SDOH-Listserv Bulletin No. 5, February 23, 2004
Historical Perspectives and Key Reference Books on the Social Determinants
of Health

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An Historical Perspective on the Social Determinants of Health
During the mid 1800's political economist Frederich Engels studied the
health conditions of working people in England and identified the factors
responsible for social class differences in health. His 1845 work, The
Condition of the Working Class in England, describes the horrendous living
and working conditions which workers were forced to endure (Engels,
1845/1987). Engels showed, as one of many examples, how profoundly
different death rates within a suburb of Manchester were directly
correlated with quality of housing and quality of streets. He was
remarkably perceptive in identifying the mechanisms by which disease and
early death came to the working classes.  He described how material
conditions of life - poverty, poor housing, clothing, and diet, and lack of
sanitation -- directly led to the infections and diseases common among the
poor. Engels also explored how the day-to-day stress of living under such
conditions contributed to illness and injury. The adoption of
health-threatening behaviours such as
drink was seen as means of coping with such disastrous conditions of life.
Engels concluded:

"All conceivable evils are heaped upon the poor?They are given damp
dwellings, cellar dens that are not waterproof from below or garrets that
leak from above? They are supplied bad, tattered, or rotten clothing,
adulterated and indigestible food.  They are exposed to the most exciting
changes of mental condition, the most violent vibrations between hope and
fear... They are deprived of all enjoyments except sexual indulgence and
drunkenness and are worked every day to the point of complete exhaustion of
their mental and physical energies?"(Engels, 1845/1987, p. 129)

British Contributions
      More recently, re-interest in the social determinants of health was
sparked by the publication of the Black Report and the Health Divide
(Townsend, Davidson, & Whitehead, 1992). These UK reports described how
lowest employment-level groups showed a greater likelihood of suffering
from a wide range of diseases and dying prematurely from illness or injury
at every stage of the life cycle. Additionally, health differences occurred
in a step-wise progression across the socio-economic range with
professionals having the best health and manual labourers the worse.
Skilled workers' health was midway between the extremes. These two reports
- and the many that have followed up on these themes -- stimulated the
study of health inequalities and the factors that determine these
inequalities and directed attention to the role public policy plays in
either increasing or reducing health inequalities.

Health inequalities and the social determinants of these inequalities are
active areas of inquiry among British researchers. Their studies frequently
focus on inequalities in health among members of different employment
strata with recognition that membership in such groups is strongly
correlated with income and education levels. British researchers also study
the health effects of poverty and how indicators of disadvantage usually
cluster together.  Much of the available data on social determinants of
health is British, as are some of the best theorisations of how these
factors influence health across the life span. The United Kingdom is also
the source of many ideas of how to apply these findings to promote health.

What are Social Determinants of Health?
The term social determinants of health appears to have grown out the search
by researchers to identify the specific exposures by which members of
different socio-economic groups come to experience varying degrees of
health and illness. While it was well documented that individuals in
various socio-economic groups experienced differing health outcomes, the
specific factors and means by which these factors led to illness remained
to be identified.

One of the first modern efforts to identify these factors was seen in the
1996 volume Health and Social Organization: Towards a Health Policy for the
21st Century (Tarlov, 1996). In the chapter Social Determinants of Health:
The Sociobiological Translation, Tarlov took the environment health field
from the Lalonde report -- the others being biology and genes, health care,
and lifestyle -- and fleshed out these environmental determinants of
health. In his model, inequalities in the quality of social determinants of
housing, education, social acceptance, employment, and income become
translated into disease-related processes.

Another stimulus to developing the concept of the social determinants of
health was findings of national differences in overall population health.
As one illustration, the health of Americans compares unfavourably to the
health of citizens in most other industrialised nations (Hofrichter, 2003).
This is the case for life expectancy, infant mortality, and death by
childhood injury despite the USA's overall greater wealth. In contrast, the
population health of the Scandinavian nations is generally superior to most
other nations.  Could the same factors that explain health differences
among groups within nations explain the differences seen between national
populations?

Current Concepts of the Social Determinants of Health
      There are a variety of contemporary approaches to social determinants
of health. The commonalities among these are particularly illuminative.

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 (World Health
Organization, 1986). These prerequisites of health are clearly concerned
with structural aspects of society and the organisation and distribution of
economic and social resources.
Health Canada outlines various determinants of health -- some of which are
social 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 (Health
Canada, 1998). Within this framework, the specific concepts of physical and
social environments can be criticised for lacking grounding in concrete
experiences of peoples' lives and lacking policy relevance - i.e. there
usually is no Ministry of Physical Environments or Ministry of Social
Environments.

 A British working group charged with the specific task of identifying
social determinants of health named the social [class health] gradient,
stress, early life, social exclusion, work, unemployment, social support,
addiction, food, and transport (Wilkinson & Marmot, 2003). This listing is
more grounded in the everyday experience of people's lives and
policy-making structures and avoids the potential problem of policy
irrelevance. Indeed, the stimulus for this work was the European Office of
the World Health Organization wanting to raise these issues among
policymakers and the public.
The organisers of the 2002 York University Social Determinants of Health
Across the Life Span conference synthesised these formulations to identify
eleven key social determinants of health. Four criteria were used to
identify these social determinants of health (Raphael, 2004).

