Rachel's Democracy & Health News #875, Octover 5, 2006


[Rachel's introduction: As we saw last week, the health of U.S. citizens is poor, compared to that of other wealthy, industrialized societies. In Part 2 of this important essay, Dennis Raphael shows that U.S. public health policies largely ignore the primary determinants of health: early life, education, employment and working conditions, food security, housing, income and its distribution, social safety net, social exclusion, and unemployment and employment security.]

By Dennis Raphael

[Editors' introduction: Dr. Dennis Raphael is a professor in the School of Health Policy and Management, York University, Toronto. In recent years he has edited two volumes on the social determinants of health -- Staying Alive: Critical Perspectives on Health, Illness, and Health Care (2006), and The Social Determinants of Health: Canadian Perspectives (2004). He is the author of Inequality is Bad for Our Hearts; Why Low Income and Social Exclusion are Major Sources of Heart Disease in Canada (2001). If you have a high-speed internet connection, you can see and hear Dr. Raphael delivering an interesting lecture. If you are not familiar with the concept of "social determinants of health," you might read this short article in Wikipedia. In manuscript, this article was originally titled, "Public Policies Drive the Deteriorating Population Health Profile in the USA."]

The USA Public Health Scene

Numerous writers have considered how the USA population health and public policy profiles are linked (9, 35, 36, 65, 75). Certainly, the evidence urges the raising of these issues and seeking their policy solutions through public health action. It is therefore, fascinating to interrogate contemporary public health documents such as the Institute of Medicine's The Future of the Public's Health (22), Healthy People 2010 (23), and documents from the American Public Health Association (APHA) (76, 77) for their attention to these issues. The dominant model is organized around themes of:

a) racial and ethnic disparities with little concern for how broader determinants of health cause these disparities;

b) access to health care rather than issues of income and other resource distribution, and

c) a wide gap between knowledge concerning the broader determinants of health and action to address these determinants in the policy sphere (4).

National Policy Documents and Reports

Like other USA documents, Healthy People 2010 contains a chapter on the broader determinants of health and its health model is consistent with a broader health perspective. It has a prominent emphasis on issues of access to health care which is not surprising given that 17% or 45 million Americans are without health insurance coverage.

However, closer inspection of the document reveals that the role played by broader determinants of health is undeveloped. The Leading Health Indicators "[R]eflect the major health concerns in the United States at the beginning of the 21st century." These objectives -- physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care -- are firmly planted in the biomedical and behavioural public health model.

Explicit indicators of poverty or income levels, unemployment or job security, or any other obvious indicator of broader determinants of health are absent. Any and all examples of influencing policy are limited to legislative changes designed to promoting healthy behaviors or access to health care. There is little recognition of early life, education, employment and working conditions, food security, housing, income and its distribution, social safety net, social exclusion, and unemployment and employment security as primary determinants of health.

The Institute of Medicine's The Future of the Public's Health has similar shortcomings (Institute of Medicine, 2002). It has a chapter on developments in population health, yet these concepts do not diffuse to the rest of the volume. Virtually all issues to be addressed are health care-related or behaviorally-focused around diet, tobacco use, or physical activity. Policy is conceived narrowly as legislation related to risk behaviors and health protection.

APHA policy statements and numerous "Fact Sheets" reveal an emphasis on access to health care, the situating of health differences in terms of racial and ethnic disparities, and attention to modifying behavioral risk factors for disease and illness (76, 77). They describe differences in health status among White, African-American, Hispanics and Latinos, American Indian and Alaskan natives, and Asian Americans and Pacific Islanders, but highlight findings of unequal access to, and quality of, health care treatment.

Broadening the Scope

Some public health agencies address broader influence upon health. The report America's Health: State Health Rankings provides data and rankings for states on four sets of indicators of which two have a broad scope (78). Community Environment (violent crime, lack of health insurance, infectious disease, children in poverty, and occupational fatalities), and Health Policies (percent of health dollars for public health, per capita public health spending, and adequacy of prenatal care) focus on broader health determinants.

A commentary accompanying the report points out that the infant mortality rate in the USA showed the first increase in 40 years, ranking the USA 28th internationally. Yet, like many other USA analyses, the emphasis for action is primarily health care-related with a consistent, though undeveloped call to address persistent disparities, particularly among racial/ethnic groups.

A few innovative local public health initiatives address broader determinants of health. Many of these are state-level initiatives occurring under the auspices of a Robert Wood Johnson Foundation program (25). The predominant activity of these is the creation of data bases and community networks to meet basic public health functions. Only Minnesota has highlighted broader determinants of health and the role they play in health inequalities. A Call To Action: Advancing Health for All Through Social and Economic Change calls for public policy action to influence the broader determinants of health (24). However, a new governor has modified the health department mandate threatening this unique emphasis. A noteworthy exercise taking place in New York City is the Agenda for a Healthy New York where an alliance is educating the public with the goal influencing a range of broader determinants of health (79).

In summary, public health activity in the USA is characterized by a) a focus on providing access to health care access to its citizens; b) ethnic and racial disparities in health rather than a range of health determinants; c) a reluctance to consider the role structural aspects of society such as the distribution of economic and social resources play in influencing health; and d) a blind-spot as to the broad public policy antecedents of these determinants.

The Role of Public Health in Linking Population Health and Public Policy

Clearly, structural analyses of population health have had little penetration into public health discourse. The increasingly conservative public policy environment in the USA associated with reduced assistance payments, reduction of entitlements to the poor, and growing income and wealth inequalities combines with Americans' generally negative attitudes towards the roles of governments to make an activist public health agenda problematic (3, 9, 80).

