Our health is a reflection of the experiences in which we are born, live, work and age. Fundamentally, our experiences are shaped by the distribution of resources and power which are controlled by policy choices. The wealthy have more resources often at the expense of the poor. This means our social status determines our overall health. Unequal distribution of resources leads to health inequalities.
Clearly individual behaviors, such as practicing unsafe sex and drug use, place the individual at a greater risk for disease transmission. However, the distribution of infectious disease is influenced by social determinants that put in place systems to deal with the prevention and control of illness. Historically, programs primarily focus on individual-level interventions as it has been thought that health is the sole responsibility of the individual. Understanding the patterns of disease and their social determinants allow us to create more effective and efficient programs and policies.
In 2005, the World Health Organization established the Commission on Social Determinants of Health to investigate the factors that produce health disparities and develop strategies to reduce them. Their final report, published August of 2008, suggests three recommendations (in summary):
- Improve daily living conditions: (a) The best possible way to improve living conditions is to invest in early childhood development. This will see that more children are reaching their potential and have a positive influence on the health of society. (b) Now that more people in the world are living in urban settings consequently means more people are living in urban slums. The commission calls for greater availability of affordable housing, clean water, sanitation and electricity. Also, social programs to reduce violence and crime are essential with people living in closer proximity to each other. (c) Fair employment and wages provides financial security in addition to personal development and self-esteem. And all people should be protected from unforeseen disruptions such as illness, disability or loss of income. This includes a policy for universal healthcare to promote good and equitable health coverage.
- Tackle the inequitable distribution of power, money and resources: The commission calls for health equity to be a marker for government performance of wealth distribution. They suggest a progressive tax, increased global aid and legislation to ensure all groups in society have equal opportunities and representation.
- Measure and understand the problem and assess the impact of action: A well calculated assessment ensures that action is effective and efficient so as to provide better policies and programs. The public, civil and private sectors should understand and be responsible for the role they play to promote a healthy society.
The former US Surgeon General, Dr. David Satcher, calls for a new way of thinking about health. Public health professionals and the federal government need to address social determinants and frame their work around health equity. In the late 1950s Dr. William Foege reviewed the death certificates of the Seattle-King Country area in order to understand the health of the population. He noted the fallacy of this method:
‘While death certificates might list heart attacks or cancer, cigarette smoking is responsible for one in four deaths, but tobacco use is rarely indicated on death certificates. Factor in diet and alcohol consumption, and we can account for 40% of deaths. Studying death certificates is a poor way to understand what is really happening to a population’s health.
The real causes of many deaths are social determinants such as illiteracy, fatalism, gender bias, racial bias, unemployment, and poverty. Poverty is the single biggest factor contributing to adverse health outcomes, and health outcomes worsen as poverty becomes more severe. In 1424, Hongxi, emperor of the Ming Dynasty in China, who himself grew up in poverty, said, “We must treat poverty like we would treat drowning. There is no time to lose.”’