The social determinants of what?

Abstract

There was much excitement over the final report of the WHO Commission on Social Determinants of Health (2008) and there was good reason for it. The report underscores the enormous strides made in public health research over the last 40 years. For students entering the field of public health in 2010 it may seem self-evident that social factors influence health; the rhetoric is now commonplace in many parts of the world, although not in all. We must not forget, however, that what now seems ‘‘evident’’, such as the claim that socio-economic status (SES) influences health in individuals and groups, was not always common knowledge. Pioneers of the social epidemiology movement worked long and hard to convince the medical establishment, and adherents to the individual risk factor model, that social conditions matter when it comes to health. We have indeed come a long way. There remains imprecision, however, in the study of social determinants of health. One of these issues will be the topic of this commentary. I focus specifically on the blurring of ‘‘the social determinants of health’’ with ‘‘the social determinants of inequalities in health’’. I will also briefly discuss the importance of capability theory (Sen 1992) in helping to distinguish the two. It has been argued that the ‘‘social determinants of health’’ concept has acquired a dual meaning referring both to the social factors promoting and undermining the health of individuals and populations as well as to the social processes underlying the unequal distribution of these factors between groups occupying unequal positions in society (Graham 2004). This blurring of the two is a fundamental problem that goes well beyond mere questions of nomenclature. When we refer to the social determinants of health we are concerned with the overall effect of some social phenomenon on the health of individuals or populations. These determinants are currently seen to include socio-structural influences, such as living and working conditions, as well as social practices such as smoking, exercising, drinking alcohol, etc. When intervening on the social determinants of health we seek to create positive trends in them, such as increasing living standards and reducing smoking, for example. This approach has often associated with the population health approach of Geoffrey Rose (1984) who suggested that the greatest gain in health is experienced when every member of a population improves her status on the determinant of concern. Recent debate, however, has suggested that this particular policy focus on social determinants of health may well improve the average level of health of a population, but may do little for, or may even worsen social inequalities in health (Frohlich and Potvin 2008). So for instance, policies focused on reducing smoking rates in the general population have been successful in bringing population smoking levels down but are believed to be aggravating the social distribution of smoking along SES lines (Smith et al. 2009). I surmise that part of this unintended consequence is due to an oversight by those of us swayed by the population Katherine L. Frohlich is a recipient of a Canadian Institutes of Health Research (CIHR) new investigator award and a Humboldt Fellowship for experienced researchers. She would like to acknowledge the Wissenschaftszentrum Berlin (WZB) Public Health Group for giving her office space and critical intellectual interaction during her sabbatical stay there. In the case of this commentary she would particularly like to acknowledge the comments from Michael Wright and Thomas Schlich.