populations.

Social work should renew efforts to engage more effectively at a policy level either with international institutions with responsibilities influencing health or with non-governmental organisations working for health related development. In addition, alliances should be sought with social movements seeking reforms leading to improved population and individual health. Examples of these are the People’s Health Movement, the Global Forum for Health Research and the World Social Forum. This dimension of practice requires changed perspectives and strengthened international social work organisations to meet the challenges of globalisation.

A widespread issue is the grossly inadequate provision of social work and social services which contribute to individual, family and population health across the range of community, clinic and hospital settings. This results in unmet demand with many people unable to access social work services at the point of need. Low levels of social work and social services resources sometimes lead to forms of rationing, for example, by not advertising services, which result in the unjust allocation of scarce resources. A core objective of IFSW policy is to extend the availability of social work services focusing on health across the range of work settings. This has to be supported by sufficient, appropriately focused basic and post-basic education and training for all social workers.

All social workers should constantly question the health consequences of their actions. IFSW policy opposes overt or covert actions or policies which are discriminatory or which exacerbate health inequalities. For example, policies and practices involving indigenous peoples and child migrants have sometimes resulted in the destruction of family and community life and life long physical and emotional health problems. Social workers should pay attention to the economic and political roots of the troubles people bring to them and give sufficient attention to ensuring that service recipients have a say in the direction and priorities of service provision. Services should always be provided by workers trained to be culturally competent.

Statement

1. Health is a key aspect of all fields of social work – practice, education, research and policy making – and in all settings.

IFSW will seek to ensure that social workers locally, nationally and internationally identify and challenge any deleterious health effects of social policies on people’s life chances and experience and to advocate for policies that are health promoting, protecting and sustaining.
IFSW will promote the employment of social workers throughout health services as an essential site for social work activity.

2. Health is not merely the absence of disease, it encompasses physical, mental, emotional and social wellbeing

IFSW will promote an holistic understanding of health in policy making and practice
IFSW will oppose the commodification and commercialisation of people’s bodies and the exploitation and coercion of people for their bodies or their body parts.

3. Health is a central dimension of people’s lives.

IFSW acknowledges that individuals, their families and friends perform the largest share of health work and will advocate for policies to support their efforts
IFSW will work for a universal understanding by social workers in all settings of the centrality of health to the lives of those with whom they work

4. Health is an issue of fundamental human rights.

IFSW will work towards all people achieving their right to health over the whole course of their lives
IFSW will work to secure universal access to basic health sustaining resources including the eradication of poverty
IFSW will work for universal access to affordable health promoting and preventive services and to treatment, care and support in times of illness, frailty and debility
IFSW will work to realise the right of individuals and their families to participate in decisions affecting their health.

5. Health status is primarily determined by social, economic, environmental and political conditions and is an issue of social equality and justice.

IFSW will advocate for more equal distribution of the resources that underpin health, including a minimum guaranteed income, food security, clean water, adequate shelter, warmth and clothing, education and safe and sustained relationships
IFSW will challenge environmental policies and practices that lead to multiple health damage and argue the importance of environmental sustainability for health
IFSW will oppose and seek to prevent the threats and damage to health caused by violence and conflict and seek to mitigate their consequences
IFSW will oppose and seek to prevent threats and damage to health caused by unregulated neo-liberal economic policies and to mitigate their consequences.

6. Securing and sustaining health depends on local, national and global health and social policies and practices.

IFSW will press for population based, public health policies and programmes, that emphasise health promotion, protection and maintenance
IFSW will press for a central emphasis on universal primary health services in line with the Alma Ata principles
IFSW will argue that it is primarily the responsibility of governments rather than markets to ensure universal access to health and to health services.

7. Securing and sustaining health depends on the concerted actions of international institutions, governments, civil society and peoples.

IFSW will collaborate with international, governmental, non-governmental and people’s health agencies and movements in the collective pursuit of socially just social and health policies and practices, including policies on the migration of health workers and intellectual property
IFSW will seek to ensure that governments act on the international commitments they have made to promote the universal right to health
IFSW will advocate that those who use health services and who bear the health consequences of health and social policy decisions are entitled to be involved in the planning and evaluation of services for health

Notes

Health is multi-dimensional. Many of the issues raised below are also addressed in other Policy statements of IFSW, including statements on human rights, globalisation and environment, poverty, HIV/ AIDS, older persons, women, rural communities, peace and social justice, and indigenous peoples. This Policy is to be read in conjunction with them.
We use the term ‘impairment’ rather than ‘disability’ here and elsewhere, as a descriptive term which does not imply who or what is the disabling factor.
See the IFSW policy on Globalisation and the Environment
We choose the term ‘health inequalities’ rather than ‘inequities’ or ‘disparities’ while acknowledging that different terms are currently used in different countries and individuals. We mean to describe a pattern of structured inequality persisting over time with identifiable patterns of benefit and harm.
We have avoided using the terms clients, customers or service users in this statement as they have different connotations in different countries and regions of the world.

This Policy Statement was approved by the IFSW General Meeting in Salvador de Bahia, Brazil August 14, 2008. It was authored by Paul Bywaters, Emeritus Professor of Social Work, Coventry University, United Kingdom and Dr. Lindsey Napier, Faculty of Education and Social Work, University of Sydney, Australia for the Social Work and Health Inequalities Network.