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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