The document discusses social determinants of health and health inequities. It defines social determinants as the circumstances where people are born, live, work and age that are shaped by economics, social policies and politics. Health inequities refer to unjust differences in health status between population groups that are avoidable. The document reviews the historical context of addressing social determinants, from the WHO constitution in 1948 to current efforts by the Commission on Social Determinants of Health. It presents frameworks that illustrate how social factors get "under the skin" to impact health and discusses measuring social economic position. The document also highlights the social gradient seen in health outcomes between and within countries in a global context. It proposes an integral approach is needed to

1. Social determinants
& global health
Joyce Browne, MD PhD
Julius Center, UMCU
The Netherlands
UMCU Global Health 2, March 2019
1

2. Learning objectives
• To understand the social determinants of health,
how they operate, and how they can be changed to
improve health and reduce health inequalities.
• Recognize and address the social gradients that
occur in a global health context
• To discuss how commercial and corporate
determinants influence heath
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3. Understanding social determinants
6

4. Definitions
• Social determinants
• Health (in)equity
• Common measurements?
7

5. The social determinants of health
are the circumstances in which
people are born, grow up, live,
work and age, and the systems
put in place to deal with illness.
These circumstances are in turn
shaped by a wider set of forces:
economics, social policies, and
politics.
Definition: social determinants
8

6. 9

7. Health inequalities can be defined as
differences in health status or in the distribution
of health determinants between different
population groups. (..) It is important to
distinguish between inequality in health and
inequity.
Health inequalities can be attributable to:
1. Biological variations or free choice
– Unavoidable?
2. External environment and conditions
mainly outside the control of the
individuals concerned.
– Unnecessary and avoidable / unjust and
unfair?
– If so: the resulting health inequalities
also lead to inequity in health.
Definition: health inequities
10WHO glossary of terms

8. 11
Definition: health inequities

9. Inequality or inequity in health outcome?
Can you come up with examples?
• Inequality which is not an inequity
• Inequality which is an inequity
13

10. Why are we talking about social determinants?
http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health 14

11. Why are we talking about social determinants?
http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health 15

12. Historical context of the Social Determinants
in Health
16

13. Historical context of the Social Determinants in
Health (1)
1948
• WHO constitution: acknowledgement of “impact of social and political
conditions on health” and need for intersectoral to achieve health gains.
1950s-
1960s
• Little regard for social contexts, strong focus on technology and disease-
specific campaigns.
1978
• Alma-Ata Declaration on Primary Health / Health for All.
Asserted need to strengthen health equity by addressing social conditions
through intersectoral programs
1980s
• Limited political will
- Neoliberal governments in many European countries and the US with
market-oriented reforms in health care
- Structural Adjustment Programs for developing countries: reduced
government’s social and public spending
• At the same time: biomedical paradigm was challenged: Black Report (UK)
17

14. Historical context of the Social Determinants in
Health (1)
1948
• WHO constitution: acknowledgement of “impact of social and political
conditions on health” and need for intersectoral to achieve health gains.
1950s-
1960s
• Little regard for social contexts, strong focus on technology and disease-
specific campaigns.
1978
• Alma-Ata Declaration on Primary Health / Health for All.
Asserted need to strengthen health equity by addressing social conditions
through intersectoral programs
1980s
• Limited political will
- Neoliberal governments in many European countries and the US with
market-oriented reforms in health care
- Structural Adjustment Programs for developing countries: reduced
government’s social and public spending
• At the same time: biomedical paradigm was challenged: Black Report (UK)
18

15. Historical context of the Social Determinants in
Health (1)
1948
• WHO constitution: acknowledgement of “impact of social and political
conditions on health” and need for intersectoral to achieve health gains.
1950s-
1960s
• Little regard for social contexts, strong focus on technology and disease-
specific campaigns.
1978
• Alma-Ata Declaration on Primary Health / Health for All.
Asserted need to strengthen health equity by addressing social conditions
through intersectoral programs
1980s
• Limited political will
- Neoliberal governments in many European countries and the US with
market-oriented reforms in health care
- Structural Adjustment Programs for developing countries: reduced
government’s social and public spending
• At the same time: biomedical paradigm was challenged: Black Report (UK)
19

