The Case for the Social Determinants of Health Discourse
26 August 2016 in Health
In 1998, Ann Robertson wrote that the ways in which a society thinks about health care are constructed by discourses of health. Discourses of health are the theoretical structures that define 'health' and make causal claims about what practices will produce health. The biomedical model is the predominant health discourse in Canada with its main focus on surgical and medical curative methods. In the biomedical model, health is understood as an ideal state of the physical organism that is achieved by scientific-technical interventions to re-adjust the body to its healthy equilibrium when disease or accident disrupts it. The biomedical model thus prioritizes the financing of a scientific health care system as the means to promote health.
The biomedical discourse of health underlies the construction of the Canadian public health care system from the 1950s to 1971, when the basic structure of the current health care system was completed. As the universal health care system was developing, rising health care costs raised concern in the federal government. As Robert Evans, a health economist explains, these concerns of the federal government were exacerbated when epidemiological data revealed that morbidity (illness) and mortality (death) rates had not decreased with greater access to health care services, and that the population was not significantly healthier. In 1969 a government task force was created to study the actual and future costs of a universal health insurance care system. The results of this task force would become the basis of the renowned publication of then Minister of National Health and Welfare's Marc Lalonde's, A New Perspective on the Health of Canadians (Health and Welfare Canada, 1974).
Lalonde's (1974) green paper purportedly signaled a paradigm shift in health discourse because it postulated that increased funding of health care services, would not improve health. Instead, Lalonde argued that the greatest improvements in health would be derived from individual lifestyle changes and improvements in the quality of physical and social environments. The Lalonde Report (1974) as it came to be known, was important because it opened a new discourse on health: that which would become the social determinants of health discourse. The Lalonde report introduced the health field concept from which the social determinants of health discourse ultimately derived. The social determinants of health discourse shifts attention away from health as an abstract state of a biological organism to resituate it in an ecological perspective. To promote health the social determinants of health discourse recommends environmental and social changes to address the structural inequalities that those groups of people who are most unhealthy suffer. What is called health promotion today is still understood to be a part of the social determinants of health model. I would argue however, that this contemporary understanding is actually distinct and opposed to the social and economic implications of the social determinants of health model that derives from the Lalonde Report.
The emergence of social determinants of health
The Lalonde (1974) report was published during an era that was rife with social, economic and political changes. Social movements such as feminism and environmentalism challenged the dominance of the biomedical model as a sufficient explanation for the causes of disease and wellness. These social movements and the new thinking that derived from the Lalonde Report were making it clear that poverty could not be ignored as a primary cause of ill health. The social determinants of health model emerged as researchers sought to explain how experiences of daily living conditions in conditions of structural inequality in access to basic life-requirements influenced the health of individuals within a population. The term ‘social determinants of health’ was officially used in 1996 by David Blane, Eric Brunner, and Richard Wilkinson, the editors of Health and Social Organization: Towards a Health Policy for the 21st Century, who were expanding upon Lalonde’s (1974) health field concept.
Lalonde's health field concept consisted of four elements: human biology, health care organization, environment(s) and lifestyle. Since 1996, the actual social determinants of health have been variously theorized in academic literature and numerous national and international policy documents. While the list has grown over the years, what has remained consistent is the basic claim that the causes of ill health are not diseases in the abstract but rather are the social conditions in which people live. In 2008, the World Health Organization's [WHO] Commission on Social Determinants of Health [CSDH] stated bluntly that "social injustice is killing people on a grand scale" (WHO, 2008, 1). The World Health Organization's evidence clearly depicts that length of life expectations are positively correlated with levels of poverty. If it is true that social structure determines health, then it follows that spending money on the scientific health care system without addressing the social causes through public policies that correct inequality will not work.
The Canadian government's awareness of the relationship among social, economic and political factors was first articulated in the Lalonde Report (1974). It is esteemed for its recognition that investing in resources beyond immediate health care services was critical for the health of populations. Numerous publications that followed the Lalonde Report honoured this awareness of social and economic influences on health. A key example is Achieving Health for All: A Framework for Health Promotion, released in 1986 by Jake Epp, then Minister of Health and Welfare. Its release coincided with the release of the WHO's Ottawa Charter for Health Promotion (1986). Epp's framework was concerned with growing health inequalities despite universal health care. The Epp report (1986) and Ottawa Charter (1986) like the Lalonde report (1974) recommended shifting health services from costly acute care hospitals to health services that were less costly, such as home care, and community care. This new health promotion discourse advocated for strategies that included community participation and empowerment of individuals within their communities, yet public policies during this period still did not reflect these perspectives according to Dennis Raphael of York University. Minimal changes to social and health policy occurred in Canada. According to Raphael it was the ideological disagreements within health promotion practice that ultimately prevented the implementation of the Ottawa Charter’s major strategies (Raphael, 2009).
While ignored in public policy, the social determinants of health made great strides theoretically. In 2002, York University's School of Health Policy and Management hosted the "Social Determinants of Health Across the Lifespan: A Current Accounting and Policy Implications" conference. This conference identified social determinants of health that affect the health of Canadians and addressed the real causes of health inequalities, primarily social and economic policies that have corporatized public services. In 2002, the list of social determinants of health compiled at the York University conference included Aboriginal status, early life including pre and post-natal and maternal health, education, employment, working conditions, food and housing security, gender, health care services, income distribution, social safety net, social exclusion, and employment security (Raphael, 2009, p.7). In 2010 Juha Mikkonen and Dennis Raphael added race and disability to this list and these 14 social determinants of health have been published as The Canadian Facts (2010). Mikkonen and Raphael stressed that these determinants were not to be understood in isolation but rather were to be understood as interrelated factors that collectively influence and determine health status.
Today in 2016, there remains the recognition that social and economic determinants of health impact the health of individuals and populations. The Ontario Public Health Standards (2014) guide Ontario health programs by addressing "determinants of health and reducing health inequities" (4) primarily by identifying at risk populations. The former Ontario Agency for Health Protection and Promotion, now Public Health Ontario (PHO) strategic plan for 2014-2019's mission is to "promote health and contribute to reducing health inequities" (2013, 5) through scientific and technical research. The Chief Medical Officer of Health in the opening message of the Ontario Public Health Sector Strategic Plan for 2014-2019 states "the social, economic and environmental determinants of health—the conditions which people are born, grow, live, and work are different for each Ontarian—and result in poorer health for some" (2) but there is no explanation why these differences exist. The PHO strategic plan has aligned with Ontario's Public Health Sector Strategic Plan for 2014-2019 and together they promise to be the 'roadmap' that will lead Ontarians to top levels of health.
While this roadmap designed to increase overall health in the province of Ontario acknowledges awareness of social and economic influences on health in the same way that the Lalonde and Epp reports did, the strategic goals do not challenge the social and economic structures which determine equal distribution of resources. With small exceptions, health promotion continues to focus on identifying and eliminating negative risk behaviours. Again, minimal discussion of structural or policy change can be located in these current documents which represent Ontario's strategic plan for 2014-2019. For this reason it is imperative to advocate for the social determinants of health discourse as the most appropriate discourse for health care today. For some time now, at least forty years, the evidence has grown and supports the fact that social and economic structures largely determine health. Moreover, it can be concluded that continuing to spend money on the consequences of risk behaviours in isolation of addressing social causes that influence health behavior in an effort to correct inequality simply will not work.