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Social Determinants of Health: Us and Them

November 27, 2013

The United Kingdom and the U.S. present strikingly different approaches to the social determinants of health (and illness). Health care is just one determinant of population health, along with factors that include social protection, access to employment, and supportive conditions for parenting, education, and family-building.

I previously mentioned the recent (October 30) WHO review of social determinants and disparities in the European region. The WHO takes a holistic view of social determinants of health, stating frankly that the lower health status of the poor, and the social gradient in health between and within countries, is caused by unequal distribution of power, income, goods, and services. The results are inequities in the immediate, visible circumstances of people’s lives—their access to health care, the quality of schools and access to higher education, their conditions of work, leisure, homes and neighborhoods, and the degree of protection from disadvantage or economic calamity as a result of ill health.

The WHO is blunt in describing the structural determinants and conditions of daily life that are responsible for a major part of health inequities. “This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.”

Poverty is especially salient, illustrated by the emerging research on the relationship between safety-net programs and toxic stress and its long-term consequences. Poverty, joblessness, and economic insecurity are a daily reality for many Americans. Long-term unemployment reached its highest levels on record in 2010, and today 36% of all unemployed workers (4.1 million) have been out of work for more than half a year. The minimum wage has been allowed to erode and is now 20% lower, after adjusting for inflation, than in the late 1960s. 17.6 million households experience food insecurity, and the Supplemental Nutrition Assistance Program (SNAP—formerly the Food Stamp Program) has 47 million participants. More than 90% of SNAP benefits go to families living below the poverty line and nearly two-thirds of the recipients are children, elderly, or disabled.

In this context, the U.S. House of Representatives has proposed cutting food stamp benefits by $40 billion over 10 years. These so-called hard-choice austerities would be in addition to the $5 billion in cuts that went into effect on November 1, when increases to SNAP that were included in the 2009 stimulus law were allowed to expire.

What can one say? Nicholas Kristof in an article for the New York Times describes Congressional slashing of food stamp benefits as “a mark of shortsighted cruelty.” Kristof also provides the assessment of Dr. Irwin Redlener, professor of pediatrics at Columbia University and president of the Children’s Health Fund: “The cutback in food stamps represents a clear threat to the nutritional status and health of America’s children. ”

Nobel Prize winning economist Joseph Stiglitz responded along similar lines:

There is no economic justification: The [farm] bill actually distorts our economy by promoting the kind of production we don’t need and shrinking the consumption of those with the smallest incomes. There is no moral justification either: It actually increases misery and precariousness of daily life for millions of Americans….[It] clearly harms both America’s children and the world’s in a variety of ways. For these proposals to become law would be a moral and economic failure for the country.

The federal actions in the U.S. are confounding, especially in comparison to responses beyond our borders. In 2005, in the spirit of social justice, the WHO established a Commission on Social Determinants of Health, publishing a final report in 2008. The Commission compiled evidence on what can be done to promote health equity, and identified three guiding principles of action: (1) acknowledge that there is a problem and ensure that health inequity is measured; (2) improve the conditions of daily life; and (3) tackle the inequitable distribution of power, money, and resources.

In Britain, the Secretary of State for Health commissioned an independent review of health inequalities, a project led by Professor Sir Michael Marmot, and in early 2010 a report Fair Society, Healthy Lives (the “Marmot Review”) was published. The recommendations of the Marmot Review focused on actions that could be taken outside the healthcare system to reduce health inequalities. Activities across the UK were undertaken on local implementation of the Review recommendations, and in 2011, the Institute of Health Equity was launched to support efforts to tackle inequalities in health.

The following year, Director-General Margaret Chan addressed the WHO Executive Board and emphasized the goal,

We want to see better health and well-being for all, as an equal human right. Good policies that promote equity have a better chance. We must tackle the root causes [of ill health and inequities] through a social-determinants approach that engages the whole of government and the whole of society.

Also in 2012, Dr. Cecil Wilson, the current president of the World Medical Association and former president of the AMA stated in his inaugural presidential address that a theme of his presidency was the social determinants of health.

In Britain, meanwhile, they rejected the common response of weary reluctance to the evidence on social determinants of health—it is simply all too difficult, or politically dangerous to face social and economic factors—the causes of the causes. Bravely moving forward, the Institute of Health Equity released a remarkable report in March 2013, its plain title hiding radical intent, Working for Health Equity: The Role of Health Professionals. This report focuses on actions and strategies that can be developed within the healthcare system, and particularly by the health workforce, where it is demonstrated there is abundant scope for effective action.

Royal Colleges and other organizations were asked to provide statements for action to give practical guides for health professionals to develop and use in their roles. The result was an enthusiastic response, with 19 statements for action provided by the following professional groups:

  • Nurses
  • Social workers and social care
  • Clinical Commissioning Groups
  • General practitioners
  • Pediatricians
  • Midwives
  • Obstetricians and gynecologists
  • Hospital doctors
  • Dentists and oral health teams
  • Psychiatrists
  • Medical students
  • Allied health professionals
  • Music therapists
  • Dieticians
  • Occupational therapists
  • Physiotherapists
  • Speech and language therapists
  • Paramedics
  • Radiographers

The report offers compelling evidence of how much the health system can do to influence wider social and economic conditions beyond ensuring equity of access and treatment. Britain is proving that those working within the health system have an important (but often underutilized) role in reducing health disparities through action on the social determinants of health.

Kudos. Definitely the Brits should keep calm and carry on. While we in the U.S. could at least try to do less harm.

—    Michael Lytton, AJPM Blog Editor

Further Reading in AJPM:

Marmot MG, Bell RG. Improving Health: Social Determinants and Personal Choice. Am J Prev Med 2011;40(1S1):S73–7.

Miller WD, Braveman PA, Williams DR, Kumanyika SK, (eds). Strong Medicine for a Healthier America. Am J Prev Med 2011;40(1S1).

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