The 1st criterion was that the social determinant be consistent with most
existing formulations of the social determinants of health and associated
with an existing empirical literature as to its relevance to health. All
these social determinants of health are important to health.

The 2nd criterion was that the social determinant of health be consistent
with lay/public understandings of the factors that influence health and
well-being. This was ascertained through assessment of available empirical
work on Canadians' understandings of what aspects of Canadian life
contribute to health and well-being. All these social determinants of
health are understandable to citizens.

The 3rd criterion was that the social determinant of health be clearly
aligned with existing governmental structures and policy frameworks (e.g.
Ministries of Housing, Native Affairs, Labour, Education, etc.) All these
social determinants of health have clear policy relevance to
decision-makers and citizens.

The 4th criterion was that the social determinant of health be an area of
either active governmental policy activity (e.g. health care services,
education) or policy inactivity that have provoked sustained criticism
(e.g. food security, housing, social safety net). All these social
determinants of health are especially timely and relevant.

The 11 social determinants of health identified by the organizers of the
York University conference are: aboriginal status, early life, education,
employment and working conditions, food security, health care services,
housing, income and its distribution, social safety net, social exclusion,
unemployment and employment security.

The inclusion of health services, housing and the social safety net as
social determinants of health is unusual. Health services are included in
the belief that a well-organised and rationalised health care system could
be an important social determinant of health - if this is not currently the
case. Housing is normally included within another determinant (e.g.
physical environments or social exclusion) which is surprising considering
its centrality to human health and well-being. The social safety net is
increasingly recognised as an important determinant of the health of
populations but to date is not explicitly included in available
formulations. Aboriginal status is another social determinant of health
that is not explicitly explored in most conceptualisations of social
determinants of health.  It represents the interaction of culture, public
policy, and the mechanisms by which systematic exclusion from participation
in Canadian life profoundly affects health.

Key Reference Books on the Social Determinants of Health
      All of the following have been essential for me in understanding the
idea and implications of the social determinants of health. I have
specifically excluded articles - except when relevant to the text above -
from this list.  Please send me titles of books I may have missed.

