from Raphael, D. (in press). A society in decline: The political and economic
determinants of health inequalities in the USA. In R. Hofrichter (ed.) Health
and social justice: A reader on politics, ideology, and inequity in the
distribution of disease.  San Francisco: Jossey Bass/Wiley.


Defining Health, Population Health, Societal Determinants of Health, and

Economic Inequality

     The ideas that shape this consideration of population health and health

inequalities in the USA are rooted in concepts outlined by the World Health

Organization (WHO) within the Ottawa Charter for Health Promotion. These

concepts have strongly influenced thinking about health and promoting it in

Canada and Europe, but less so in the USA.  There is evidence however, that this

may be changing.  Health refers to both the health status of individuals and to

the health of communities. Among individuals, health refers to the incidence of

illness and premature death as well as the presence of physical, social and

personal resources that allow for the achievement of personal goals. Considering

communities, health refers to the presence of economic, social and environmental

structures that support the physical, psychological, and social well-being of

community members

     Population health is primary concerned with the societal or structural

factors that determine the overall health of the population.  The term has taken

various forms but the most developed view is that of Health Canada that builds

upon work by the Canadian Institute for Advanced Research. The Federal,

Provincial, and Territorial Advisory Committee on Population Health defines it

so:



     Population health refers to the health of a population as measured by

     health status indicators and as influenced by social, economic and physical

     environments, personal health practices, individual capacity and coping

     skills, human biology, early childhood development, and health services.



     Societal determinants of health are the social, economic, and political

conditions within a society that influence whether people stay healthy or become

ill.  There is an emerging consensus concerning what these societal determinants

might be. There is less consensus on the mechanisms by which these determinants

actually influence health. There is even less consensus on how these societal

determinants of health can be influenced to improve health.

     Economic inequality refers to the unequal distribution in income and wealth

among residents within a nation, state/province, or locality. Increasing

economic inequality is becoming more of a focus for the public policy community

in the USA, Canada, and UK. Its measurement takes forms that consider its

overall distribution within a jurisdiction such as the Gini, Theil, or Robin

Hood indices, or more focussed indicators such as the percentage of income or

wealth shared by a particular percentage of the population, e.g., lower 50% of a

nation, state, or municipality.



The Importance of the Societal Determinants of Health

     It has been known for many decades that most of the profound improvements

in health in the USA, Canada, and other western countries over the past century

are not due to advances in medical and health care but rather to changes within

the structures and resources of society and how they are organized. To provide

just one illustration, the public health community and the general public assume

that the discoveries of the causes of, and means of immunizing children against,

infectious diseases were responsible for much of the decline in mortality from

common childhood diseases. While these developments certainly supported health,

it is apparent that improvement in general social conditions were most

responsible for these advances.  It is estimated that improved medical care

accounts for 10-15% of increased longevity in the USA and Canada since 1900.

     More recently, these same communities assume that lifestyle behaviours are

primarily responsible for differences in the occurrence of diseases such heart

disease, stroke, and cancer between and within nations. But British studies

carried out more than two decades ago found most of the variation in health and

disease among individuals in health could not be accounted for by these factors.

More recently, any number of USA studies reveal that behavioural risk factors

such as alcohol and tobacco use, body mass index, diet and physical activity

account for a rather small proportion of variance in mortality rates as compared

to income. These and other studies indicate there are additional factors that

predict illness and death. What might these be?

     Societal factors that affect population health go by a variety of titles

such as prerequisites for health, determinants of health, and social

determinants of health, among others. The Ottawa Charter for Health Promotion

identifies the prerequisites for health as peace, shelter, education, food,

income, a stable ecosystem, sustainable resources, social justice and equity.

Health Canada accepted direction from the Canadian Institute for Advanced

Research  in outlining determinants of health -- only some of which are societal

determinants -- of income and social status, social support networks, education,

employment and working conditions, physical and social environments, biology and

genetic endowment, personal health practices and coping skills, healthy child

development, and health services. A British working group identifies social

determinants of health as the social [class health] gradient, stress, early

life, social exclusion, work, unemployment, social support, addiction, food, and

transport.

     A more comprehensive societal determinants of health approach sets about

considering the determinants of even these determinants. Analysis is done of the

roles government ideology and policymaking play in influencing a range of

societal determinants by increasing income and wealth inequality and weakening

communal social structures. And even more complex analyses discuss how the

implementation of health-threatening neo-liberal policies occurs in the service

of powerful multinational corporations bent on maximizing profit through

economic globalization and the internationalization of capital. In all of these

analyses, an important mediator between political, economic, and social policy

and population health is income and wealth inequality within jurisdictions...

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