From the Social to the Ultimate Determinants of Health

The notion that health is influenced by society, and the politics governing it, has been around for generations. Rudolf Virchow, known for his advancement of public health, is quoted famously for his 1841 declaration that “medicine is a social science, and politics is nothing else but medicine on a large scale”.

The contemporary uptake of this idea can be found in the increasingly popular concept of ‘social determinants of health’ (SDOH).  Introduced in the 1970s, SDOH theory arose as a critical response to a public health agenda narrowly focused on an individualized and bio-medical understanding of health.  Popularized in the 1990s, SDOH seem to be of increasing concern nowadays and are generally understood to represent the resources by which people control the conditions of their life. These resources include things like food, housing, income, education, employment, our physical environments, as well as their distribution across society.

But should all social determinants be treated with equal concern? In other words, are certain determinants more important than others in influencing the health of populations?

In 1995, researchers Link and Phelan introduced a distinction which begins to answer this question.  Highlighting the importance of SDOH (without explicit reference to the concept), Link and Phelan distinguish between SDOH which ‘contextualize risk factors’ and those which represent the fundamental determinants of health. Whereas the former explain “how people come to be exposed to individually-based risk factors such as poor diet, cholesterol, lack of exercise, or high blood pressure” (p81),the latter are broadly conceptualized to include things like “money, knowledge, power, prestige, and the kinds of interpersonal resources embodied in the concepts of social support and social networks”(p87).

The main point of this distinction is that even if we change the contexts within which people are exposed to individually based risk factors (things like access to parks, healthy foods, and health care), unless we address the fundamental determinants of health, the link between socio-economic status and health will continue to shape population health profiles. This is because fundamental causes are associated with multiple risk factors as well as multiple health outcomes. Moreover, we live in a dynamic world system where new diseases and risk factors are always emerging and those with greater access to resources will always be better positioned to respond to them.

A SDOH distinction advanced by researches more recently, distinguishes between the structural determinants of health, factors related to social positioning, and the social processes responsible for the distribution of these determinants (sometimes termed the social determinants of health inequalities).  By positioning social processes further upstream, this distinction, like Link and Phelan’s fundamental cause theory, gives strength to the idea that not all social determinants of health should be treated with equal concern.

With even greater discernment of the various ways in which SDOH can be understood, recent work by Dennis Raphael identifies seven unique SDOH discourses, each with divergent policy implications (see the SDOH discourse table below). Raphael uses the term ‘discourse’ to differentiate the various ways researchers talk about SDOH since these different approaches “appear to direct the kinds of research and professional activities that are deemed acceptable” and thus, like the Foucaultian concept of discourse, “involve issues of legitimation, power, and coercion” (p223).

SDOH Discourses

Source: Raphael, D. (2011). A discourse analysis of the social determinants of health, Critical Public Health, 21:2, 221-236

Aside from gaining insight into the type of policy implications associated with each of these discourses, from Raphael’s outline it becomes clear which type of SDOH discourses merely contextualize risk factors (discourses 1 through 3) versus those which address the fundamental determinants of health (discourses 4 through 7).  We are also able to set aside those which focus mainly on the structural determinants of health (discourses 1 through 4), and those which direct attention to the processes responsible for the distribution of these determinants (and thus also responsible for health inequalities) (discourses 5-7). Most importantly however, we are directed to the ultimate determinants of health (discourse 7): “the individuals and groups who through their undue influence upon governments create and benefit from social and health inequalities—and in the process threaten the quality of the SDH to which individuals are exposed and skew their distribution” (p229).

While SDOH theory arose as a critical response to the preponderance of individually and healthcare-based responses to disease, with Raphael’s discourse analysis, we are forced to question how far the SDOH concept has actually begun to address this concern—especially given the respectively diminishing attention directed towards the fundamental determinants of health, the policies responsible for their distribution, and the ultimate drivers of these policies: those who benefit from their disequalizing  consequences.


3 thoughts on “From the Social to the Ultimate Determinants of Health

  1. Great post. I like Vicente Navarro’s pithy formulation of the same point in his 2009 essay, “What We Mean By Social Determinants of Health”: “It is not inequalities that kill, but those who benefit from inequalities that kill.”

    Similarly, while it is always advisable to start with Virchow, it’s also good to keep in mind the ‘other’ fundamental SDOH text written by a German scholar in the 1840s, Engels’s “On the Conditions of the Working Class in England.” He accuses the British bourgeoisie, in their tolerance of the structural injustices that produced the destitution, sickness, and premature deaths of the British urban working poor, of nothing less than social murder. Anne-Emanuelle Birn writes a bit about this to good effect in her 2009 article on the CSDH’s Final Report.

  2. Health is an ot come of the Economic condition of the Society / Nationa. The national Health policy & expenditure pattern were to bereviewed. For an example, the Govt. of India’s Health policy; The Indian senario of health the social determinants are reflected in the High IMR , MMr & destitution, sickness, and premature deaths of the new borns.

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