'You cannot think about health without thinking about politics'
Rudolphina: Ms Hansen, you have been studying the structural roots of health inequity for many years. What are the main learnings from your research?
Helena Hansen: It is hard to image a health issue where the health outcome is not strongly shaped by societal and political structures. To give an example, if we look at where chronic disease is most concentrated today in the US, we see that it overlaps with patterns of segregation based on race and immigrant status.
This social divide by class and race has been institutionalised since the country came to be and was explicitly enforced by policy and urban planning. Segregated neighbourhoods were also subject to various discriminatory practises, such as 'redlining': financial services, such as bank loans to own a home or open a small business were restricted based on the neighbourhood that you lived in until the mid-20th century.
Rudolphina: How did this social divide affect the health of the marginalised groups?
Helena Hansen: The effects are intergenerational and visible to this day. Without access to home ownership or credit, families were limited in their ability to build wealth or get higher education. At the same time, their neighbourhoods are more exposed to pollution, more densely populated, and often lack access to public transportation and fresh food. All of these factors impact people's health.
So what we see in the US today is not a coincidence, but the result of long-term structural exclusion shaping the living conditions of marginalised groups and therefore their health outcomes.
Discussion: Differences between European and American health care
The panel discussion with Helena Hansen, Robert Böhm and Janina Kehr examined the differences and similarities between the US and European healthcare systems. Against the backdrop of the US opioid crisis, Kehr highlighted that in Austria medicines may not be marketed directly to consumers. She considers an opioid epidemic comparable to the USA unlikely in Austria: 'We have safeguards, the wellfare state and a functioning healthcare system that would make an epidemic of this scale - for now - hopefully not imaginable'. Hansen appealed to advocate for this strong European-style welfare state health system and for independent university health research. She urgently warned against privatisation as in the USA, where health is subordinated to the financial interests of companies and research questions are often determined by financiers from the private sector.
The lecture series 'Health in Society' is open to anyone interested in learning more about the connections between health and society. Click here for more details and the programme.
Rudolphina: Since the early 2010s, the US is facing the third wave of the opioid epidemic. What can we learn from this public health crisis about the interplay of structural racism and healthcare?
Helena Hansen: By interviewing pharmaceutical executives and addiction scientists, as well as practitioners and patients, I discovered a case study of how our pharmaceutical and biotech industries are structured by racism. I call this racial capitalism. And the latest wave of the opioid crisis is a consequence of this.
Rudolphina: How so?
Helena Hansen: In the 1990s, Purdue Pharma introduced a new extended-release pill, designed to release small amounts of the opioid over time and marketed as 'minimally addictive'. Based on this claim, they received approval to promote it widely, including to primary care doctors who do not usually prescribe opioids. As a result, opioid prescriptions increased tenfold.
The marketing heavily relied on racial stereotypes, as it was aimed at affluent white populations who were perceived as 'trustworthy patients' less prone to addiction. In practise, however, opioid misuse exploded also among whites, because anyone who wanted a rush, quickly learnt to crush this widely available pill and snort or inject the opioid. By relying on a technological fix for addiction and on racial stereotypes about who is at risk, the manufacturers overlooked how the drug would actually be used.
Rudolphina recommends: TV shows and books on the US opioid crisis
The opioid crisis in the United States is one of the most significant public health crises among industrialised nations. Widespread misuse of opioids leads to addiction and deaths caused by overdosing. In 2023 alone, about 80,000 overdose deaths involved opioids. Find out more here on the website of the Centre for Disease Prevention (CDC).
In recent years, TV shows have helped bring the crisis to a wider international audience:
- Painkiller: a fictionalised retelling of the role of pharmaceutical company Purdue Pharma in the opioid crisis and the efforts to bring the company owners down.
- Dopesick: starring Michael Keaton, it follows a small-town doctor and his patients as they become victims of a 'miracle' painkiller, while federal prosecutors fight to hold the manufacturers accountable.
We also recommend the following books:
- Whiteout by Helena Hansen, Jules Netherland, David Herzberg, the first critical analysis of how Whiteness drove the opioid crisis.
- Empire of Pain by Patrick Radden Keefe, a deeply researched history of the Sackler family, owners of Purdue Pharma, and their role in the crisis.
Rudolphina: The focus on biotechnological solutions to health issues is also reflected by today's rise of personalised medicine.
Helena Hansen: Absolutely. But I think medicine should extend the notion of personalised medicine to interventions beyond genetics, targeting the social needs of the individual.
I have been using the term 'social technologies' to highlight the importance of social interventions to improve health outcomes. 'Social technologies' are approaches that bring people together for mutual support and create a sense of meaning and belonging ‒ factors that are central to long-term recovery in addiction and mental health. In South L.A., for example, where access to fresh food is limited and environmental conditions are poor, community gardening has become a widespread response. It not only improves access to fresh food but also strengthens social ties.
This matters because in mental health and addiction, the social context is a very important driver of health outcomes. It's not just genetics, and it is a real failure of our health care system that we haven't systematically developed the social technologies to go along with the molecular technologies. This failure is built on the belief that technology is the answer.
Food deserts in the United States
Food deserts are areas, often low-income urban or rural neighbourhoods, that lack reasonable access to fresh, nutritious foods. Instead, residents have to rely on fast food or convenience stores. 'In southern L.A., for example, trucks go around to sell canned foods because there's so few grocery stores in the area, despite California being the bread basket of the US', says Helena Hansen. 'There is no public transport, and low-income households don't necessarily have a car.'
It is a failure of our health care system that we haven't systematically developed the social technologies to go along with the molecular technologies.Helena Hansen
Rudolphina: The individual has little control over many social determinants of health, such as income, place of residence, gender, social status. How can society address this challenge and make health more equitable for all?
Helena Hansen: It's true, we cannot do much on our own, it takes collective action. Health outcomes are so intimately linked to living conditions and the policies and institutions that drive them, that we cannot think about health without thinking about politics.
Therefore, I am calling for what I refer to as 'structural competency': Doctors should not only understand the structural drivers of their patient’s health but be able to act on those. This means collaborating with community organizations and with other sectors like housing agencies and legal aid organizations. It also means advocating for health promoting policies and institutions.
We've seen a positive example of this during the AIDS epidemic, when doctors teamed up with activists to shift research priorities. This put them in the position to actually improve their patient’s health. And when doctors can better help their patients, we see that it also improves their own well-being.
Rudolphina: Speaking about politics, this semester, Rudolphina takes a closer look at the challenges facing democracy and human rights. What is the relation between democracy and health equity?
Helena Hansen: Health is fundamental to make use of our potential. This is widely accepted. And all those societal factors that we talked about, from housing to economic opportunities and education, determine most of the variance in health outcomes.
Health was a major agenda of the civil rights movement in the 1960s and 1970s and is still at the centre of human rights activism in the US. For example, and that is a little-known story, the Black Panther Party also ran free clinics, and health inequality was what drew people to the party. The 'Young Lords', a Latin American movement, took over a hospital in the South Bronx to demand more investment and providing free tuberculosis screenings in their community. Today, safe spaces for undocumented migrants often include health care and clinical services.
Therefore, I think the right for health is an effective platform for mobilising democratic action ‒ both democracy and health care require active and constant care and participation.
Rudolphina: Thanks for stopping by for the interview!