Acheson, D. (1998). Independent Inquiry Into Inequalities In Health.
Stationary Office. Retrieved, from the World Wide Web:
http://www.official-documents.co.uk/document/doh/ih/contents.htm .
Auerbach, J. A., & Belous, R. (Eds.). (1998). The Inequality Paradox:
Growth Of Income Disparity. Washington DC: National Policy Association.
Auerbach, J. A., & Krimgold, B. (Eds.). (2001). Income, Socioeconomic
Status, and Health: Exploring the Relationships. Washington, DC: National
Policy Association.
Bartley, M. (2003). Understanding Health Inequalities. Oxford UK: Polity
Press.
Bartley, M., Blane, D., & Davey Smith, G. (Eds.). (1998). The Sociology of
Health Inequalities. Oxford UK: Blackwell Publishers.
Benzeval, M., Judge, K., & Whitehead, M. (1995). Tackling Inequalities in
Health: An Agenda for Action. London: Kings Fund.
Berkman, L., & Kawachi, I. (Eds.). (2000). Social Epidemiology. New York:
Oxford University Press.
Blane, D., Brunner, E., & Wilkinson, R. (Eds.). (1996). Health and Social
Organization. London: Routledge.
Canadian Institute on Children's Health. (2000). The Health of Canada's
Children: A CICH Profile 3rd Edition. Ottawa, Canada: Canadian Institute on
Children's Health (CICH).
Davey Smith, G. (Ed.). (2003). Inequalities in Health: Life Course
Perspectives. Bristol UK: Policy Press.
Davey Smith, G., Dorling, D., & Shaw, M. (Eds.). (2001). Poverty,
Inequality and Health in Britain: 1800-2000: A  Reader. Bristol, UK: The
Policy Press.
Dunn, J., Hargreaves, S., & Alex, J. S. (2002, March). Are Widening Income
Inequalities Making Canada Less Healthy? Ontario Public Health Association
(OPHA);The Health Determinants Partnership - Making Connections Project, at
http://www.opha.on.ca/publications/income_inequalities.pdf
Engels, F. (1845/1987). The Condition of The Working Class In England. New
York: Penguin Classics.
Evans, R. G., Barer, M. L., & Marmor, T. R. (Eds.). (1994). Why Are Some
People Healthy And Others Not? The Determinants of Health Of Populations.
Hawthorne, New York: Aldine DeGruyter.
Evans, T., Whitehead, M., Diderichsen, F., Bhuya, A., & Wirth, M. (Eds.).
(2001). Challenging Inequities in Health: from Ethics to Action. New York:
Oxford University Press.
Gordon, D., Shaw, M., Dorling., D., & Davey Smith, G. (1999). Inequalities
in Health: The Evidence Presented to the Independent Inquiry into
Inequalities in Health. Bristol UK: The Policy Press.
Gordon, D., & Townsend, P. (Eds.). (2000). Breadline Europe: The
Measurement of Poverty. Bristol, UK: The Policy Press.
Graham, H. (Ed.). (2001). Understanding Health Inequalities. Buckingham,
UK: Open University Press.
Health Canada. (1998). Taking Action on Population Health:  A Position
Paper for Health Promotion and Programs Branch Staff. Health Canada, at
http://www.hc-sc.gc.ca/hppb/phdd/pdf/tad_e.pdf .
Hofrichter, R. (Ed.). (2003). Health and Social Justice: A Reader on
Politics, Ideology, and Inequity in the Distribution of Disease. San
Francisco: Jossey Bass.
Kawachi, I., & Kennedy, B. (2002). The Health of Nations: Why Inequality Is
Harmful to Your Health. New York: New Press.
Kawachi, I., Kennedy, B., & Wilkinson, R. (Eds.). (1999). The Society and
Population Health Reader: Volume I, Income Inequality and Health (Vol. 1).
New York: New Press.
Keating, D. P., & Hertzman, C. (Eds.). (1999). Developmental Health and the
Wealth of Nations. New York: Guilford Press.
Leon, D., & Walt, G. (Eds.). (2001). Poverty, Inequality and Health: An
International Perspective. Oxford, UK: Oxford University Press.
Lessard, R. (1997). Social Inequalities in Health: Annual Report of the
Health of the Population. Direction De La Sante Publique, at
http://www.santepub-mtl.qc.ca/Publication/rapportannuel/1998/rapport1998.html
Lessard, R., Roy, D., Choinière, R., Lévesque, J., & Perron, S. (2002).
Urban Health: A Vital Factor in Montreal's Development. . Available at: .
Montreal: Direction de Santé Publique. Retrieved February 20, 2004,
http://www.santepub-mtl.qc.ca/Publication/autres/annualreport2002.html
Mackenbach, J., & Bakker, M. (Eds.). (2002). Reducing Inequalities in
Health: A European Perspective. London UK: Routledge.
Marmot, M., & Wilkinson, R. (2000). Social Determinants of Health. Oxford,
UK: Oxford University Press.
Mitchell, R., Dorling, D., & Shaw, M. (2000). Inequalities in Life and
Death. What if Britain Were More Equal. Bristol, UK: The Policy Press.
Navarro, V. (Ed.). (2002). The Political Economy of Social Inequalities:
Consequences for Health and Quality of Life. Amityville, NY: Baywood Press.
Pantazis, C., & Gordon, D. (Eds.). (2000). Tackling Inequalities: Where Are
We Now and What Can Be Done? Bristol, UK: Policy Press.
Rainwater, L., & Smeeding, T. M. (2003). Poor Kids in a Rich Country:
America's Children in Comparative perspective. New York: Russell Sage
Foundation.
Raphael, D. (2002a, June). Poverty, Income Inequality and Health In Canada.
Centre for Social Justice Foundation for Research and Education, at
http://www.socialjustice.org/pubs/income&Health.pdf .
Raphael, D. (2002b). Social Justice Is Good For Our Hearts: Why Societal
Factors -- Not Lifestyles -- Are Major Causes Of Heart Disease In Canada
And Elsewhere. Centre for Social Justice Foundation for Research and
Education (CSJ), at http://www.socialjustice.org/pubs/justiceHearts.pdf .
Raphael, D. (July, 2004). Social Determinants of Health: Canadian
Perspectives. Toronto: Canadian Scholars Press.
Shaw, M., Dorling, D., Gordon, D., & Smith, G. D. (1999). The Widening Gap:
Health Inequalities and Policy in Britain. Bristol, UK: The Policy Press.
Stansfeld, S. A., & Marmot, M. (Eds.). (2002). Stress and the Heart:
Psychosocial Pathways to Coronary Heart Disease. London: BMJ Books.
Tarlov, A. (1996). Social determinants of health: The sociobiological
translation. In D. Blane, E.  Brunner, & R. Wilkinson (Eds.). (1996).
Health and Social Organization. London: Routledge.
Tesh, S. (1990). Hidden Arguments: Political Ideology and Disease
Prevention Policy. New Brunswick, NJ: Rutgers University Press.
Townsend, P., Davidson, N., & Whitehead, M. (Eds.). (1992). Inequalities in
Health: the Black Report and the Health Divide. New York: Penguin.
Vleminckx, K., & Smeeding, T. (Eds.). (2001). Child Well-Being, Child
Poverty And Child Policy In Modern Nations. Bristol: The Policy Press.
Wilkinson, R. (2001). Mind the Gap: Hierarchies, Health and Human
Evolution. London: Weidenfeld and Nicolson.
Wilkinson, R., & Marmot, M. (2003). Social Determinants of Health: The
Solid Facts.  Copenhagan, Denmark: World Health Organization (WHO), Europe
Office, at http://www.euro.who.int/document/e81384.pdf .
Wilkinson, R. G. (1996). Unhealthy Societies: The Afflictions of
Inequality. New York: Routledge.
World Health Organization. (1986). Ottawa Charter for Health Promotion.
World Health Organization (WHO), Europe Office, at
http://www.who.dk/policy/ottawa.htm .

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