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In their paper entitled ‘Rose’s population strategy of prevention need not increase social inequalities in health’, McLaren et al. offer a cogent response to our earlier paper ‘The inequality paradox: the population approach and vulnerable populations’. It is a pleasure, and was indeed our goal, to see a lively debate sparked by our initial musings. It is therefore an equal pleasure to respond to their paper as part of a further debate. McLaren et al.’s argument rests in part on the idea that not all population prevention interventions influence social inequalities in health to the same extent. They argue that their influence depends on whether the strategy is what they call structural or agentic; the former targets the conditions in which behaviours occur, the latter, behaviour change among individuals. They conclude that structural interventions are less likely to worsen social inequalities in health than agentic strategies. While this distinction is interesting it may be somewhat distracting given that social inequalities in health, we have argued in the past, arise due to the interplay of ‘both’ structure and agency. While McLaren et al. rightly cite Anthony Giddens as an important 20th century thinker with respect to the structure/agency debate, they fail to mention that among Giddens’ most important contributions to sociology has been his structuration theory. Structuration theory is based on the idea that both agency, defined as the ability to deploy a range of causal powers, and structure, objectified as the rules and resources in society, give rise to people’s social practices, which are the activities that make and transform the world we live in (referred to by people in public health as behaviours). Using the heuristic of collective lifestyles, it has been argued that an adequate tackling of inequalities in health should address all three aspects of structuration theory (agency, social structure and social practices) rather than structure or agency alone. Indeed, we thank the authors for bringing us back to some of our earlier reflections with regard to the structure/agency relationship as it plays a crucial role in our new argument regarding vulnerable populations. By using the term vulnerable populations, we sought to move away from risk factor epidemiological thought, which tends to focus largely on behaviour alone, and suggest that some groups are vulnerable with regard to their agency, their position with regard to the social structure and their social practices. It is only by focusing on all three that one would be able to reduce social inequalities in health, as all three are at the base of these inequalities. However, we agree with McLaren et al. that the use of the term vulnerable populations is not without problems, including potential stigmatization. One might consider instead the concept of exclusionary process developed by the Social Exclusion Knowledge Network of the WHO Commission on the Social Determinants of Health. Their critique of the notion of vulnerability is that it emphasizes a state without identifying causes, and that it becomes a characteristic of people and not the result of a process. On the contrary, an exclusionary process originates in the unequal distribution of four types of resources: material, cultural, social and political. It is the unequal distribution of these resources that reproduces health inequalities. This notion of exclusionary processes points to the importance of working upstream in order to address some of the original causes that led to the unequal distribution of these resources. A final note is warranted regarding our perspective on participation. The authors suggest that participatory strategies may ultimately be agentic if structural conditions are not addressed. It is true that the public health literature tends to be ideological and offers little theoretical breadth with regard to the conditions required in the participatory process. In our view participatory planning is a political process. This process Published by Oxford University Press on behalf of the International Epidemiological Association

Commentary: Structure or agency? The importance of both for addressing social inequalities in health