Exploring a revolutionary framework that connects social, health, environmental, and cognitive justice to reinvent public health for the 21st century.
Imagine a world where everyone enjoys perfect health, where medicine has eliminated disease, and life expectancy stretches decades longer than today. Now imagine the cost: constant health monitoring, every meal regulated by authorities, your body's data forever available to government agencies, and all personal health choices made for you. Does this sound like a utopia or a dystopia?
This isn't just science fiction—it's the central paradox explored in Project Itoh's novel Harmony, where achieving perfect health requires surrendering fundamental freedoms . This fictional dilemma mirrors our very real crisis in public health utopias. For decades, we've dreamed of "health for all," yet that vision remains frustratingly distant. Our current approaches are failing, and the COVID-19 pandemic painfully exposed how fragile our health systems truly are, with inequalities determining who lives and who dies 6 .
"The crisis of utopias in public health isn't a reason for despair, but an opportunity to dream better—and more realistically."
But there's hope emerging from this crisis. Revolutionary thinking from Brazilian scholar Boaventura de Sousa Santos and others offers a new framework: the four justices. This approach connects social, health, environmental, and cognitive justice into a comprehensive roadmap for reinventing public health 1 . In this article, we'll explore how this innovative framework could finally help us build a truly healthy world—without sacrificing our humanity.
In Harmony's fictional world, citizens receive "super-medicine" through advanced technology. A device called WatchMe constantly monitors their health at the molecular level, while home-based systems called Medicare instantly synthesize and deliver precise medications . Diseases are virtually eliminated, and people enjoy extraordinary longevity.
Sounds ideal, right? Yet in this world, health becomes oppression. Citizens must constantly prove their healthworthiness, privacy disappears, and any non-compliant behavior is socially punished. The novel's characters struggle with profound existential despair despite their physical wellness—some even choose suicide .
This fictional scenario reflects a real-world pattern: our pursuit of perfect health solutions often creates new problems. The "Universal Health Coverage" (UHC) initiative, for instance, aims to ensure everyone receives quality healthcare without financial hardship. But in practice, it often emphasizes financial protection over comprehensive care, leaving quality and accessibility issues unaddressed 6 .
According to public health scholars, our crisis stems from a "broader crisis of utopias" within Western civilization 1 . We've embraced a narrow, Eurocentric vision of progress that separates:
This fragmented approach has led to what Santos calls the "destructive potential of Eurocentric, Western and capitalist modernity" 1 . We're trying to solve health problems with the same thinking that created them.
The four justices framework proposes that we can't fix public health by focusing on healthcare alone. Instead, we must address four interconnected types of justice:
Health justice expands our understanding of what creates health beyond medical care. It includes:
The COVID-19 pandemic revealed how countries with stronger public health systems and greater social solidarity managed the crisis more effectively 6 .
Environmental justice recognizes that health isn't just about what happens in doctors' offices—it's about whether we have clean air, safe water, and healthy environments 1 .
Communities fighting toxic dumping sites or polluting industries aren't just protecting their environment—they're protecting their health. This perspective connects public health directly to political ecology and the movement for health and dignity 2 .
Cognitive justice may be the most revolutionary concept. It challenges the idea that Western science is the only valid way of knowing about health 1 .
This means respecting:
Santos calls these alternative ways of knowing "Epistemologies of the South"—recognizing that communities outside the Western tradition have developed profound understanding of health and healing 1 .
The four justices framework shows how different forms of justice intersect. For instance, environmental justice requires cognitive justice—respecting community knowledge about local environments 2 . Similarly, health justice requires social justice—addressing the economic systems that create health inequities 1 .
While theories matter, science requires evidence. A revealing study examined how emancipation from foster care affects health risk behaviors—a perfect test case for how social systems impact health 7 .
Do health risk behaviors like substance use and sexual risk-taking increase after youth leave the foster care system, or are they established patterns from earlier experiences?
Researchers followed 151 foster youth ages 16-20 for 12 months, surveying them about substance use and attitudes toward sexual risk behaviors at baseline, 6 months, and 12 months. The unique design tracked these behaviors both before and after emancipation for different youth 7 .
| Characteristic | Percentage | Number |
|---|---|---|
| Female | 56% | 85 of 151 |
| Emancipation at 18 | 67% | Not specified |
| Emancipation at 19 | 20% | Not specified |
| Emancipation at 20 | 10% | Not specified |
| Emancipation at 21 | 3% | Not specified |
The findings overturned conventional wisdom:
Showed no significant change as youth approached or experienced emancipation. This suggests that substance use behaviors were already established while youth were still in foster care 7 .
Actually became more cautious as emancipation approached, contradicting expectations that leaving the system would increase risk-taking 7 .
| Health Behavior | Before Emancipation | After Emancipation | Statistical Significance |
|---|---|---|---|
| Substance Use | Established patterns | No significant change | B = 0.01, p = 0.81 |
| Attitudes to Sexual Risk | More cautious approach | Continued caution | B = 1.67, p < 0.01 |
This study demonstrates several key principles:
The foster care system itself—with its instability and trauma history—appears to establish health behaviors long before emancipation.
Interventions need to happen early, while youth are still in the system, not just as they're leaving.
Female participants reported less substance use but more positive attitudes toward sexual risk-taking, revealing how different factors interact in health behaviors 7 .
| Gender | Substance Use | Attitudes to Sexual Risk |
|---|---|---|
| Female | Significantly less (B = -1.15, p = 0.03) | More positive (B = 3.09, p < 0.01) |
| Male | More frequent | More cautious |
How do researchers study complex social health problems? Here are key tools from the studies we've examined:
| Research Method | Purpose | Example from Studies |
|---|---|---|
| Multilevel Modeling | Track changes over time in relation to specific events | Analyzing health behaviors before/after emancipation 7 |
| Political Ecology Analysis | Examine power relationships in environmental health | Studying communities fighting environmental threats 2 |
| Epistemological Diversity | Include different knowledge systems in research | Valuing indigenous health knowledge alongside Western science 1 |
| Natural Experiments | Observe real-world policy changes | Studying health impacts when foster care is extended to age 21 8 |
| Longitudinal Cohort Studies | Follow populations over extended periods | Tracking foster youth through emancipation transition 7 |
The foster care study demonstrates the importance of testing assumptions. Rather than assuming emancipation caused health risks, researchers let evidence guide them—finding that problems started much earlier 7 . This exemplifies the scientific humility needed for effective public health.
From foster care systems to indigenous communities protecting their environments, every community offers insights about health justice. The COVID-19 pandemic revealed how countries with stronger social welfare systems managed the crisis better 6 —natural experiments showing the connection between social and health justice.
"The real utopia isn't a perfect world without disease—it's a world where justice, in all its forms, creates the conditions for health to flourish."
The crisis of utopias in public health isn't a reason for despair, but an opportunity to dream better—and more realistically. The four justices framework doesn't offer magical solutions, but something more valuable: a comprehensive approach that connects the dots between social systems, environmental conditions, knowledge diversity, and healthcare itself.
As Brazilian public health scholar Boaventura de Sousa Santos argues, we need "realistic paths of hope from the present" 1 . This means:
The path forward isn't about finding one perfect solution, but about weaving multiple justices together. It requires scientists who listen to communities, doctors who understand social contexts, and all of us recognizing that our health is ultimately connected to everyone else's.
The real utopia isn't a perfect world without disease—it's a world where justice, in all its forms, creates the conditions for health to flourish.