Men are born free and remain free and equal in rights. Social distinctions can be based only on public utility.” The first article of the French Declaration of the rights of Man and of the Citizen of 26th August 1789 subsequently served in 1791 as the preamble to the Constitution of the French Republic. Yet from a person’s birth, obvious health inequalities emerge and these have a direct impact on life expectancy, with a particularly negative effect on those with the lowest incomes. Preventable premature mortality also affects the different social classes in a very selective way.
Redressing these inequalities is therefore a question of social justice, but action taken on this front should not be an act of charity in which good will supersedes competence. Knowledge, know-how and life-skills are indispensable. These cannot be plucked from the air but are the outcome of a necessary learning process, enriched by experience. However, the acquisition of these skills is patently absent in the basic training for a great number of occupations including those in which professionals are commonly faced with social inequalities and the impact of these on health. This point has been made very clearly in a certain number of reports commissioned by successive governments, including that of the French High Council for Public Health in 2009. The high-level conference on public health held in France in January 2016 under the auspices of the Prime Minister, aimed to emphasize the essential preconditions for the success of any new health law, including training health professionals on the Indexes of Social Health. The instigators of this publication aim to contribute to meeting this challenge and perpetuate dynamics initiated a decade ago.
The fruits of shared experience
Starting in 2003, some stakeholders working for the NGO “Médecins du Monde” [Doctors of the World] began to set up postgraduate degree courses in University Medical Schools in several towns, on the subjects of health, solidarity and vulnerability, first in Grenoble, then in Lille, Paris, Bordeaux, Montpellier, Strasbourg, Nancy and Clermont-Ferrand. Open to a wider public than just doctors, these degrees were backed by those Deans of Medical Faculties who were sensitive to the importance of these issues, and by various key local players in the medical and social fields: local and departmental authorities, regional health agencies, mutual insurance societies, health centres, public hospitals, other associations. In every case, all these actors were closely involved in the conception and implementation of the teaching courses created. As a result of these alliances and synergies, the content of these courses and the skills targeted went beyond the ambit of serious poverty to deal with wider health inequalities all the way along the gradient of health inequalities which characterise human communities.
This book is the fruit of the experience of these remarkable “co-building” dynamics. It illustrates the contribution of French associations as catalysts and innovators, just as Alexis de Tocqueville hoped they would. At the beginning of the 19th century, he saw them as having a political role to play, just as Didier Fassin today calls the actions of health practitioners the “tools of social construction”. Without this creative energy, the book would not have been written. These project leaders and the skills they deployed in the teaching courses they designed are referred to in most chapters.
A content, the result of proven educational experience
The chapters are structured around six themes, following a logical progression directly inspired by the university experiences mentioned above, and by the annual evaluations made by the students on the courses. A general framework is first provided with reference to historical, political, technical and legal benchmarks, the knowledge of which is essential if readers are to understand the concepts conveyed as they advance through the book.
Then, following a logic which is commonplace in the analysis of health issues, three approaches are used to analyse the situations: one based on specific populations, another on the type of local community (or the lack of any links to a specific community) and a third approach dealing with the most common health problems found among the most disadvantaged. These approaches define the following three parts. The crucial question of the difficulties often experienced when implementing initiatives in favour of the socially disadvantaged is then considered. This is the part of the book that deals with the “conditions for the success” of the solutions applied. The sixth and final part is the logical consequence of the first: since the processes producing health inequalities are various, the ways of solving them are also necessarily to be found in the convergence and synergies in the spheres of competence and the institutions which contribute to health promotion initiatives. The book ends on the issue of alliances, networks and partnerships.
Subhead: A wide readership
The book is intended for various different groups including those undergoing initial, in-service or lifelong training, or simply professionals, politicians and policymakers and those who are confronted with or interested in these issues. It targets, among others:
- students enrolled on the various health, solidarity and vulnerability courses already available;
- students and professionals in the health, social and welfare spheres;
- students following graduate and post-graduate medical studies and those studying for other healthcare professions;
- students in healthcare management institutes (IFCS);
- professionals training at the French National Public Administration Centre (CNFPT);
- politicians and heads of associations and organisations;
- … and all stakeholders not mentioned here who are called upon to deal with the issue of the access of vulnerable sections of society to health services.
Translated from the French by Fay Guerry