by Quinn O'Neill
It seems to be widely understood that you can ensure your own good health by eating fresh fruits and vegetables, avoiding junk food, exercising regularly, and not smoking. It’s an empowering idea that places the individual in charge of his own health, but there’s a flip side: if good health is attributable to the healthy choices that we make as individuals, then poor health must also be a choice.
This kind of thinking shapes our views on health care reform. If people choose to smoke, be sedentary, and consume an unhealthy diet, then why should the rest of us be expected to pay for their treatment when they end up with poor health? They made bad choices and so they should suffer the consequences.
The problem with this reasoning is that none of us makes decisions independently of our living conditions, and we have limited control over these conditions. We can’t blame children for learning unhealthy eating habits from their parents and we can’t blame a teenager who starts smoking as a result of peer pressure for being so desperate to fit in. Nor can we blame them for becoming unhealthy adults as a result of this early experience.
The most powerful influences on our health are not a matter of personal choice. They are well known to health care professionals as the “social determinants of health” and, unfortunately, they seem to be a well kept secret. “Health care” continues to be framed in public disourse as a system for providing medical services rather than a system for optimizing health within our society. If we care about health, we ought to be as interested in preventing illness as in treating it.
A 2003 report by the World Health Organization made this distinction clear. It says “Health policy was once thought to be about little more than the provision and funding of medical care: the social determinants of health were discussed only among academics. This is now changing. While medical care can prolong survival and improve prognosis after some serious diseases, more important for the health of the population as a whole are the social and economic conditions that make people ill and in need of medical care in the first place.”
I'm not convinced that the public’s concept of health policy is changing for the better. Poverty and social inequality, which contribute to poor health, continue to grow, while the inaffordability of medical services impoverishes the ill and injured. Meanwhile, our health care professionals dispense their services to those who can afford them without giving much more than lip service to the socioeconomic and political forces behind growing public health problems. Whenever health care reform is discussed, the social determinants of health ought to come up, yet they seldom do.
The WHO report mentioned above provides a very readable overview of these important factors. The determinants themselves, though widely accepted, vary depending on the organization and the given document’s authorship. This WHO report discusses ten factors, but another WHO site describes seven, and a Canadian version lists fourteen. Invariably, some or all of the following are included:
- Poverty/Income/Inome Distribution
- Education
- Physical Environment
- Early Life/Early Childhood Development
- Social Exclusion
- Working conditions
- Unemployment/Job Security
- Social support
- Food Insecurity
- Housing
- Social Safety Network
- Health Services
- Transport
- Addiction
- Stress
- Gender
- Race
- Disability
The variability from one source to another is undoubtedly due to overlap and interrelatedness among the determinants. Poverty, for example, has a strongly detrimental effect on early childhood development and educational level. Adults' educational attainment in turn affects their employment and income, and will shape the early life circumstances of their children.
Many of these factors may also compound to destroy health. The WHO report notes that drug use is a response to social breakdown as well as an important factor in worsening inequalities in health. People may turn to alcohol as a means of coping with difficult socioeconomic circumstances and their alcohol dependence may worsen their situation by resulting in loss of employment, social support, and other requisites for health.
On a positive note, the connections among these factors mean that investment in one area is likely to have positive effects that radiate to other areas. Investing in affordable public transportation, for example, may improve access to grocery stores, social and recreational activities, and health resources. It may also reduce pollution, improve respiratory ailments that are aggravated by pollution, and reduce motor vehicle accidents and associated deaths and disabilities.
Restricting our concept of health care to the provision of medical services limits our power to improve health at the population level. If we want to reduce the need for medical care – and the amount we spend on it – health policy must address the factors that most powerfully determine health.
If we could individually control the social determinants of our own health, we would each choose to be born into a healthy environment to great parents, to be well-off, to have great social support, and to live low-stress lives. We generally can’t choose these conditions for ourselves but we can make choices. Poverty will impair the health of nearly a quarter of American children and stunt their potential to become healthy adults who contribute to society. This isn’t their choice, it’s ours. Collectively, we've chosen to tolerate a political and economic system that promotes social inequality.
True health care reform doesn’t begin in the kitchen; it begins with an understanding that the social conditions that we create collectively affect everyone’s health.