The focus on racial and ethnic health differences represents a carryover from the civil rights activities of the 1960s as well as the intellectual and political barriers to addressing issues of income and social class (81). The effects of this is remove increasing income and wealth gap among Americans and issues important to the majority of Americans such as wages, employment security and working conditions, as public health issues. The focus on health care represents a reasoned response to an egregious situation whereby over 45 million citizens are not insured for health care costs. But again, the effect of this focus is to divert attention from a variety of health determinants whose quality is rooted in the public policy processes.

There are no shortage of suggestions on how public health researchers and workers could begin to address the structural issues that shape the presence of health inequalities and the USA population health profile (37, 42, 82). It is not my intention to repeat these here. What is obvious is that for the most part these suggestions have not been taken up to any discernible degree by the public health community in the USA. Why might this be the case?

In a series of interviews with prominent health researchers and policy advocates across the USA, I investigated the reasons for public health neglect of these broader issues. No surprises emerged from these analyses. The rise of neo-liberal and neo-conservative forces -- reflecting both a breakdown of the post-war consensus among government, business, and labor and the legacies of the Reagan Revolution -- have served to actively suppress virtually all public health activity related to addressing broader determinants of health. This is especially the case for issues related to income and as noted by Navarro,(56) social class as an object of inquiry and analyses has always been the subject of derision by academic researchers, policymakers, and elected officials.

Difficulties in addressing broader determinants of health and their public policy antecedents is not a problem of evidence, it is a problem of political will on the parts of public health researchers and workers and their governmental masters. This analysis suggests three key roles public health workers and researchers could play in raising these issues: education, motivation, and activation in support of the social determinants of health. These activities would help build the political supports by which public policy in support of the social determinants of health could be implemented. Each is considered in turn.


In the USA the general public health community and the American public -- remain woefully uninformed about, and stubbornly resistant to the concept and implications of the social determinants of health. At a minimum public health researchers and workers could carry out -- and publicize the findings from -- critical analysis of the social determinants of health and their role in influencing health. There is no shortage of areas in which these activities could take place: social determinants of health such as poverty, housing and food insecurity, and social exclusion appear to be the primary antecedents of just about every affliction known to humankind. My short list of such afflictions includes coronary heart disease, type II diabetes, arthritis, stroke, many forms of cancer, respiratory disease, HIV/AIDS, Alzheimers, asthma, injuries, death from injuries, mental illness, suicide, emergency room visits, school drop-out, delinquency and crime, unemployment, alienation, distress, and depression. Examples of such analyses and critiques of the dominant paradigms are available (83, 84).


Public health researchers and workers can shift public, professional, and policymakers' focus on the dominant biomedical and lifestyle health paradigms to a social determinants of health perspective by collecting and presenting stories about the impact social determinants of health have on people's lives. Ethnographic and qualitative approaches to individual and community health produce vivid illustrations of the importance of these issues for people's health and well-being (85). There is some indication that policymakers -- and certainly the media -- may be responsive to such forms of evidence (86). In addition, community-based activities allow community members to provide their own critical reflections on society, power and inequality (87-89). These approaches allow the voices of those most influenced by the social determinants of health to be heard and hold out the possibility of their concern being translated into community and political activity on their part and policy action on the part of health and government officials.


The final role is the role that is the most important but potentially the most difficult: supporting political action in support of health. There is increasing evidence that the quality of any number of social determinants of health within a jurisdiction is shaped by the political ideology of governing parties (35). Nations with a larger left-cabinet share from 1946 to the 1990s had the lowest child poverty rates and highest social expenditures; nations with less left-share had the highest poverty rates and lowest social expenditures (36). Poverty rates and government action in support of health -- the extent of government transfers -- is higher when popular vote is more directly translated into political representation through proportional representation (38).

The USA has never had members of a left political party in federal government. The USA does not have a viable left party (90, 91) and some argue the Democratic Party does not qualify as a center party applying international baselines. Similarly, the strength of the labor movement is a strong determinant of both public policy and population health (92). The USA has the lowest union membership density (13%) and lowest collective agreement coverage (14%) of any wealthy industrialized nation (93). Strengthening workers' rights to organize and improve wages, benefits, and employment security is clearly a public health issue that requires action in the political sphere (94, 95). The implications are clear: population health will be improved by support of political parties, governments, and policymakers that propose public policies in favor of health. Public health in the USA would be well-served by diverting at least a small portion of current focus and activities towards these broader issues. Some beginnings have been made in this direction in the USA (24, 79, 96-98) and certainly numerous examples from outside the USA are available (28, 52, 99-101).


A political approach to addressing health inequalities and promoting population health recognizes the public policy conditions necessary for health. These conditions include equitable distribution of wealth and progressive tax policies that create a large middle class, strong programs that support children, families, and women, and economies that support full employment. While the USA has become an outlier among wealthy industrialized nations in its public policy approaches in favor of health, American history shows that there have been periods of progressive activity and legislative action in support of its citizens (102). There is also increasing recognition that the USA model of public policy is inappropriate for meeting the challenges of a post-industrial economy (103). Political reversals are possible in democracies. The United Kingdom emerged from two decades of neo- liberal conservative rule to elect a labor government in 1997 committed to reducing health inequalities. New Zealand took a similar neo-liberal course during the 1990s, but has now reversed direction. Ideologies are malleable and national social policies can be changed.

The best means of promoting population health and reducing health inequalities through a social determinants of health perspective involves citizens being informed about the political and economic forces that shape the health of a society. Once so empowered, they can consider political and other means of influencing these forces. This is not a role that public health researchers and workers have considered their own. It appears rather a daunting task, but one that hold the best hope of promoting the health of citizens in the USA. Is this possible?


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