Introduction to the Social Determinants

Introduction to the “Social Determinants of Health” debate

This topic, though not new, raises debates and controversies.

Some people criticize the term “social determinant” stating that it assumes the existence of a dominant social logic that conditions social actors, who then lose their capacity for collective transformation and weaken their quest for identity.

Others hold the view that “social determination” of the health-disease process is a strongly explanatory expression, entailing strategic elements for compelling social change.

Still others prefer to use the expression “determinants of health” without adding the word “social,” which would restrict determination by excluding any political, environmental, economic, cultural, psychological, spiritual or other determinants. Instead, for others, the word “social” is an umbrella term encompassing all such attributes.

Controversies also arise between the expressions “determinants of health” and “determinants of inequities in health.” For some people, the former refers to the risk factors in classical epidemiology. In distinguishing both expressions, they see in the latter a stronger potential for transformation that would lead to a better understanding of unfair hierarchies in social structures, thus revealing the “true cause” of health inequity.

This discussion is not yet closed. But as you undergo this learning process it is important that you understand how rich and polysemous the concept of “social determinants of health” is and that you wonder whether it would be necessary to find a common language to ensure concerted political actions.

As long as no consensus is reached for a “lingua franca” the concept of “social determinants of health” should be considered in all its bearings. Understanding the health-disease process from this angle will give us a broader and more politicized view and will help us understand the need for more coordinated and integrated public policies designed on consensus —by governments, social movements and NGOs— aimed at improving life quality.

Why is it necessary to focus on the Social Determinants of Health?

The social conditions in which people live have a dramatic impact on their health. In fact, circumstances such as poverty, poor schooling, food insecurity, exclusion, social discrimination, bad housing conditions, deficient sanitation in early childhood and poor occupational skills in adulthood are all major determining factors of inequality both among and withincountries in terms of health, disease and mortality rates

To improve the health conditions of the world population and increase equity in health, new action strategies that address the social factors affecting health are required. This does not mean that equitable health care systems are no longer important. But we must recognize that more often than not health care systems are part of the problem, and therefore, these systems plus new strategies are indispensable to lower or eradicate health inequities.

Social circumstances —social stratification and position— determine not only social inequities (at the population level) but also health inequities, through intermediary determinants. The institutional, socioeconomic and macroeconomic contexts, the social values adopted by a given society, and inequitable public policies are all key factors in causing social inequities. Individuals and social groups in the lowest social strata run twice the risk of serious illness and premature death. Material and psychological causes contribute to these risks, their effects extending to all causes of disease and death and to all social groups. Social disadvantages may be absolute or relative, and they tend to affect the same social groups, resulting in a lifelong, accumulated impact on health.

Not only do inequalities appear across countries, but radical differences are found within any given country. Health differences occur along the social ladder and involve socioeconomic, political, cultural and geographical dimensions. One way of measuring inequity is to pay attention to the distance between those at the top and those at the bottom of the social ladder. Nevertheless, all along the social gradient there are unfair inequalities that may well be avoided.

The influence of social determinants becomes evident not only when comparing the distance between those at the top and those at the bottom of the social ladder, but also when health indicators are checked against other variables along the social scale. In Bangladesh and Thailand, low-income young women having completed their secondary education have better health indicators than other girls with only primary education or no schooling at all. No analysis should focus only on the situation of those living in poverty; the poorest among the poor see the Final Report of the Women and Gender Equity Knowledge Networks available in Links, Full Texts) When we analyze the social distribution of health along the entire social ladder, it is clear that we are all involved.

Food-for-Thought Activity