16. • Published in 1980 by the
Thatcher Government
(over a Bank Holiday
Weekend)
• Analysis of General
Household Survey (GHS)
data (collection started
in 1970), by occupation
as an indicator of SES
The Black Report
Full report available at: http://www.sochealth.co.uk/resources/public-health-and-wellbeing/poverty-and-inequality/the-
black-report-1980/
20

17. Consistent social class gradient in
infant, child and adult mortality
21

18. Class differences were
also observed for
different causes of
adult mortality
• Infectious and parasitic diseases
• Endocrine, nutritional and
metabolic diseases
• Diseases of the nervous system,
digestive system, genic-urinary
tract
• Accidents, poisonings and
violence
22

19. Historical context of the Social Determinants in
Health (2)
1980s-
1990s
• Increase in scientific evidence for SDH
(e.g. Whitehall studies, UK)
• Political landscape: (social-)democrats
and continued market system approach
2004
• Commission on Social Determinants of
Health (CSDH)
2008
• CSDH Report published
2013
• Statement of the UN Platform on Social
Determinants in Health about the post-
2015 development agenda
23

20. • British Civil Services
• Prospective cohort study
(1967-1977)
• 18 000 male servants
between 20-64
Conclusion:
• Social gradient based on
seniority/occupation in
overall mortality and
range of specific diseases
Whitehall I
24

21. • British Civil Service, London
offices
• Prospective cohort, start
1985
• 10,308 civil servants
between 35-55 (33%
female)
Conclusions:
• Social gradient in
morbidity for men and
women
• Causal factors identified
– lifestyle (smoking, lack of
physical activity, obesity,
biometric markers), early life
factors, the way work is
organized, work climate, social
influences
Whitehall II
Bosma et al, 1998
25

22. Historical context of the Social Determinants in
Health (2)
1980s-
1990s
• Increasing scientific evidence for SDH
(e.g. Whitehall studies, UK)
• Political landscape: (social-)democrats
and continued market system approach
2004
• Commission on Social Determinants of
Health (CSDH)
2008
• CSDH Report published
2013
• Statement of the UN Platform on Social
Determinants in Health about the post-
2015 development agenda
26

23. How do you measure social economic position (social status)?
27

24. How is an individual’s social economic position
(social status) operationalized?
• Three levels:
– Individual
– Household
– Neighborhood
– (Country)
• Various time intervals
• Which factors are commonly used to describe social
economic position?
28

25. How is social economic position (social status)
operationalized?
Factors commonly used to describe social economic
position
– Education
– Income
– Occupation
– Social class
– Race/ethnicity
– Gender
29

26. How do social factors operate? (How do
they get ‘under the skin’?)

27. How do social factors operate?
31 31

28. Social stress resulting from
(perception of) social status
• Hypthalamus-pituitary-
adrenal axis (chronic)
• Sympatic nervous
system/(nor)adrenatine
(acute)
Psychosocial approach
32

29. Economic and political
determinants of health
and disease, beyond the
perception of inequalities
• Lack of resources, but also
access to education,
health services,
transportation,
environmental controls,
availability of food, quality
of housing, etc etc
Social production of disease / political economic
of health
33

30. Bringing it together: a conceptual framework
of social determinants of health (CSDH)
• Socio-economic and political context
• Structural determinants and socioeconomic position
(or “distal” factors)
• Intermediate factors
(or “proximal” factors)
..and their impact on health
34

31. Bringing it together: a conceptual framework of social determinants of health
35

32. Social determinants and global health
36

33. Social gradient in pre-mature death and life
expectancy between countries
Marmot, 2005. Lancet
World Health Statistics 2013, WHO 2014
37

