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From the Social to the Ultimate Determinants of Health

From the Social to the Ultimate Determinants of Health

Picture of Courtney McNamara

The notion that health is influenced by society, and the politics governing it, has been around for generations. Rudolf Vicherow, 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? Or 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:

Raphael 2011

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.

[This is a cross-posted piece from Healthy Policies]


The Center for Health Journalism’s two-day symposium on domestic violence will provide reporters with a roadmap for covering this public health epidemic with nuance and sensitivity. The first day will take place on the USC campus on Friday, March 17. The Center has a limited number of $300 travel stipends for California journalists coming from outside Southern California and a limited number of $500 travel stipends for those coming from out of state. Journalists attending the symposium will be eligible to apply for a reporting grant of $2,000 to $10,000 from our Domestic Violence Impact Reporting Fund. Find more info here!


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