Market failure is bad for your health but social injustice is worse

Smith and Petticrew succinctly outline the challenges we face in evaluating the impact of public health interventions tackling social determinants: challenges driven by multiple agencies with varying and sometimes conflicting interests, complex causal pathways and outcomes that extend beyond health. Looking ahead they call for a new evaluation approach, one that focuses on the whole before it focuses on any single part: a macro- rather than a micro-approach. They generously invite comment, which is valuable as their conclusions are important and bear repetition and re-emphasis. Some readers may take issue with points they make along the way. Does the contemporary agenda on socio-economic factors really represent a move away from infectious disease when prevalence of diseases such as tuberculosis remains one of the most blatant indicators of a breakdown in social and economic structure? 1 Is the interest in social determinants really so recent or have the authors overlooked the efforts of Farr, or Virchow and others who followed who saw poverty and its associated social and political conditions as the root cause of ill health and political reform, economic development and education as legitimate instruments of public health? 2 Others will not see themselves in the simple portrait painted of the micro-evaluation even when they locate themselves in that camp. The use of mixed methods, while not common, is not the exclusive domain of macro-evaluation. 3