34. Social gradient in maternal mortality
Rosmans (2006)
38

35. • Eight key reproductive,
maternal, newborn and
child interventions:
– Satisfied need for family
planning
– ≥ 1 ANC
– Skilled attendant at birth
– Measles vaccination
– DPT vaccination
– BCG vaccination
– Oral rehydration and
continued feeding
– Care seeking for pneumonia
Social gradient in maternal health services
coverage
Bhutta (2010) / Countdown to 2015 decade report
39

36. Social gradient in infant mortality between and
within countries
CSDH report, 2008
40

37. Inequities are also present within cities

38. Quick assignment: https://www.gapminder.org/dollar-street
Are there differences in determinants in this street?
42

39. How to address the social inequalities in
health?
43

40. Implementation of any policy or intervention
requires involvement of various actors
• What actors/stakeholders should be involved?
44

41. Implementation of any policy or
intervention requires involvement of
various actors
Health
Development
Strategies
Multilateral
Organizations
Civil society
Bilateral
organizations
National
governments
Private sector
Philanthropic
organizations
Community - National – International
45

42. CSDH report: an integral approach is necessary:
What three measures would you propose?
46 46

43. 1. Improve daily living conditions
2. Tackle inequitable distribution
of power, money and resources
3. Measure and understand the
problem and assess the impact
of action
CSDH recommendations
49

44. 1. Improve daily living conditions
Equity from the start (life course), fair
employment, healthy living and work
conditions, social protection, universal health
care
2. Tackle inequitable distribution of
power, money and resources
Health equity in all policies, fair financing,
market responsibility, gender equity, political
empowerment, good global governance
3. Measure and understand the
problem and assess the impact
of action
Monitoring, research, training
Global movement
CSDH recommendations
50

45. Commercial determinants of health
Kickbusch I, Allen L and Franz C; Lancet Global Health 2016

46. Tobacco: example of commercial & social
determinant and effective policy (SDG 3.A)

47. Public health analysis of the power of the
corporate sector
Commercial determinants of health:
“a synergistic, multidisciplinary field that addresses the
drivers and channels through which corporations
propagate the non-communicable diseases
pandemic.”
• Expanded the term ‘corporate determinants of
health’, coined by Miller in 2013

48. Conceptual framework of the commercial
determinants of health

49. Channels through which influence is
exerted
Marketing: enhances desirability and
acceptability of unhealthy
commodities
Extensive supply chains: amplify
company influence around the globe
Lobbying: impede policy barriers
Corporate social responsibility
strategies: deflect attention and
whitewash tarnished reputations

50. What is necessary for an effective response?
McKee and Stuckler (2018):
“at the heart of an extremely complex subject lies the
nature of power. An effective response to the corporate
and commercial determinants of health must address
the power imbalance between the global corporations,
which are accountable only to their owners and
shareholders, and governments, which are accountable
to their citizens”

51. Four ways corporations exert power & how
to balance this (1)
They identify four ways corporations exert power and
to to restore a balance to align corporate behavior
more to public good.
NB, power includes
• Visible power: laws and regulations
• Hidden power: access to key decision makers or
rules or procedures that include or exclude certain
groups

52. Four ways corporations exert power & how
to balance this
1. Defining the narrative
2. Set the rules and procedures by which society is
governed
3. Determine the rights, living and working conditions of
ordinary people
4. Take ownership of knowledge and ideas

53. What can be done about it?
• Challenge dominant narratives
– E.g. with social determinants: focus how people’s choices
are structured by forces outside their immediate control
– Illuminate how corporate actors share narratives
• Shape norms for health policymaking, support measures
that impose checks and balances on corporate power
– FCTC Article 5.3: excludes tobacco industry from health
policy making
• Support communities that have stood up
– E.g. US: local administrators that have adopted soda taxes,
by evaluate it’s impact
• Alignment with other social movements
– E.g. health and environment

54. .. With a strong industry lobby

55. • Social determinants play a major role in all aspects of health
and disease, and can be categorized in structural and
intermediate affects through various pathways.
• The importance of SDH and health equity is increasingly
internationally recognized and applied, for example in the
SDGs
In conclusion
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56. Want to know more about social
determinants?
• Online Social determinants game
www.playspent.org
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